Neutrophil to lymphocyte ratio predicts appropriate therapy in idiopathic dilated cardiomyopathy patients with primary prevention implantable cardioverter defibrillator

Fatih M. Uçar, Burak Açar


Objectives: To investigate whether an inflammatory marker of neutrophil to lymphocyte ratio (NLR) predicts appropriate implantable cardioverter defibrillator (ICD) therapy (shock or anti tachycardia pacing) in idiopathic dilated cardiomyopathy (IDC) patients.Methods: We retrospectively examined IDC patients (mean age: 58.3 ± 11.8 years, 81.5% male) with ICD who admitted to outpatient clinic for pacemaker control at 2 tertiary care hospitals in Ankara and Edirne, Turkey from January 2013-2015. All ICDs were implanted for primary prevention. Hematological and biochemical parameters were measured prior procedure.


Results: Over a median follow-up period of 43 months (Range 7-125), 68 (33.1%) patients experienced appropriate ICD therapy. The NLR was increased in patients that received appropriate therapy (4.39 ± 2.94 versus 2.96 ± 1.97, p less than 0.001).To identify independent risk factors for appropriate therapy, a multivariate linear regression model was conducted and age (β=0.163, p=0.013), fasting glucose (β=0.158, p=0.017), C-reactive protein (CRP) (β=0.289, p less than 0.001) and NLR (β=0.212, p less than 0.008) were found to be independent risk factors for appropriate ICD therapy.


Conclusions: Before ICD implantation by using NLR and CRP, arrhythmic episodes may be predictable and better antiarrhythmic medical therapy optimization may protect these IDC patients from unwanted events.

Saudi Med J 2017; Vol. 38 (2): 143-148

doi: 10.15537/smj.2017.2.15929

How to cite this article:

Uçar FM, Açar B. Saudi Med J. 2017 Feb;38(2):143-148.

doi: 10.15537/smj.2017.2.15929.


appropriate therapy; implantable cardioverter defibrillator; neutrophil to lymphocyte ratio; inflammation; idiopathic dilated cardiomyopathy

Full Text:



Bardy GH, Lee KL, Mark DB, Poole JE, Packer DL, Boineau R. et al. Amiodarone or an implantable cardioverter-defibrillator for congestive heart failure. N Engl J Med 2005; 352: 225-237.

Hua W, Niu H, Fan X, Ding L, Xu YZ, Wang J, et al. Group ICDS: Preventive effectiveness of implantable cardioverter defibrillator in reducing sudden cardiac death in the Chinese population: a multicenter trial of ICD therapy versus non-ICD therapy. J Cardiovasc Electrophysiol 2012; Suppl 1: S5-S9.

Moss AJ, Hall WJ, Cannom DS, Daubert JP, Higgins SL, Klein H, et al. Improved survival with an implanted defibrillator in patients with coronary disease at high risk for ventricular arrhythmia. Multicenter Automatic Defibrillator Implantation Trial Investigators. N Engl J Med 1996; 335: 1933-1940.

Moss AJ, Zareba W, Hall WJ, Klein H, Wilber DJ, Cannom DS, et al. Prophylactic implantation of a defibrillator in patients with myocardial infarction and reduced ejection fraction. N Engl J Med 2002; 346: 877-883.

Daubert JP, Zareba W, Cannom DS, McNitt S, Rosero SZ, Wang P, et al. Inappropriate implantable cardioverter-defibrillator shocks in MADIT II: frequency, mechanisms, predictors, and survival impact. J Am Coll Cardiol 2008; 51: 1357-1365.

Thavikulwat AC, Tomson TT, Knight BP, Bonow RO, Choudhury L. Appropriate Implantable Defibrillator Therapy in Adults with Hypertrophic Cardiomyopathy. J Cardiovasc Electrophysiol 2016; 27: 953-960.

Poole JE, Johnson GW, Hellkamp AS, Anderson J, Callans DJ, Raitt MH, et al. Prognostic importance of defibrillator shocks in patients with heart failure. N Engl J Med 2008; 359: 1009-1017.

Vollmann D, Luthje L, Vonhof S, Unterberg C. Inappropriate therapy and fatal proarrhythmia by an implantable cardioverter-defibrillator. Heart rhythm 2005; 2: 307-309.

