640 Original Investigation

The association between platelet/lymphocyte ratio and

coronary artery disease severity

Murat Yüksel, Abdulkadir Yıldız, Mustafa Oylumlu, Abdurrahman Akyüz, Mesut Aydın,
Hasan Kaya, Halit Acet, Nihat Polat, Mehmet Zihni Bilik, Sait Alan
Department of Cardiology, Faculty of Medicine, Dicle University; Diyarbakır-Turkey

ABSTRACT
Objective: In this study, we aimed to explore the association between platelet-to-lymphocyte ratio (PLR) and the severity of atherosclerosis in
coronary artery disease (CAD).
Methods: Clinical and laboratory data of 388 patients who underwent coronary angiography were evaluated retrospectively. Gensini score,
which indicates the severity of atherosclerosis, was calculated for all of the patients. Patients with CAD were categorized as mild and severe
atherosclerosis, according to their Gensini score. Eighty patients with normal coronary arteries formed the control group. Mean PLR values of
the three study groups were compared. Also, PLR value was tested for whether it showed a positive correlation with Gensini score.
Results: The mean PLR of the severe atherosclerosis group was significantly higher than that of the mild atherosclerosis and controls groups
(p<0.001). Also, PLR was positively correlated with Gensini score in CAD patients. A cut-off value of 111 for PLR predicted severe atherosclero-
sis with 61% sensitivity and 59% specificity. Pre-procedural PLR level was found to be independently associated with Gensini score, together
with WBC, age, and low HDL level, in the multivariate analysis.
Conclusion: Our study suggests that high PLR appears to be additive to conventional risk factors and commonly used biomarkers in predicting
severe atherosclerosis. (Anatol J Cardiol 2015; 15: 640-7)
Keywords: atherosclerosis, coronary artery disease, Gensini score, platelet-lymphocyte ratio

Introduction relative thrombocytosis. Previous studies demonstrated an

association between high circulating platelet count and major
Cardiovascular diseases (CVDs) are still the leading cause of adverse cardiovascular outcomes in patients with coronary
death all over the world, despite modern therapeutic advances. artery disease (CAD) and also in healthy adults (8-10). Platelet-
It is known that inflammation plays a substantial role in the ini- to-lymphocyte ratio (PLR) is a new prognostic marker that inte-
tiation and propagation of the complex atherosclerotic process grates the risk prediction of these 2 parameters into 1. It gives an
(1) that lies beneath CVD. The role of inflammation in CVD has idea about both the aggregation and inflammation pathways, and
been studied extensively, and a consistent relationship between it may be more valuable than either platelet or lymphocyte count
various inflammatory markers and CVD has been established in alone in the prediction of coronary atherosclerotic burden. PLR
the past (2-4). A low blood lymphocyte count has been shown to was found to be useful in predicting poor prognosis in cancer
be related with worse cardiovascular consequences in patients population (11-13) and in predicting critical limb ischemia in
with CAD and chronic heart failure (5-7). In cases of sustained peripheral artery disease (14) previously. Moreover, higher PLR
inflammation, lymphocyte counts decrease due to increased value emerged as a significant independent predictor of long-
lymphocyte apoptosis. Lymphocytes represent a more conve- term survival in patients presented with acute coronary syn-
nient immune response, while neutrophils cause a destructive drome (15) and as an independent predictor of no-reflow devel-
inflammatory reaction. Also, ongoing inflammatory conditions opment in patients undergoing primary PCI (16). In line with
lead to increased proliferation in megakaryocytic series and these findings, a high PLR tertile of a recent study population
Address for Correspondence: Dr. Murat Yüksel, Dicle Üniversitesi Kalp Hastanesi, 1. Kat
Kardiyoloji Kliniği, 21280, Sur-Diyarbakır-Türkiye
Phone: +90 412 248 80 01 Fax: +90 412 248 85 23 E-mail: [email protected]
Accepted Date: 10.06.2014 Available Online Date: 11.07.2014
©Copyright 2015 by Turkish Society of Cardiology - Available online at www.anatoljcardiol.com
DOI:10.5152/akd.2014.5565
 Yüksel et al.
Anatol J Cardiol 2015; 15: 640-7 Platelet/lymphocyte ratio and CAD 641

