Prognostic value of the nutritional inflammatory score in NSTEMI: A decade of follow-up

Özden Seçkin; Serkan Ünlü; Yusuf Bozkurt Şahin

doi:10.26900/hsq.2958

Authors

Özden Seçkin Gazi University Hospital / Türkiye 0000-0001-7385-4419
Serkan Ünlü Gazi University Hospital / Türkiye 0000-0001-6179-8579
Yusuf Bozkurt Şahin Etlik City Hospital, University of Health Sciences / Türkiye 0000-0003-3523-8783

10.26900/hsq.2958

Abstract

To evaluate the prognostic value of the Nutritional Inflammatory Score (NIS) and neutrophil-to-lymphocyte ratio (NLR) in predicting long-term major adverse cardiovascular events (MACE) and all-cause mortality in patients with non-ST segment elevation myocardial infarction (NSTEMI). This retrospective cohort study included 314 patients with NSTEMI who were admitted between 2013 and 2016. Baseline NIS (calculated as albumin/NLR) and NLR values were obtained from admission laboratory data. The primary outcome was MACE, defined as a composite of cardiovascular death, recurrent myocardial infarction, heart failure hospitalization, and repeat revascularization. The secondary outcome was all-cause mortality. Patients were followed for a mean of 99.7 ± 22.0 months. Cox regression analysis, receiver operating characteristic (ROC) curves, and Kaplan-Meier survival estimates were used to assess prognostic significance. Multivariate Cox regression showed that NIS was an independent predictor of both MACE (HR: 0.719, 95% CI: 0.631–0.819, p<0.001) and all-cause mortality (HR: 0.885, 95% CI: 0.788–0.994, p=0.040). NLR was predictive of MACE but not mortality. NIS demonstrated superior predictive performance (AUC: 0.886 for MACE; 0.799 for mortality). Kaplan-Meier analysis showed significantly higher event and mortality rates in patients with lower NIS values. NIS, a simple and readily accessible marker that integrates inflammatory and nutritional status, is a strong independent predictor of long-term outcomes in NSTEMI patients. It outperforms NLR and may enhance clinical risk stratification and personalized patient management.

Keywords:

NSTEMI nutritional inflammatory score neutrophil-to-lymphocyte ratio MACE long-term outcomes mortality

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References

1. Berg ES, Tegn NK, Abdelnoor M, Røysland K, Ryalen PC, Aaberge L, et al. Long-term outcomes of invasive vs conservative strategies for older patients with non–ST-segment elevation acute coronary syndromes. J Am Coll Cardiol. 2023;82(21):2021–30. doi: 10.1016/j.jacc.2023.09.809

2. Kite TA, Kurmani SA, Bountziouka V, Cooper NJ, Lock ST, Gale CP, et al. Timing of invasive strategy in non-ST-elevation acute coronary syndrome: A meta-analysis of randomized controlled trials. Eur Heart J. 2022;43(33):3148–61. doi:10.1093/eurheartj/ehac213

3. Byrne RA, Rossello X, Coughlan J, Barbato E, Berry C, Chieffo A, et al. 2023 ESC guidelines for the management of acute coronary syndromes: Developed by the task force on the management of acute coronary syndromes of the European Society of Cardiology (ESC). Eur Heart J Acute Cardiovasc Care. 2024;13(1):55–161. doi: 10.1093/ehjacc/zuad107

4. Jobs A, Collet J-P, Thiele H. Optimal timing of invasive angiography in non-ST-segment elevation acute coronary syndromes—Do we need more data?. European Heart Journal. 2021;42(4):353-4. 10.1093/eurheartj/ehaa930

5. Poredos P, Poredos AV, Gregoric I. Endothelial dysfunction and its clinical implications. Angiology. 2021;72(7):604-15. doi: 10.1177/0003319720987752

