| Objectives:The aim of this study was to investigate the ratio of atherosclerotic inflammatory cells to anti-atherosclerotic inflammatory cells(inflammatory cell subsets)of peripheral blood in the diagnosis and prediction of the prognosis of patients with Acute Coronary Syndrome(ACS)Undergoing Percutaneous Coronary Intervention(PCI).And to explore whether the combined use of multiple indicators can further improve the prognosis diagnosis and predictive value of poor prognosis in ACS patients after PCI.Methods:We consecutively enrolled 1744 eligible inpatients who undergoing PCI in the Division of Cardiology from January 2016 to December 2018.Patients were followed up for 1142(850,1414)days after PCI,186 patients were lost to follow-up.The remaining eligible inpatients(1558 cases)were divided into 2groups according to the Major Adverse cardiac Events(MACE).MACE1group(63 cases,66(61,72)years old):consisted of all-cause mortality patients,cardiac mortality,,hospitalized again for severe heart failure(heart function level IV according to NYHA classification)or Acute Myocardial Infarction(AMI)patients;Non-MACE(NMACE)1 group(1495 cases,59(52,65)years old): no MACE1 occurred patients.Or,MACE2 group(38 cases,65(60,72)years old): consisted of cardiac mortality patients,hospitalized again for severe heart failure(heart function level IV according to NYHA classification)or AMI patients;NMACE2 group(1520 cases,59(52,65)years old): no MACE2 occurred patients.The relationship of the Ratio of Neutrophils to lymphocytes(NLR),the Ratio of Monocytes to Lymphocytes(MLR),the Ratio of Platelets to Lymphocytes(PLR),the combination of the two factors and combination of the three factors with ACS patients undergoing PCI who occurred MACE was quantitatively analyzed through diagnostic tests and COX proportional hazards regression model.Results:1 Comparison of baseline characteristics1.1 Comparison of baseline characteristics according to the MACE1(all-cause mortality,cardiac mortality,hospitalized again for severe heart failure or AMI)Compared with the NMACE1 group,the ratio of the patients with age≥65 years old,cerebral infarction history,heart failure history,cardiogenic shock history,NLR≥2.67,MLR≥0.33,PLR≥225.49,decreased albumin,elevated creatine kinase isoenzyme,elevated creatinine,Ejection Fraction<40%,discharged diuretic were higher in the MACE1 group[50.8%(32/63)vs22.7%(340/1495);25.4%(16/63)vs 13.8%(206/1495);31.7%(20/63)vs9.2%(138/1495);12.7%(8/63)vs 1.1%(17/1495);73.0%(46/63)vs52.2%(780/1495);49.2%(31/63)vs 33.3%(498/1495);30.2%(19/63)vs12.8%(192/1495);11.1%(7/63)vs 4.6%(69/1495);57.1%(36/63)vs46.0%(688/1495);9.5%(6/63)vs 2.4%(36/1495);12.7%(8/63)vs2.2%(33/1495);17.5%(11/63)vs 6.6%(99/1495).The differences were statistically significant(all P < 0.05)].Compared with the NMACE1 group,the ratio of the patients with unstable angina pectoris,discharged aspirin,discharged clopidogrel,discharged ticagrelor,discharged renin-angiotensin receptor antagonists/angiotensin converting enzyme inhibitors and discharged statins were lower in the MACE1 group[23.8%(15/63)vs 40.2%(601/1495);77.8%(49/63)vs 99.2%(1483/1495);68.3%(43/63)vs 79.1%(1182/1495);7.9%(5/63)vs 20.1%(300/1495);30.2%(19/63)vs 45.4%(679/1495);77.8%(49/63)vs 98.9%(1478/1495).The differences were statistically significant(all P < 0.05)].1.2 Comparison of baseline characteristics according to the MACE2(cardiac mortality,hospitalized again for severe heart failure or AMI)Compared with the NMACE2 group,the ratio of the patients with age≥65 years old,cerebral infarction history,heart failure history,cardiogenic shock history,STEMI,decreased absolute value of lymphocytes,elevated absolute value of monocyte,elevated mean platelet volume,NLR≥2.67,MLR≥0.43,PLR≥225.49,decreased albumin,elevated creatinine,Ejection Fraction <40%,discharged diuretic were higher in the MACE2group[47.4%(18/38)vs 23.3%(354/1520);28.9%(11/38)vs 13.9%(211/1520);44.7%(17/38)vs 9.3%(141/1520);21.1%(8/38)vs 1.1%(17/1520);60.5%(23/38)vs 44.1%(671/1520);31.6%(12/38)vs 17.3%(263/1520);34.2%(13/38)vs 20.9%(317/1520);2.6%(1/38)vs 