that presented with STEMI showed poorer outcomes compared Abbott Laboratory, Abbott Park, Illinois, USA). Plasma low-densi-
to the low PLR group, and PLR was found to be an independent ty lipoprotein cholesterol (LDL) concentrations were calculated
predictor of in-hospital mortality in patients with STEMI (17). using the Friedewald equation (18).
Gensini score was established to expose the severity and
extent of coronary atherosclerosis. There are many studies Coronary angiography and assessment of coronary
demonstrating the relationship between systemic inflammation atherosclerosis severity
and coronary atherosclerosis; however, to our knowledge, there Selective coronary angiography was performed for all
are no data about the relationship between PLR and severity of patients enrolled in the study by Judkins technique through the
coronary atherosclerosis yet. In this context, we aimed to inves- femoral artery using the Allura Xper FD10 (Philips, Amsterdam,
tigate the usefulness of a recently defined cardiovascular risk the Netherlands). All of the coronary angiograms were evaluat-
marker, PLR, in predicting the severity of coronary atherosclero- ed by 2 interventional cardiologists who were blinded to the
sis. patient information and to each other. A thorough review of each
coronary angiogram established the lesion location and percent-
Methods age of luminal stenosis among all coronary artery lesions.
CAD was defined as the presence of stenosis of at least 50%
Study population of the vessel diameter in any of the main coronary arteries,
The present study is a single-center and retrospectively according to the American College of Cardiology/American
designed study, consisting of 388 eligible consecutive patients Heart Association (ACC/AHA) lesion classification (19). The
who underwent selective coronary angiography between May Gensini scoring system was used to identify the severity of CAD
and July 2013 in our clinic. Informed consent was obtained from (20). This method classifies and scores the degree and extent of
all of the participants, and the study was approved by the local the stenosis of the coronary arteries. This system scores 1 point
ethics committee. for 1% to 25% stenosis, 2 points for 26% to 50%, 4 points for 51%
A thorough physical examination was performed for all of to 75%, 8 points for 76% to 90%, 16 points for 91% to 99% steno-
the patients included in the study, and they were asked for their sis, and 32 points for total occlusion. The score is then multiplied
history of previous myocardial infarction, hypertension, diabetes by a factor representing the importance of the lesion’s location
mellitus, smoking and non-cardiac diseases and family history in the coronary arterial system. For the location, scores are
of CAD. Arterial hypertension was considered in patients with at multiplied by 5 for a left main lesion; 2.5 for the proximal left
least three repeated measurements of blood pressure above 140 anterior descending (LAD) or left circumflex (LCX) artery; 1.5 for
mm Hg systolic and 90 mm Hg diastolic or active use of antihy- the mid-segment LAD and LCX; 1 for the distal segment of the
pertensive medication. Diabetes mellitus was defined as fasting LAD and LCX, first diagonal branch, first obtuse marginal branch,
plasma glucose levels above 126 mg/dL in at least two different right coronary artery, posterior descending artery, and interme-
measurements or active use of anti-diabetic drugs. Smoking diate artery; and 0.5 for the second diagonal and second obtuse
was defined as current smoking or ex-smokers who forwent marginal branches.
smoking in the past 6 months. A positive family history for CAD According to their coronary angiograms, patients were cat-
was considered a history of CAD or sudden cardiac death in a egorized into three groups. The first group consisted of 80
first-degree relative before the age of 55 years for men and 65 patients with normal coronary arteries (control group). The rest
years for women. of the patients with coronary artery disease were divided into
Patients with moderate or advanced valvular heart disease, two according to their Gensini score: (21, 22) those with mild
clinically decompensated congestive heart failure, malignancy, atherosclerosis (n=156; Gensini score <25 points) and severe
hematological disorder, severe renal or hepatic insufficiency, atherosclerosis (n=152; Gensini score ≥25 points).
active infection or systemic inflammatory conditions, or autoim-
mune disorders and patients using steroids were excluded. Statistical analysis
Continuous variables were defined as means and standard
Biochemical and hematological parameters deviation; categorical variables were given as percentages.
After an overnight fasting, peripheral venous blood samples The normality of distribution for continuous variables was con-
were drawn from patients. Total and differential leukocyte firmed with the Kolmogorov-Smirnov test. According to the
counts were measured by an automated hematology analyzer distribution pattern of the continuous variables, the indepen-
(Abbott Cell- Dyn 3700; Abbott Laboratory, Abbott Park, Illinois, dent-sample t-test or the Mann-Whitney U test was used for
USA). Absolute cell counts were used in the analyses. PLR was continuous variables, and the chi-square test was used for
computed as platelet count divided by lymphocyte count. Total categorical variables. One-way analysis of variance (ANOVA)
and high-density lipoprotein cholesterol (HDL), triglycerides, and or Kruskal-Wallis test was used to compare 3 groups. When
fasting plasma glucose levels were measured using the Abbott there was a significant difference between the three study
Architect C16000 auto-analyzer (Architect C16000 auto-analyzer; groups, the comparison of two groups in terms of the relevant
 Yüksel et al.
642 Platelet/lymphocyte ratio and CAD Anatol J Cardiol 2015; 15: 640-7

