Low Lymphocyte Ratio as a Novel Prognostic Factor in Acute Heart Failure: Results from the Pre-RELAX-AHF Study

Abstract

Background: Previous studies have suggested that a lower lymphocyte ratio (Ly%) in the white blood cell (WBC) differential count is related to worse outcomes in patients with acute heart failure (AHF) and other cardiovascular disorders. Methods: In the Pre-RELAX-AHF study, 234 patients with AHF, systolic blood pressure >125 mm Hg and brain natriuretic peptide ≧350 pg/ml or equivalent were randomized to 1 of 4 intravenous doses of relaxin or placebo and followed up for 6 months following randomization. Complete blood count and differential were performed by a central laboratory at baseline and then daily to day 5 and on day 14. Results: The WBC count by itself was not associated with measures of disease severity or outcome, and patients with Ly% <13% had similar baseline characteristics to patients with Ly% >13%, except for a higher baseline WBC count, elevated baseline glucose, older age and higher rates of peripheral vascular disease. However, patients with Ly% <13% had less improvement of dyspnea, greater worsening of heart failure, longer length of initial hospital stay and fewer days alive and out of hospital. Statistical significance was reached for all-cause death by days 60 and 180 (hazard ratio = 1.11 per percent decrease, 95% confidence interval 1.03–1.19; p = 0.0048). Conclusions: Despite no association with any baseline characteristic known to strongly predict outcome in AHF, low Ly% is associated with less symptom relief and worse in-hospital and postdischarge clinical outcomes.

Predictive Value of Low Relative Lymphocyte Count in Patients Hospitalized for Heart Failure With Reduced Ejection Fraction

“…10 Despite this heterogeneity in study design, similar to our experience, low lymphocyte counts were highly related to known HHF predictors of adverse outcomes. [8][9][10][11] Furthermore, all studies consistently demonstrated that relative lymphopenia was an independent predictor of postdischarge events. [8][9][10][11] Earlier studies are limited because findings were based on relatively small sample sizes and largely single-center experiences.…”

“…[8][9][10][11] Furthermore, all studies consistently demonstrated that relative lymphopenia was an independent predictor of postdischarge events. [8][9][10][11] Earlier studies are limited because findings were based on relatively small sample sizes and largely single-center experiences. The present study represents the largest experience to date to investigate the prognostic role of lymphopenia in the setting of HHF.…”

“…All previous studies in HHF used relative lymphocyte percentage instead of absolute counts. [8][9][10][11] Cutoffs for abnormally low values ranged from 13% 10,11 to 25%. 8 Patient follow-up Hazard ratios were calculated using Cox proportional hazard models.…”

“…Few small studies have suggested that lymphopenia may confer increased risk for mortality in stable outpatients [4][5][6][7] and patients with HHF. [8][9][10][11] Although low lymphocyte count is currently recognized in certain risk stratification scores for chronic heart failure, 12 contemporary HHF prognostication models lack inclusion of this potentially valuable parameter. 13,14 The Efficacy of Vasopressin Antagonism in Heart Failure Outcome Study with Tolvaptan (EVEREST) trial [15][16][17] allows for systematic and in-depth analysis of the role of lymphocytes in a large cohort of patients with HHF with reduced ejection fraction (EF), well treated with evidence-based HF therapies, with close follow-up and monitoring.…”

Low prealbumin is strongly associated with adverse outcome in heart failure

“…Total cholesterol,6 25 albumin8 26 and total lymphocyte count,8 27 have been used as markers of undernutrition with recognised association with morbidity and mortality also in HF.…”