0.3%(5/1520);73.7%(28/38)vs 52.5%(798/1520);39.5%(15/38)vs 18.6%(282/1520);36.8%(14/38)vs 13.0%(197/1520);13.2%(5/38)vs 4.7%(71/1520);13.2%(5/38)vs 2.4%(37/1520);18.4%(7/38)vs 2.2%(34/1520);23.7%(9/38)vs6.6%(101/1520).The differences were statistically significant(all P <0.05)].Compared with the NMACE2 group,the ratio of the patients with unstable angina pectoris,discharged aspirin,discharged clopidogrel,discharged renin-angiotensin receptor antagonists/angiotensin converting enzyme inhibitors and discharged statins were lower in the MACE2group[18.4%(7/38)vs 40.1%(609/1520);68.4%(26/38)vs 99.1%(1506/1520);52.6%(20/38)vs 79.3%(1205/1520);21.1%(8/38)vs 45.4%(690/1520);68.4%(26/38)vs 98.8%(1501/1520).The differences were statistically significant(all P < 0.05)].2 Diagnostic experiment2.1 The diagnostic value of NLR,MLR,PLR,combination of the two factors and combination of the three factors for MACE1 in patients with ACS Undergoing PCIThe ROC-AUC of the NLR,MLR,PLR,combination of NLR and MLR,combination of NLR and PLR,combination of MLR and PLR,and combination of the three factors for all-cause mortality,hospitalized again for severe heart failure or AMI were 0.613(95% CI 0.541 0.686);0.588(95% CI0.508 0.668);0.610(95% CI 0.535 0.685);0.641(95% CI 0.575 0.707);0.652(95% CI 0.581 0.723);0.627(95% CI 0.550 0.705);0.663(95% CI 0.5940.732),respectively.Among them,the diagnostic value of combination of three factors was the highest.The diagnostic value of combination of any two factors was greater than that of any single factor.The difference was statistically significant(all P<0.05).The optimal diagnostic value of NLR was2.67,the sensitivity and specificity were 0.754 and 0.448,respectively.The optimal diagnostic value of MLR was 0.33,the sensitivity and specificity were0.525 and 0.661,respectively.The best diagnostic threshold of PLR was225.49,the sensitivity and specificity were 0.311 and 0.871,respectively.The difference was statistically significant(all P<0.05).2.2 The diagnostic value of NLR,MLR,PLR,combination of the two factors and combination of the three factors for MACE2 in patients with ACS Undergoing PCIThe ROC-AUC of the NLR,MLR,PLR,combination of NLR and MLR,combination of NLR and PLR,combination of MLR and PLR,and combination of the three factors for cardiac mortality,hospitalized again for severe heart failure or AMI were 0.615(95% CI 0.521 0.710);0.627(95% CI0.521 0.734);0.629(95% CI 0.526 0.732);0.673(95% CI 0.593 0.752);0.687(95% CI 0.596 0.777);0.678(95% CI 0.579 0.777);0.724(95% CI,0.643 to0.806),respectively.Among them,the diagnostic value of combination of three factors was the highest.The diagnostic value of combination of any two factors was greater than that of any single factor.The difference was statistically significant(all P<0.05).The optimal diagnostic value of NLR was2.67,the sensitivity and specificity were 0.778 and 0.475,respectively.The optimal diagnostic value of MLR was 0.43,the sensitivity and specificity were0.444 and 0.813,respectively.The best diagnostic value of PLR was 225.49,the sensitivity and specificity were 0.389 and 0.870,respectively.The difference was statistically significant(all P < 0.05).3 The Kaplan-Meier survival curves of ACS patients undergoing PCI according to the optimal diagnostic thresholds of NLR,MLR,and PLR into low,medium,high,and extremely high-risk groups3.1 Kaplan-Meier survival curve for MACE1Median survival time of the low,medium,high and extremely high-risk groups were 1213.00(903.75,1449.25)day,1137.50(852.00,1137.50)days,985.00(814.00,1381.75)days,944.50(763.00,1276.00)days,respectively.The overall survival time distribution in the four groups was significantly different,χ2 =28.534,P(Log Rank)<0.001.3.2 Kaplan-Meier survival curve for MACE2Mean survival time of the low,medium,high and extremely high risk groups were 1206.50(901.25,1445.00)days,1088.00(844.50,1408.50)days,974.50(795.50,1322.75)days,980.00(762.00,1391.00)days,respectively.The overall survival time distribution in the four groups was significantly different,χ2= 28.012,P(Log Rank)<0.001.4 The COX proportional