Table 1. Comparison of baseline demographic characteristics and cardiovascular risk factors of the study population*
Control group Mild atherosclerosis Severe atherosclerosis
(n=80) (n=156) (n=152) P
Age, years 57.8±10.5 59.8±10.8 63.7±12.2 <0.001a
Male, n (%) 47 (60) 92 (59) 102 (67) 0.288
Coronary risk factors
Family history, n (%) 6 (8) 15 (10) 19 (13) 0.473
Smoking, n (%) 27 (34) 39 (25) 49 (32) 0.237
Hypertension, n (%) 27 (34) 56 (36) 70 (46) 0.105
Diabetes, n (%) 20 (25) 37 (24) 46 (30) 0.412
Biochemical parameters
Total cholesterol, mg/dL 180 (154-213) 178 (152-212) 175 (146-206) 0.810*
LDL, mg/dL 110 (85-128) 113 (89-139) 109 (87-136) 0.793*
HDL, mg/dL 40 (33-48) 36 (31-42) 34 (29-39) <0.001*, b
Triglyceride, mg/dL 125 (92-201) 140 (105-190) 136 (91-197) 0.456*
Glucose, mg/dL 108.9±27.8 129.7±61.8 146.1±69.5 <0.001c
Creatinine, mg/dL 0.79±0.15 0.87±0.20 1.01±0.55 <0.001d
Hematologic parameters
Hemoglobin, g/dL 13.5±1.6 13.6±1.5 13.7±1.6 0.548
WBC, x10 /L 9
8.3±2.4 8.5±2.6 10.1±3.4 <0.001e
Platelet, x109/L 248±63 241±57 279±58 <0.001f
Lymphocyte, x10 /L 9
2.5±0.9 2.4±0.9 2.3±1.1 0.337
PLR 106.2±36.9 113.8±60.8 141.7±73.1 <0.001g
MPV, fL 8.3±1.3 8.3±1.5 8.4±1.4 0.715
HDL - high-density lipoprotein; LDL - low-density lipoprotein; MPV - mean platelet volume; N/S - non-significant, PLR- platelet-to-lymphocyte ratio; SD-standard deviation; WBC- white
blood cell count;
*Values are mean±SD; median (25-75 percentiles), or n (%). Comparison between three groups was performed with one-way ANOVA or *Kruskal-Wallis test.
For the results of post hoc tests or Mann-Whitney U test with Bonferroni correction, the significance levels are:
P1 (control vs. mild atherosclerosis); P2 (control vs. severe atherosclerosis); P3 (mild vs. severe atherosclerosis)
a
P1=0.450 (N/S); P2=0.001; P3=0.010
b
P1=0.006; P2<0.001; P3=0.027 (N/S due to Bonferroni correction)
c
P1=0.044; P2<0.001; P3=0.058 (N/S)
d
P1=0.317 (N/S); P2<0.001; P3=0.005
e
P1=0.797 (N/S); P2<0.001; P3<0.001
f
P1=0.509 (N/S); P2=0.004; P3<0.001
g
P1=0.729 (N/S); P2<0.001; P3=0.001

parameter was performed with post hoc tests in one-way (SPSS Inc, Chicago, Illinois, USA). A two-tailed p value <0.05
ANOVA and with Mann-Whitney U test after Bonferroni cor- was considered statistically significant.
rection in Kruskal-Wallis test. Correlations were assessed
using either Pearson’s correlation test or Spearman’s rank test Results
according to the distribution pattern of the variable. Independent
associations between Gensini score and independent vari- A total of 308 patients with coronary artery disease (men
ables were assessed by backward stepwise multiple linear 63%, mean age: 62±12 years) and 80 control subjects (59% male,
regression analysis by including all parameters showing p mean age: 59±10 years) with normal coronary arteries were
value of less than 0.1 on univariate analysis [patient age, PLR, enrolled in the study. Baseline demographic, biochemical, and
white blood cell (WBC), high-density lipoprotein (HDL), serum hematological characteristics of the groups are outlined in Table
creatinine]. Standardized β regression coefficients and their 1. The study groups were comparable in terms of gender and
significance from the multiple linear regression analysis were traditional coronary risk factors, while patients in the severe
reported. Receiver operating characteristic (ROC) curve analy- atherosclerosis group were older compared to the mild athero-
sis was used to determine the optimum cut-off level of pre- sclerosis group and controls (p=0.038 and p=0.033, respectively).
procedural PLR values to predict severe coronary atheroscle- Fasting serum glucose was significantly higher in the severe
rosis. Statistical analyses were performed using SPSS 16.0 atherosclerosis group than the mild atherosclerosis group
 Yüksel et al.
Anatol J Cardiol 2015; 15: 640-7 Platelet/lymphocyte ratio and CAD 643

ROC Curve
160 1.0

0.8
140

0.6

Sensitivity
120
PLR

0.4
100

0.2
Area under curve=0.645,
95% Cl: 0.587-0.703;
80 p<.001
Controls Mild Severe
Atherosclerosis Atherosclerosis 0.0
(Gensini (Gensini 0.0 0.2 0.4 0.6 0.8 1.0
score <25) score ≥25)
1-Specificity