Aribas A, Akilli H, Gul EE, Kayrak M, Demir K, Duman C, et al. Can neutrophil/lymphocyte ratio predict recurrence of non-valvular atrial fibrillation after cardioversion? Anadolu Kardiyol Derg 2013; 13: 123-130.

Kaya H, Ertas F, Islamoglu Y, Kaya Z, Atilgan ZA, Cil H, et al. Association between neutrophil to lymphocyte ratio and severity of coronary artery disease. Clin Appl Thromb Hemost 2014; 20: 50-54.

Uthamalingam S, Patvardhan EA, Subramanian S, Ahmed W, Martin W, Daley M, et al. Utility of the neutrophil to lymphocyte ratio in predicting long-term outcomes in acute decompensated heart failure. Am J Cardiol 2011; 107: 433-438.

Tamhane UU, Aneja S, Montgomery D, Rogers EK, Eagle KA, Gurm HS. Association between admission neutrophil to lymphocyte ratio and outcomes in patients with acute coronary syndrome. Am J Cardiol 2008; 102: 653-657.

Chatterjee S, Chandra P, Guha G, Kalra V, Chakraborty A, Frankel R, et al. Pre-procedural Elevated White Blood Cell Count and Neutrophil-Lymphocyte (N/L) Ratio are Predictors of Ventricular Arrhythmias During Percutaneous Coronary Intervention. Cardiovasc Hematol Disord Drug Targets 2011; 11: 58-60.

Gibson PH, Cuthbertson BH, Croal BL, Rae D, El-Shafei H, Gibson G, et al. Usefulness of neutrophil/lymphocyte ratio as predictor of new-onset atrial fibrillation after coronary artery bypass grafting. Am J Cardiol 2010; 105: 186-191.

Shao Q, Chen K, Rha SW, Lim HE, Li G, Liu T. Usefulness of Neutrophil/Lymphocyte Ratio as a Predictor of Atrial Fibrillation: A Meta-analysis. Arch Med Res 2015; 46: 199-206.

McMurray JJ, Adamopoulos S, Anker SD, Auricchio A, Bohm M, Dickstein K, et al. ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. Eur Heart J 2012; 33: 1787-1847.

American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Society of Echocardiography, American Heart Association, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, et al. ACCF/ASE/AHA/ASNC/HFSA/HRS/SCAI/SCCM/SCCT/SCMR 2011 Appropriate Use Criteria for Echocardiography. A Report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Society of Echocardiography, American Heart Association, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Critical Care Medicine, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance American College of Chest Physicians. J Am Soc Echocardiogr 2011; 24: 229-267.

Hogye M, Mandi Y, Csanady M, Sepp R, Buzas K. Comparison of circulating levels of interleukin-6 and tumor necrosis factor-alpha in hypertrophic cardiomyopathy and in idiopathic dilated cardiomyopathy. Am J Cardiol 2004; 94: 249-251.

Albert CM, Ma J, Rifai N, Stampfer MJ, Ridker PM. Prospective study of C-reactive protein, homocysteine, and plasma lipid levels as predictors of sudden cardiac death. Circulation 2002; 105: 2595-2599.

Bruins P, te Velthuis H, Yazdanbakhsh AP, Jansen PG, van Hardevelt FW, de Beaumont EM, et al. Activation of the complement system during and after cardiopulmonary bypass surgery: postsurgery activation involves C-reactive protein and is associated with postoperative arrhythmia. Circulation 1997; 96: 3542-3548.

Kanoupakis EM, Manios EG, Kallergis EM, Mavrakis HE, Goudis CA, Saloustros IG, et al. Serum markers of collagen turnover predict future shocks in implantable cardioverter-defibrillator recipients with dilated cardiomyopathy on optimal treatment. J Am Coll Cardiol 2010; 55: 2753-2759.

Levine YC, Rosenberg MA, Mittleman M, Samuel M, Methachittiphan N, Link M, et al. B-type natriuretic peptide is a major predictor of ventricular tachyarrhythmias. Heart Rhythm 2014; 11: 1109-1116.

Streitner F, Kuschyk J, Veltmann C, Brueckmann M, Streitner I, Brade J, et al. Prospective study of interleukin-6 and the risk of malignant ventricular tachyarrhythmia in ICD-recipients--a pilot study. Cytokine 2007; 40: 30-34.

