Robert Capodilupo

Utility of the Neutrophil to Lymphocyte Ratio in Predicting Long-Term Outcomes in Acute Decompensated Heart Failure

Neutrophil-to-lymphocyte ratio (NLR) has been associated with poor outcomes in patients with acute coronary syndromes. However, its role for risk stratification in acute decompensated heart failure (ADHF) has not been well described. In this study, 1,212 consecutive patients admitted with ADHF who had total white blood cell and differential counts measured at admission were analyzed. The patients were divided into tertiles according to NLR. The association between NLR and white blood cell types with all-cause mortality was assessed using Cox regression analysis. During a median follow-up period of 26 months, a total of 284 patients (23.4%) had died, and a positive trend between death and NLR was observed; 32.8%, 23.2%, and 14.2% of deaths occurred in the higher, middle, and lower tertiles, respectively (p <0.001). After adjusting for confounding factors, multivariate analysis demonstrated that patients in the higher NLR tertile had the highest mortality (adjusted hazard ratio 2.23, 95% confidence interval (CI) 1.63 to 3.02, p <0.001), followed by those in the middle tertile (adjusted hazard ratio 1.62, 95% CI 1.16 to 2.23, p = 0.001). Furthermore, tertiles of NLR were superior in predicting long-term mortality compared with white blood cell, neutrophil, and relative lymphocyte counts. Patients in the higher NLR tertile (adjusted odds ratio 3.46, 95% CI 2.11 to 5.68, p <0.001) had a significantly higher 30-day readmission rate. In conclusion, higher NLR, an emerging marker of inflammation, is associated with an increased risk for long-term mortality in patients admitted with ADHF. NLR is a readily available inexpensive marker to aid in the risk stratification of patients with ADHF.

Usefulness of Acute Delirium as a Predictor of Adverse Outcomes in Patients >65 Years of Age With Acute Decompensated Heart Failure

Delirium is an acute confusional state that is very prevalent in older patients hospitalized with acute decompensated heart failure (ADHF). The association between delirium and ADHF outcome has not been well described. We analyzed 883 consecutive patients >65 years of age admitted with ADHF. Acute delirium was diagnosed based on the Confusion Assessment Method. Delirious patients (total n = 151) had an increased in-hospital all-cause death compared to nondelirious patients (n = 17, 11%, vs n = 45, 6%; adjusted odds ratio [OR] 1.93, 95% confidence interval [CI] 1.07 to 3.48, p = 0.02). Of those surviving to discharge (n = 821), on multivariable logistic regression analysis, delirium was independently associated with increased risk of 30-day (adjusted OR 4.24, 95% CI 2.77 to 6.47, p <0.001) and 90-day (adjusted OR 3.72, 95% CI 2.51 to 5.54, p <0.001) rehospitalizations for ADHF and higher nursing home placement (adjusted OR 2.70, 95% CI 1.59 to 5.30, p <0.001) after adjusting for age, gender, cardiac risk factors, dementia, activities of daily living, instrumental activities of daily living, coronary artery disease, atrial fibrillation, left ventricular ejection fraction, angiotensin-converting enzyme inhibitor and/or angiotensin receptor blocker, β blockers, Charlson co-morbidity index, and other potential confounders. Furthermore, delirium was strongly associated with 90-day all-cause mortality in patients discharged from the hospital (adjusted hazard ratio 2.10, CI 1.53 to 2.88, p <0.0001). In conclusion, acute delirium serves as an important prognostic determinant of in-hospital and posthospital discharge outcomes including increased ADHF readmission risk in older hospitalized patients with ADHF. Thus, delirium plays an important role in the risk stratification and prognosis of patients with ADHF.