Figure 1. Mean platelet-to-lymphocyte ratio (PLR) of controls and mild Figure 2. The receiver operating characteristic (ROC) curve analysis of
and severe atherosclerosis groups platelet-to-lymphocyte ratio for predicting severe atherosclerosis
(p=0.045) and controls (p<0.001); also, it was significantly higher
Table 2. Multivariate linear regression analysis to determine
in mild atherosclerosis than control subjects (p=0.033). The independent variables significantly associated with Gensini score
mean serum creatinine level of the severe atherosclerosis group
was significantly higher than that of the mild atherosclerosis Dependent Independent
variable variables B β t P VIF
and control groups (p=0.003 and p<0.001, respectively), while it
was comparable between the latter two groups (p=0.284). The Gensini Age 0.574 0.192 3.891 <0.001 1.112
severe atherosclerosis group had significantly lower HDL levels PLR 0.076 0.141 2.873 0.004 1.097
compared to controls (p<0.001), whereas it was similar between WBC 3.019 0.265 5.514 <0.001 1.055
the severe and mild atherosclerosis groups (p=0.137). Glucose 0.036 0.064 1.284 0.200 1.127
Among hematological parameters, hemoglobin levels were
Creatinine 8.678 0.097 1.953 0.052 1.123
similar between all three groups. WBC was significantly higher
HDL -0.505 -0.133 -2.787 0.006 1.044
in the severe atherosclerosis group than in the other two groups
HDL - high-density lipoprotein; PLR - platelet-to-lymphocyte ration; WBC - white blood
(p<0.001 for both), whereas it was similar between the mild ath- cell count. B - standardized β regression coefficients
erosclerosis and control groups (p=0.779).
The severe atherosclerosis group had significantly higher
severe atherosclerosis with a sensitivity of 61% and specificity
platelet counts compared to the mild atherosclerosis group
of 59% (area under ROC curve=0.645, 95% CI: 0.587-0.703;
(p<0.001) and controls (p=0.001), though platelet counts of the
p<0.001; Fig. 2). Also, fasting plasma glucose was positively cor-
last two groups were similar (p=0.671). Lymphocyte count was
related with Gensini score (r=0.256, p<0.001). This correlation
comparable between all three groups (p=0.337). PLR was signifi-
cantly higher in the severe atherosclerosis group compared to was valid after the exclusion of 92 diabetic cases from the study
the mild atherosclerosis (p<0.001) and control groups (p<0.001) population (r=0.221, p<0.001).
(142±73, 114±61, and 106±37 respectively, p<0.001 for ANOVA; Independent associations between Gensini score and
Fig.1). PLR was also significantly higher in patients with CAD independent variables were assessed by multivariate linear
(n=308) compared to controls (n=80) (128±68 vs. 106±37, p<0.001). regression analysis by including all parameters showing cor-
PLR was found to be correlated with age (r=0.285; p<0.001), relation with a p value of less than 0.1 on univariate analysis
CRP (r=0.245; p=0.001) (CRP was available for only 144 partici- (patient age, PLR, WBC, HDL, serum creatinine, fasting serum
pants), fasting serum glucose level (r=0.187; p=0.014), and neu- glucose). Pre-procedural PLR was independently associated
trophil count (r=0.922; p<0.001). Also, PLR values of patients with with Gensini score (β=0.141, p=0.004), together with WBC
CAD (n=308) correlated significantly with their Gensini scores (β=0.265, p<0.001), HDL (β=-0.133, p=0.006), and age (β=0.192,
(r=0.268, p<0.001). Using a cut-off level of 111, PLR predicted p<0.001; Table 2).
 Yüksel et al.
644 Platelet/lymphocyte ratio and CAD Anatol J Cardiol 2015; 15: 640-7

In addition, the patients with CAD (n=308) were further Total Gensini Scores
divided into three tertiles based upon their PLR values (lower 60
than 97.8, higher than 131.7, and those in between). The mean
Gensini score of patients in the high PLR tertile was signifi-
cantly higher than that of the middle and lower tertiles (p=0.002 50
and p<0.001, respectively), while mean Gensini scores of the
middle and lower PLR tertiles were similar (p=0.564; Fig. 3).
40