Theuns DA, Smith T, Szili-Torok T, Muskens-Heemskerk A, Janse P, Jordaens L. Prognostic role of high-sensitivity C-reactive protein and B-type natriuretic peptide in implantable cardioverter-defibrillator patients. Pacing Clin Electrophysiol 2012; 35: 275-282.

Flevari P, Theodorakis G, Leftheriotis D, Kroupis C, Kolokathis F, Dima K, et al. Serum markers of deranged myocardial collagen turnover: their relation to malignant ventricular arrhythmias in cardioverter-defibrillator recipients with heart failure. Am Heart J 2012; 164: 530-537.

Cheng A, Zhang Y, Blasco-Colmenares E, Dalal D, Butcher B, Norgard S, et al. Protein biomarkers identify patients unlikely to benefit from primary prevention implantable cardioverter defibrillators: findings from the Prospective Observational Study of Implantable Cardioverter Defibrillators (PROSE-ICD). Circ Arrhythm Electrophysiol 2014; 7: 1084-1091.

Köklü E, Yüksel İÖ, Arslan Ş, Bayar N, Çağırcı G, Gencer ES, et al. Is Elevated Neutrophil-to-Lymphocyte Ratio a Predictor of Stroke in Patients with Intermediate Carotid Artery Stenosis? J Stroke Cerebrovasc Dis 2016; 25: 578-584.

Lattanzi S, Cagnetti C, Provinciali L, Silvestrini M. Neutrophil-to-Lymphocyte Ratio Predicts the Outcome of Acute Intracerebral Hemorrhage. Stroke 2016; 47: 1654-1657.

Rotzius P, Thams S, Soehnlein O, Kenne E, Tseng CN, Björkström NK, et al. Distinct infiltration of neutrophils in lesion shoulders in ApoE-/- mice. Am J Pathol 2010; 177: 493-500.

Drechsler M, Megens RT, van Zandvoort M, Weber C, Soehnlein O. Hyperlipidemia-triggered neutrophilia promotes early atherosclerosis. Circulation 2010; 122: 1837-1845.

Ndrepepa G, Braun S, Mehilli J, von Beckerath N, Schömig A, Kastrati A. Myeloperoxidase level in patients with stable coronary artery disease and acute coronary syndromes. Eur J Clin Invest 2008; 38: 90-96.

Leclercq A, Houard X, Philippe M, Ollivier V, Sebbag U, Meilhac O, et al. Involvement of intraplaque hemorrhage in atherothrombosis evolution via neutrophil protease enrichment. J Leukoc Biol 2007; 82: 1420-1429.

Onsrud M, Thorsby E. Influence of in vivo hydrocortisone on some human blood lymphocyte subpopulations. I. Effect on natural killer cell activity. Scand J Immunol 1981; 13: 573-579.

Avci A, Alizade E, Fidan S, Yesin M, Guler Y, Kargin R, et al. Neutrophil/lymphocyte ratio is related to the severity of idiopathic dilated cardiomyopathy. Scand Cardiovasc J 2014; 48: 202-208.

Yildiz A, Yuksel M, Oylumlu M, Polat N, Akil MA, Acet H. The association between the neutrophil/lymphocyte ratio and functional capacity in patients with idiopathic dilated cardiomyopathy. Anatol J Cardiol 2015; 15: 13-17.

Yildiz A, Oylumlu M, Yuksel M, Aydin M, Polat N, Acet H, et al. The Association Between the Neutrophil-to-Lymphocyte Ratio and the Presence of Ventricular Premature Contractions in Young Adults. Clin Appl Thromb Hemost 2015; 21: 475-479.

Thune JJ, Pehrson S, Nielsen JC, Haarbo J, Videbæk L, Korup E, et al. Rationale, design, and baseline characteristics of the DANish randomized, controlled, multicenter study to assess the efficacy of Implantable cardioverter defibrillators in patients with non-ischemic Systolic Heart failure on mortality (DANISH). Am Heart J 2016; 179: 136-141.


  • There are currently no refbacks.

Saudi Medical Journal is copyright under the Berne Convention and the International Copyright Convention. All rights reserved. Saudi Medical Journal is an Open Access journal and articles published are distributed under the terms of the Creative Commons Attribution-NonCommercial License (CC BY-NC). Readers may copy, distribute, and display the work for non-commercial purposes with the proper citation of the original work. Electronic ISSN 1658-3175. Print ISSN 0379-5284.