6. Shannon CM, Ballew SH, Daya N, Zhou L, Chang AR, Sang Y, et al. Serum albumin and risks of hospitalization and death: Findings from the Atherosclerosis Risk in Communities study. J Am Geriatr Soc. 2021;69(10):2865-76. doi: 10.1111/jgs.17313

7. Arnold N, Lechner K, Waldeyer C, Shapiro MD, Koenig W. Inflammation and cardiovascular disease: The future. Eur Cardiol. 2021;16:e20. doi: 10.15420/ecr.2020.50

8. Ye Z, Hu T, Wang J, Xiao R, Liao X, Liu M, et al. Systemic immune-inflammation index as a potential biomarker of cardiovascular diseases: A systematic review and meta-analysis. Front Cardiovasc Med. 2022;9:933913. doi: 10.3389/fcvm.2022.933913

9. Yamamoto T, Kawada K, Obama K. Inflammation-related biomarkers for the prediction of prognosis in colorectal cancer patients. Int J Mol Sci. 2021;22(15):8002. doi: 10.3390/ijms22158002

10. Dziedzic EA, Gąsior JS, Tuzimek A, Paleczny J, Junka A, Dąbrowski M, et al. Investigation of the associations of novel inflammatory biomarkers—Systemic inflammatory index (SII) and systemic inflammatory response index (SIRI)—With the severity of coronary artery disease and acute coronary syndrome occurrence. Int J Mol Sci. 2022;23(17):9553. doi: 10.3390/ijms23179553

11. Liu T-W, Chen C-M, Chang K-H. Biomarker of neuroinflammation in Parkinson’s disease. Int J Mol Sci. 2022;23(8):4148. doi: 10.3390/ijms23084148

12. Pan Q, Zhang W, Li X, Chen Z, Yang Y, Wang G. Sex difference in the association between neutrophil to lymphocyte ratio and severity of coronary artery disease. Angiology. 2022;73(5):470-7. doi: 10.1177/00033197211070884

13. Sheinenzon A, Shehadeh M, Michelis R, Shaoul E, Ronen O. Serum albumin levels and inflammation. Int J Biol Macromol. 2021;184:857–62. doi: 10.1016/j.ijbiomac.2021.06.140

14. Yang S-B, Zhao H-W. Associations between albumin/neutrophil-to-lymphocyte ratio score and new-onset atrial fibrillation in patients with acute myocardial infarction undergoing PCI. J Inflamm Res. 2025;18:61–71. doi: 10.2147/JIR.S500743

15. Ayrancı MK, Küçükceran K, Dundar ZD. NLR and CRP to albumin ratio as a predictor of in-hospital mortality in the geriatric ED patients. Am J Emerg Med. 2021;44:50–5. doi: 10.1016/j.ajem.2021.01.053

16. Wullur Y, Taslim NA. Neutrophil-lymphocyte ratio, prognostic nutritional index and CRP-albumin ratio significantly predict mortality in ICU patients with low nutrition risk. Nutr Clín Diet Hosp. 2024;44(3). doi: 10.12873/443wullur

17. Kahraman S, Agus HZ, Avci Y, Serbest NG, Guner A, et al. The neutrophil to lymphocyte ratio (NLR) is associated with residual syntax score in patients with ST-segment elevation myocardial infarction. Angiology. 2021;72(2):166–73. doi: 10.1177/0003319720958556

18. Eyiol A, Ertekin B, Acar T. The association between systemic inflammatory indices and prognosis in acute coronary syndrome. Ann Clin Anal Med. 2024;15:514–8. doi: 10.4328/ACAM.22216

19. Cao X, Zhao M, Li H, Xu D, Li M, Zhang X, et al. Three new inflammatory markers C reactive protein to albumin ratio, neutrophil to lymphocyte ratio, and platelet to lymphocyte ratio correlated with relapsing polychondritis disease activity index. Clin Rheumatol. 2021;40(11):4685–91. doi: 10.1007/s10067-021-05827-z