Discussion
30
The association between neutrophil-to-lymphocyte ratio, a
novel hematological indicator of inflammatory status in the body,
and various cardiac disorders has been studied extensively in 20
previous researches (23-30), including the prediction of severe
atherosclerosis in patients undergoing coronary angiography
(22, 31, 32). Similarly, PLR, a recent hematological parameter 10
indicating the inflammatory and prothrombotic state, has been
shown to be associated with poor prognosis in patients with
0
cardiovascular diseases; however, there are limited data about Low Middle High
the association between PLR and coronary artery disease PLR Tertile PLR Tertile PLR Tertile
severity.
In the present study, we found that high PLR level was inde- Figure 3. Mean Gensini scores of patients in each PLR tertile
PLR - platelet-to-lymphocyte ration
pendently associated with the severity of coronary atheroscle-
rosis. Patients with high pre-procedural PLR had significantly logic mechanisms underlying these findings are speculative.
higher Gensini scores, and there was a positive correlation However, it is reasonable that the lymphocyte count indicates an
between PLR values and Gensini scores of patients with CAD. early marker of physiologic stress and systemic inflammation. In
Additionally, this study showed that pre-procedural PLR >111 our study, the PLR values of participants were positively corre-
predicted severe atherosclerosis with a sensitivity of 61% and lated with CRP levels, and they showed a significant positive
specificity of 59%. PLR was independently associated with correlation with neutrophil count, supporting that PLR may indi-
Gensini score, together with age, WBC, and low HDL, in the mul- cate an inflammatory state in the body.
tivariate analysis. To our best knowledge, this study is the first Increased proliferation in megakaryocytic series and relative
report investigating the relationship between PLR and severity of thrombocytosis are two results of the ongoing inflammatory
atherosclerosis. state in the body, which results in a prothrombotic condition. It
The initiation, progression, and propagation of atherosclero- is reported that healthy adults with increased platelet counts
sis in the coronary arterial wall are influenced by multiple fac- have an augmented risk of thrombotic complications. The circu-
tors. Inflammation plays a crucial role at all stages of atheroscle- lating platelets may contribute to the initiation of atheromatous
rosis, from initiation through progression and, finally, in the plaque formation and trigger its complications (10). High platelet
thrombotic consequences of this disease (1, 22, 32, 33). and low lymphocyte counts in the circulation have been sug-
Lymphocytopenia is a common finding in chronic inflammatory gested to be risk indicators of worse cardiovascular outcomes
states because of increased lymphocyte apoptosis. Moreover, in previous studies (6-10, 34, 35). A recently developed new
the leukocyte production in bone marrow makes a shift towards prognostic marker, high PLR, integrates the predictive risk of
increasing neutrophils and decreasing lymphocytes in response these 2 parameters into 1. The advantage of PLR calculation
to stress. Lymphocytes represent a more convenient immune could be that it reflects the condition of both aggregation and
response, while neutrophils cause a destructive inflammatory inflammatory pathways, and it may be more valuable than either
reaction (7). The diagnostic and prognostic usefulness of a low platelet or lymphocyte count alone in the prediction of coronary
lymphocyte count was demonstrated in patients with acute atherosclerotic burden. Several new studies suggesting a rela-
coronary syndrome and stable CAD, respectively (6, 34). Low tionship between PLR and CAD have been published. Azab et al.
lymphocyte count was found to be significantly related with the (15) have shown that higher PLR values are associated with an
survival in a population-based analysis of patients with known increase in long-term all-cause mortality in patients admitted
or suspected stable CAD by Ommen et al. (6), and they suggest- with non-ST-segment elevation myocardial infarction (NSTEMI).
ed that low lymphocyte count is a potential addition to clinical In a recent study by Acar et al. (36), PLR was found to be inde-
prognostic models in patients with stable CAD and that it may pendently related with coronary collateral development in
have possible independent prognostic value. The pathophysio- patients with chronic total occlusions. In our previous study, we
 Yüksel et al.
Anatol J Cardiol 2015; 15: 640-7 Platelet/lymphocyte ratio and CAD 645

