Associations of the neutrophil-to-lymphocyte ratio with all-cause and cardiovascular mortality in patients with chest pain

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BACKGROUND: Inflammation is crucial in cardiovascular disease (CVD). While the neutrophil-to-lymphocyte ratio (NLR), a simple inflammatory marker, has been linked to adverse outcomes in various CVD populations, its prognostic significance in patients with chest pain remains unclear. This study aimed to investigate the associations of the NLR with all-cause and CVD mortality in a large cohort of chest pain patients. METHODS: This retrospective cohort study included 3048 chest pain patients. The NLR was calculated from complete blood counts, and patients were divided into three tertiles. Cox proportional hazards regression models, adjusting for confounders, were used to estimate all-cause and CVD mortality hazard ratios (HRs). Kaplan-Meier survival curves were also created, and sensitivity analyses were performed. RESULTS: A significant positive association was found between the NLR and the risk of both all-cause and CVD mortality. According to the fully adjusted model, a one-unit increase in log10 NLR correlated with a 4.68-fold increase in CVD mortality risk and a 2.37-fold increase in all-cause mortality risk. Compared with the lowest NLR tertile (T1), the highest (T3) was associated with significantly greater all-cause mortality [HR 1.43, 95% confidence interval (CI) 1.14-1.80] and CVD mortality (HR 2.03, 95% CI 1.28-3.22). An NLR ≥ 0.43 (log10) also significantly increased mortality risk. Survival decreased as NLR increased, with these relationships remaining robust in sensitivity analysis. CONCLUSION: Chest pain patients with increased NLRs are at greater risk of all-cause and CVD mortality. NLR can serve as a practical, cost-effective prognostic indicator in this group. Key messages What is already known on this topic: The neutrophil-to-lymphocyte ratio (NLR) is an established marker of systemic inflammation, and its prognostic value has been demonstrated in specific populations with diagnosed cardiovascular disease. However, its utility for risk stratification in the broader, undifferentiated population of patients initially presenting with chest pain remained unclear, warranting further investigation in a large-scale cohort. What this study adds: In this large cohort of over 3000 patients, this study provides robust evidence that an elevated NLR is a significant and independent predictor of both all-cause and cardiovascular mortality. Specifically, after full adjustment, patients in the highest NLR tertile had a 43% higher risk of all-cause mortality (HR 1.43) and a more than 2-fold greater risk of cardiovascular mortality (HR 2.03) compared to those in the lowest tertile. How this study might affect research, practice or policy: These findings support the integration of NLR-a readily available and cost-effective marker from a standard blood count-into the early risk assessment pathways for patients with chest pain. Clinicians can use the NLR to help identify higher-risk individuals who may benefit from more intensive monitoring, further diagnostic workup, or targeted therapeutic interventions upon presentation.

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