20. Hsueh WH, Hsueh S-W, Yeh K-Y, Hung Y-S, Ho M-M, Lin S-Y, et al. Albumin and neutrophil-to-lymphocyte ratio score in neoadjuvant concurrent chemoradiotherapy for esophageal cancer: Comparison with prognostic nutritional index. In Vivo. 2022;36(5):2400–8. doi: 10.21873/invivo.12973

21. Huang H, Wang C, Ji F, Han Z, Xu H, Cao M, et al. Nomogram based on albumin and neutrophil-to-lymphocyte ratio for predicting postoperative complications after pancreaticoduodenectomy. Gland Surg. 2021;10(3):877. doi: 10.21037/gs-20-789

22. Wu C-C, Wu C-H, Lee C-H, Cheng C-I. Association between neutrophil percentage-to-albumin ratio (NPAR), neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR) and long-term mortality in community-dwelling adults with heart failure: Evidence from US NHANES 2005–2016. BMC Cardiovasc Disord. 2023;23(1):312. doi: 10.1186/s12872-023-03316-6

23. Safak O, Yildirim T, Emren V, Avci E, Argan O, Aktas Z, et al. Prognostic nutritional index as a predictor of no-reflow occurrence in patients with ST-segment elevation myocardial infarction who underwent primary percutaneous coronary intervention. Angiology. 2024;75(7):689–95. doi: 10.1177/00033197231193223

24. Mikhailidis D, Ganotakis E. Plasma albumin and platelet function: Relevance to atherogenesis and thrombosis. Platelets. 1996;7(3):125–37. doi: 10.3109/09537109609023571

25. Sun K, Chen S, Xu J, Li G, He Y. The prognostic significance of the prognostic nutritional index in cancer: A systematic review and meta-analysis. J Cancer Res Clin Oncol. 2014;140(9):1537–49. doi: 10.1007/s00432-014-1714-3

26. Layland J, Oldroyd KG, Curzen N, Sood A, Balachandran K, Das R, et al. Fractional flow reserve vs. angiography in guiding management to optimize outcomes in non-ST-segment elevation myocardial infarction: The British Heart Foundation FAMOUS–NSTEMI randomized trial. Eur Heart J. 2015;36(2):100–11. doi: 10.1093/eurheartj/ehu338

27. McManus DD, Gore J, Yarzebski J, Spencer F, Lessard D, Goldberg RJ. Recent trends in the incidence, treatment, and outcomes of patients with STEMI and NSTEMI. Am J Med. 2011;124(1):40–7. doi: 10.1016/j.amjmed.2010.07.023

28. Montalescot G, Dallongeville J, Van Belle E, Rouanet S, Baulac C, Degrandsart A, et al. STEMI and NSTEMI: Are they so different? 1 year outcomes in acute myocardial infarction as defined by the ESC/ACC definition (the OPERA registry). Eur Heart J. 2007;28(12):1409–17. doi: 10.1093/eurheartj/ehm031

29. Park H-W, Yoon C-H, Kang S-H, Choi D-J, Kim H-S, Cho MC, et al. Early- and late-term clinical outcome and their predictors in patients with ST-segment elevation myocardial infarction and non-ST-segment elevation myocardial infarction. Int J Cardiol. 2013;169(4):254–61. doi: 10.1016/j.ijcard.2013.08.132

30. Aragam KG, Tamhane UU, Kline-Rogers E, Li J, Fox KA, Goodman SG, et al. Does simplicity compromise accuracy in ACS risk prediction? A retrospective analysis of the TIMI and GRACE risk scores. PLoS One. 2009;4(11):e7947. doi: 10.1371/journal.pone.0007947

31. Hosmer DW Jr, Lemeshow S, Sturdivant RX. Applied Logistic Regression. 3. Baskı. New York: John Wiley & Sons; 2013. https://www.wiley.com/en-us/Applied+Logistic+Regression%2C+3rd+Edition-p-9780470582473