showed that high pre-procedural PLR value is a significant and not give an idea about the cause-and-effect relationship
independent predictor of no-reflow development in patients between PLR and coronary atherosclerosis. Although we
undergoing primary coronary angioplasty (16). In the present found significant associations, further large-scale, prospec-
study, we found that pre-procedural PLR value correlated posi- tive studies are needed to clarify and confirm the association
tively with the amount of coronary atherosclerotic burden in between PLR and coronary artery disease severity and
CAD patients. Also, we showed that patients with high pre-pro- whether it is a result or cause of severe atherosclerosis.
cedural PLR value are more likely to exhibit severe atheroscle- Despite these limitations, to our knowledge, this is one of the
rosis on coronary angiography. We found that PLR is indepen- first studies evaluating the relationship between PLR on
dently associated with Gensini score, with a β coefficient of admission and the severity of coronary atherosclerosis
0.141 in the multivariate analysis. It means that a 10-unit assessed by Gensini score.
increase in PLR value is associated with a 1.41-point increase in
Gensini score. Conclusion
Diabetes mellitus (DM), a systemic disease characterized by
hyperglycemia, is a well-known major risk factor for CAD. High In conclusion, we suggest that high PLR appears to be addi-
serum glucose is associated with earlier micro- and macro- tive to conventional risk factors and commonly used biomarkers
vascular complications of DM. Furthermore, it has been demon- in predicting severe atherosclerosis, and PLR value correlates
strated that fasting glucose may also be independently associ- positively with Gensini score. When we consider that PLR is a
ated with the development and severity of atherosclerosis in calculation of routine complete blood count parameters that
non-diabetic patients (37, 38). Patients in all 3 groups of our study does not require any additional expense and is a readily avail-
had similar DM rates, and fasting plasma glucose was positively able marker, it can help to identify individuals at high risk for
correlated with Gensini score. After the exclusion of 92 diabetic advanced CAD who might need a more aggressive therapeutic
cases from the study population, fasting plasma glucose was approach and closer clinical follow-up.
still correlated significantly with Gensini score. This indicates
that the initiation and progression of coronary atherosclerosis Conflict of interest: None declared.
accelerate with increases in fasting plasma glucose, even in
non-diabetic patients. So, our results are in line with the litera- Peer-review: Externally peer-reviewed.
ture.
HDL works for protection against CAD, and low plasma level Authorship contributions: Concept - M.Y., A.Y., H.K.; Design - M.Y.,
H.K., A.A., M.A., N.P.; Supervision - S.A., M.Y., M.Z.B.; Resource - S.A.;
of HDL is another important risk factor for the initiation and pro-
Material - M.Z.B., N.P., H.A., M.A.; Data collection and/or processing -
gression of coronary atherosclerosis. The inverse association
A.A., H.A., N.P., M.Z.B., M.Y.; Analysis and/or Interpretation - M.Y., M.O.,
between HDL level and coronary artery disease is strong and
H.K.; Literature search - M.Y., M.O.; Writing - M.Y.; Critical review - H.K.,
consistent in population-based studies (39). Thus, in our patient M.O., A.Y.
population, it is reasonable to find that plasma HDL level was
significantly lower in the severe atherosclerosis group. Our References
results were compatible with the results of a recent study by
Karan et al. (40), in which they showed a positive correlation of 1. Hansson GK. Inflammation, atherosclerosis, and coronary artery
fasting glucose and a negative correlation of HDL with the sever- disease. N Engl J Med 2005; 352: 1685-95. [CrossRef]
ity of coronary atherosclerosis. 2. Han YC, Yang TH, Kim DI, Jin HY, Chung SR, Seo JS, et al. Neutrophil
to lymphocyte ratio predicts long-term clinical outcomes in
Study limitations patients with ST-segment elevation myocardial infarction undergo-
ing primary percutaneous coronary intervention. Korean Circ J
Our study has some limitations, including the limited num- 2013; 43: 93-9. [CrossRef]
ber of study participants from a single center and the cross- 3. Tamhane UU, Aneja S, Montgomery D, Rogers EK, Eagle KA, Gurm
HS. Association between admission neutrophil to lymphocyte ratio
sectional design. The amount of coronary atherosclerosis
and outcomes in patients with acute coronary syndrome. Am J
was evaluated only by coronary angiography; since it dis-
Cardiol 2008; 102: 653-7. [CrossRef]
plays only the lumen of coronary arteries, it does not provide
4. Duffy BK, Gurm HS, Rajagopal V, Gupta R, Ellis SG, Bhatt DL.
extensive data about the coronary plaque burden. Therefore, Usefulness of an elevated neutrophil to lymphocyte ratio in pre-
further studies performed with intravascular ultrasound and/ dicting long-term mortality after percutaneous coronary interven-
or coronary CT may provide more accurate information about tion. Am J Cardiol 2006; 97: 993-6. [CrossRef]
the amount of coronary atherosclerosis. Lack of other estab- 5. Acanfora D, Gheorghiade M, Trojano L, Furgi G, Pasini E, Picone C,
lished inflammatory markers, such as C-reactive protein, et al. Relative lymphocyte count: a prognostic indicator of mortal-
interleukin-6, and tumor necrosis factor-a, is another limita- ity in elderly patients with congestive heart failure. Am Heart J
tion of the study. Another limitation of this study is that it does 2001; 142: 167-73. [CrossRef]
 Yüksel et al.
646 Platelet/lymphocyte ratio and CAD Anatol J Cardiol 2015; 15: 640-7