hazard regression model for predicting MACE in ACS patients undergoing PCI4.1 The COX proportional hazard regression model for predicting MACE1 in ACS patients undergoing PCIAge≥65 years old,history of heart failure,history of cardiogenic shock,elevated preoperative creatinine,and ejection fraction<40% were independent risk factors for all-cause mortality,re-hospitalization for severe heart failure or AMI in ACS patients undergoing PCI,the Hazard Ratio(HR)values were 2.857,2.155,4.629,3.706,and 3.498,respectively.The risk of cardiogenic shock is highest.The difference was statistically significant(all P< 0.05).The NLR≥2.67,MLR≥0.33,PLR≥225.49 were also independent risk factors for all-cause mortality,re-hospitalization for severe heart failure or AMI.The difference was statistically significant(P=0.004).Among them,compared with the low risk group(NLR,MLR,PLR were all lower than the optimal diagnostic value),the HR value of medium risk group(Any one of NLR,MLR,PLR was higher than or equal to the optimal diagnostic value),high risk group(any two of NLR,MLR and PLR were above or equal to the optimal diagnostic value),extremely high risk group(NLR,MLR,PLR are all above or equal to the optimal diagnostic value)were2.726,2.992,5.531,respectively.The risk of medium risk group was the lowest,but it close to the risk of age≥65 years old.The risk of the high-risk group was between the risk of age≥65 and the ejection fraction<40% and higher than that in the medium-risk group.The risk of the extremely high-risk group was the highest,higher than the risk of cardiogenic shock.The predictive value of NLR for all-cause death and re-hospitalization of severe heart failure or AMI in ACS patients undergoing PCI was higher than that of PLR,with HR values of 2.938 and 2.303,respectively.4.2 The COX proportional hazard regression model for predicting MACE2 in ACS patients undergoing PCIAge≥65 years old,history of heart failure,history of cardiogenic shock,elevated preoperative creatinine,and ejection fraction<40% were independent risk factors for cardiac mortality,re-hospitalization for severe heart failure or AMI in ACS patients undergoing PCI,the HR values were2.655,3.160,7.161,5.023 and 3.611,respectively.The risk of cardiogenic shock is highest.The difference was statistically significant(all P< 0.05).The NLR≥2.67,MLR≥0.43,PLR≥225.49 were also independent risk factors for cardiac mortality and re-hospitalization for severe heart failure or AMI.The difference was statistically significant(P=0.018).Among them,compared with the low risk group,the HR value of medium risk group,high risk group,extremely high-risk group were 6.988,10.015,12.121,respectively.The risk was lowest in the medium risk group,but the risk of it was between cardiogenic shock and elevated preoperative creatinine.The risk of high-risk group was higher than that of medium risk group,and the risk of extremely high-risk group was the highest.NLR had the highest predictive value for cardiac mortality and re-hospitalization of severe heart failure or AMI in ACS patients undergoing PCI,followed by PLR,and MLR had the lowest diagnostic value,with HR values of 13.268,11.551 and 6.064,respectively.Conclusions:1 Peripheral blood inflammatory cell subsets,NLR≥2.67,MLR≥0.33,and PLR≥225.49 had diagnostic value for all-cause mortality,cardiac mortality and re-hospitalization of severe heart failure or AMI in ACS patients undergoing PCI.The combination of the two and the three of them could further improve the diagnostic accuracy.2 The ACS patients undergoing PCI were divided into low-risk,medium-risk,high-risk and extremely high-risk groups according to the number of NLR,MLR,PLR above the diagnostic value,as the degree of risk increased,the risk of poor prognosis(all-cause mortality,cardiac mortality and re-hospitalization of severe heart failure or AMI)increased and the mean survival time showed a trend of shortening.NLR alone had the highest prognostic value for poor prognosis,followed by PLR and MLR had the lowest prognostic value. |
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