6. Ommen SR, Gibbons RJ, Hodge DO, Thomson SP. Usefulness of the 20. Gensini GG. A more meaningful scoring system for determining the
lymphocyte concentration as a prognostic marker in coronary severity of coronary heart disease. Am J Cardiol 1983; 51: 606.
artery disease. Am J Cardiol 1997; 79: 812-4. [CrossRef] [CrossRef]
7. Zouridakis EG, Garcia-Moll X, Kaski JC. Usefulness of the blood 21. Oishi Y, Wakatsuki T, Nishikado A, Oki T, Ito S. Circulating adhesion
lymphocyte count in predicting recurrent instability and death in molecules and severity of coronary atherosclerosis. Coron Artery
patients with unstable angina pectoris. Am J Cardiol 2000; 86: Dis 2000; 11: 77-81. [CrossRef]
449-51. [CrossRef] 22. Kaya H, Ertaş F, İslamoğlu Y, Kaya Z, Atılgan ZA, Çil H, et al. Association
8. Nikolsky E, Grines CL, Cox DA, Garcia E, Tcheng JE, Sadeghi M, et between neutrophil to lymphocyte ratio and severity of coronary
al. Impact of baseline platelet count in patients undergoing pri- artery disease. Clin Appl Thromb Hemost 2014; 20: 50-4. [CrossRef]
mary percutaneous coronary intervention in acute myocardial 23. Polat N, Yıldız A, Yüksel M, Bilik MZ, Aydın M, Acet H, et al.
infarction (from the CADILLAC trial). Am J Cardiol 2007; 99: 1055-61. Association of neutrophil-lymphocyte ratio with the presence and
[CrossRef] severity of rheumatic mitral valve stenosis. Clin Appl Thromb
9. Iijima R, Ndrepepa G, Mehilli J, Bruskina O, Schulz S, Schomig A, et Hemost 2013 Dec 11. Epub ahead of print.
al. Relationship between platelet count and 30-day clinical out- 24. Karavelioğlu Y, Karapınar H, Yüksel M, Memiç K, Sarak T, Kurt R, et
comes after percutaneous coronary interventions. Pooled analysis al. Neutrophil to lymphocyte ratio is predictor of atrial fibrillation
of four ISAR trials. Thromb Haemost 2007; 98: 852-7. recurrence after cardioversion with amiodarone. Clin Appl Thromb
10. Thaulow E, Erikssen J, Sandvik L, Stormorken H, Cohn PF. Blood Hemost 2014 Jan 14. Epub ahead of print.
platelet count and function are related to total and cardiovascular 25. Yıldız A, Kaya H, Ertaş F, Oylumlu M, Bilik MZ, Yüksel M, et al.
death in apparently healthy men. Circulation 1991; 84: 613-7. Association between neutrophil to lymphocyte ratio and pulmo-
[CrossRef] nary arterial hypertension. Turk Kardiyol Dern Ars 2013; 41:
11. Smith RA, Ghaneh P, Sutton R, Raraty M, Campbell F, Neoptolemos 604-9. [CrossRef]
JP. Prognosis of resected ampullary adenocarcinoma by preopera- 26. Yıldız A, Oylumlu M, Yüksel M, Aydın M, Polat N, Acet H, et al. The
tive serum CA19-9 levels and platelet-lymphocyte ratio. J Association between the neutrophil-to-lymphocyte ratio and the
Gastrointest Surg 2008; 12: 1422-8. [CrossRef] presence of ventricular premature contractions in young adults. Clin
12. Smith RA, Bosonnet L, Raraty M, Sutton R, Neoptolemos JP, Appl Thromb Hemost 2013 Nov 6. Epub ahead of print. [CrossRef]
Campbell F, et al. Preoperative platelet-lymphocyte ratio is an inde- 27. Acet H, Ertaş F, Akıl MA, Oylumlu M, Polat N, Yıldız A, et al. New
pendent significant prognostic marker in resected pancreatic inflammatory predictors for non-valvular atrial fibrillation: echo-
ductal adenocarcinoma. Am J Surg 2009; 197: 466-72. [CrossRef] cardiographic epicardial fat thickness and neutrophil to lympho-
cyte ratio. Int J Cardiovasc Imaging 2014; 30: 81-9. [CrossRef]
13. Proctor MJ, Morrison DS, Talwar D, Balmer SM, Fletcher CD,
28. Arıbaş A, Akıllı H, Gül EE, Kayrak M, Demir K, Duman C, et al. Can
O’Reilly DS, et al. A comparison of inflammation-based prognostic
neutrophil/lymphocyte ratio predict recurrence of non-valvular
scores in patients with cancer. A Glasgow Inflammation Outcome
atrial fibrillation after cardioversion? Anatol J Cardiol 2013; 13: 123-
Study. Eur J Cancer 2011; 47: 2633-41. [CrossRef]
30.
14. Gary T, Pichler M, Belaj K, Hafner F, Gerger A, Froehlich H, et al.
29. Koza Y, Taş MH, Şimşek Z, Ateş ES. The relationship between
Platelet-to-lymphocyte ratio: a novel marker for critical limb isch-
neutrophil-to-lymphocyte ratio and coronary artery disease.
emia in peripheral arterial occlusive disease patients. PloS One
Anatol J Cardiol 2014; 14: 99-101.
2013; 8: e67688. [CrossRef]
30. Yıldız A, Yüksel M, Oylumlu M, Polat N, Akıl MA, Acet H. The asso-
15. Azab B, Shah N, Akerman M, McGinn JT Jr. Value of platelet/lym-
ciation between the neutrophil/lymphocyte ratio and functional
phocyte ratio as a predictor of all-cause mortality after non-ST-
capacity in patients with idiopathic dilated cardiomyopathy. Anatol
elevation myocardial infarction. J Thromb Thrombolysis 2012; 34: J Cardiol doi: 10.5152/akd.2014.5131. [CrossRef]
326-34. [CrossRef] 31. Arbel Y, Finkelstein A, Halkin A, Birati EY, Revivo M, Zuzut M, et al.
16. Yıldız A, Yüksel M, Oylumlu M, Polat N, Akyüz A, Acet H, et al. The Neutrophil/lymphocyte ratio is related to the severity of coronary
Utility of the platelet-lymphocyte ratio for predicting no reflow in artery disease and clinical outcome in patients undergoing angiog-
patients with ST-segment elevation myocardial infarction. Clin raphy. Atherosclerosis 2012; 225: 456-60. [CrossRef]
Appl Thromb Hemost 2014 Jan 14. Epub ahead of print. [CrossRef] 32. Sönmez O, Ertaş G, Bacaksız A, Taşal A, Erdoğan E, Asoğlu E, et al.
17. Temiz A, Gazi E, Güngör Ö, Barutçu A, Altun B, Bekler A, et al. Relation of neutrophil-to-lymphocyte ratio with the presence and
Platelet/lymphocyte ratio and risk of in-hospital mortality in complexity of coronary artery disease: an observational study.
patients with ST-elevated myocardial infarction. Med Sci Monit Anatol J Cardiol 2013; 13: 662-7.
2014; 20: 660-5. [CrossRef] 33. Libby P, Ridker PM, Maseri A. Inflammation and atherosclerosis.
18. Friedewald WT, Levy RI, Fredrickson DS. Estimation of the concen- Circulation 2002; 105: 1135-43. [CrossRef]
tration of low-density lipoprotein cholesterol in plasma, without 34. Thomson SP, Gibbons RJ, Smars PA, Suman VJ, Pierre RV, Santrach
use of the preparative ultracentrifuge. Clin Chem 1972; 18: 499-502. PJ, et al. Incremental value of the leukocyte differential and the
19. Ryan TJ, Faxon DP, Gunnar RM, Kennedy JW, King SB 3rd, Loop FD, rapid creatine kinase-MB isoenzyme for the early diagnosis of
et al. Guidelines for percutaneous transluminal coronary angio- myocardial infarction. Ann Intern Med 1995; 122: 335-41. [CrossRef]
plasty. A report of the American College of Cardiology/American 35. Ommen SR, Hodge DO, Rodeheffer RJ, McGregor CG, Thomson SP,
Heart Association Task Force on Assessment of Diagnostic and Gibbons RJ. Predictive power of the relative lymphocyte concentration in
Therapeutic Cardiovascular Procedures (Subcommittee on patients with advanced heart failure. Circulation 1998; 97: 19-22. [CrossRef]
Percutaneous Transluminal Coronary Angioplasty). Circulation 36. Acar G, Kalkan ME, Avcı A, Alizade E, Tabakçı MM, Toprak C, et
1988; 78: 486-502. [CrossRef] al. The relation of platelet-lymphocyte ratio and coronary collat-
 Yüksel et al.
Anatol J Cardiol 2015; 15: 640-7 Platelet/lymphocyte ratio and CAD 647

eral circulation in patients with stable angina pectoris and 39. Stone NJ, Robinson J, Lichtenstein AH, Bairey Merz CN, Lloyd-
chronic total occlusion. Clin Appl Thromb Hemost 2013 Oct 18. Jones DM, Blum CB, et al. 2013 ACC/AHA Guideline on the
[CrossRef] Treatment of Blood Cholesterol to Reduce Atherosclerotic
37. Nielson C, Lange T, Hadjokas N. Blood glucose and coronary artery Cardiovascular Risk in Adults: A Report of the American College of
disease in nondiabetic patients. Diabetes Care 2006; 29: 998-1001. Cardiology/American Heart Association Task Force on Practice
[CrossRef] Guidelines. J Am Coll Cardiol 2013 Nov 7.
38. Yan Q, Gu WQ, Hong J, Zhang YF, Su YX, Gui MH, et al. Coronary angio- 40. Karan A, Güray Y, Güray U, Demirkan B, Astan R, Baysal E, et al.
graphic studies of impaired glucose regulation and coronary artery Mean platelet volume and the extent of coronary atherosclerosis
disease in Chinese nondiabetic subjects. Endocrine 2009; 36: 457-63. in patients with stable coronary artery disease. Turk Kardiyol Dern
[CrossRef] Ars 2013; 41: 45-50. [CrossRef]