Abstract
This study analyzes the recurrence of coronary events and their relationship with the monocyte to high-density lipoprotein cholesterol ratio (MHR) and neutrophil to lymphocyte ratio (NLR) in elderly patients with coronary stent implantation. A retrospective analysis was performed on 136 cases elderly patients who received coronary stent implantation in ShengLi Oil Field Central Hospital from December 2019 to June 2023. According to the recurrence of coronary events within 1 year after surgery, patients were divided into recurrence group and non-recurrence group. The MHR and NLR values of the 2 groups were compared. Spearman correlation was used to analyze the correlation between MHR and NLR and postoperative coronary event recurrence in elderly patients with coronary stent implantation, and the predictive value of MHR and NLR values on postoperative coronary event recurrence was analyzed using receiver operating characteristic. The levels of MHR and NLR in recurrent group were higher than those in non-recurrent group (P < .05). Spearman correlation analysis showed that the levels of MHR and NLR were positively correlated with the recurrence of coronary events in elderly patients after coronary stent implantation (r = 0.342, 0.412, P < .05). Receiver operating characteristic curve showed that the area under curve of MHR and NLR combined prediction of postoperative coronary event recurrence was 0.972, the sensitivity was 97.14%, the specificity was 90.10%, and the combined prediction efficiency was better than that of each indicator alone (P < .05). The levels of MHR and NLR are closely related to the recurrence of postoperative coronary events in elderly patients with coronary stent implantation. Early determination of MHR and NLR levels can predict the recurrence of postoperative coronary events in elderly patients with coronary stent implantation.
Keywords: coronary stent implantation, correlation, monocyte to HDL cholesterol ratio, neutrophil to lymphocyte ratio, postoperative coronary events occurred again, predictive value
1. Introduction
While coronary stent implantation alleviates angina and improves myocardial perfusion in elderly patients,[1,2] its long-term efficacy remains compromised by disproportionately high rates of coronary event recurrence in this population – estimated at 25% to 40% within 2 years post-procedure.[3] This persistent vulnerability stems from unresolved clinical challenges: current risk stratification tools fail to account for age-specific pathophysiology. Traditional models underestimate recurrence risk in elderly patients due to unaddressed factors like immunosenescence, multimorbidity burden, and complex coronary anatomy.[4] This predictive shortfall impedes targeted prevention strategies. Therefore, seeking indicators related to the recurrence of coronary events in elderly patients after coronary stent implantation has important clinical value for providing early warning, optimizing treatment plans, and improving patients’ quality of life.
Monocyte to high-density lipoprotein cholesterol ratio (MHR), as an indicator of inflammation and lipid metabolism in vivo, has attracted more and more attention in the study of cardiovascular diseases in recent years.[5] Monocytes are one of the key cells involved in atherosclerosis formation and inflammation, while high-density lipoprotein cholesterol has anti-inflammatory, antioxidant and reverse cholesterol transport effects. Therefore, the level of MHR may reflect the imbalance between inflammation and lipid metabolism in the body.[6] Neutrophil to lymphocyte ratio (NLR), as another new inflammatory index, has been widely used in clinical practice because of its simplicity and ease of obtaining. Neutrophils are one of the main cells in the body’s inflammatory response, while lymphocytes are involved in immune regulation. Hence, NLR can reflect the balance of inflammation and immune status in the body.[7]
In recent years, MHR and NLR have attracted much attention in the research of cardiovascular diseases. Studies have shown that MHR and NLR can not only reflect the inflammatory state of the body, but also are closely related to the severity of coronary artery disease and the risk of cardiovascular events.[8,9] However, the role and mechanism of MHR and NLR in the recurrence of coronary events after coronary stent implantation in elderly patients are still lacking. Therefore, this study focuses on analyzing the relationship between MHR and NLR and the recurrence of coronary events in elderly patients with coronary stent implantation, and evaluating the value of the combination of MHR and NLR in predicting the recurrence of coronary events in elderly patients with coronary stent implantation.
2. Research methods and procedures
2.1. Ethical approval of the research protocol
Ethical approval from the ShengLi Oil Field Central Hospital Review Board and written informed consent from patients were obtained prior to participation in this study.
2.2. General information
The elderly patients with coronary heart disease who received coronary artery stenting in our hospital from December 2019 to June 2023 were selected as the study subjects for retrospective analysis. Inclusion criteria: all patients met the diagnostic criteria for coronary heart disease[10]; patients are over 60 years old; patients who had indications for coronary stent implantation; patients who completed 1 year postoperative follow-up; patients who had complete basic data, blood routine and other laboratory examination indicators. Exclusion criteria: patients with severe heart, lung, liver and renal insufficiency; patients who had mental illness, impairment of consciousness or speech; patients who had severe infectious diseases, systemic infections and basic thyroid gland; patients participating in other clinical trials; patients with cerebral infarction, cerebral hemorrhage and other vascular diseases; patients with congenital heart disease. According to the above criteria, 136 patients were included with median age of 70 years old and grouped to recurrence group (n = 35) and non-recurrence group (n = 101) based on the recurrence of coronary events 1 year after surgery.
2.3. Evaluation of recurrent coronary events
The recurrence of postoperative coronary events was determined according to the results of coronary angiography, symptom recurrence and laboratory indicators within 1 year after surgery. The specific evaluation criteria are as follows: Angiographically confirmed restenosis (≥50% stenosis in target vessel) or de novo lesion; recurrent angina (Canadian cardiovascular society angina class ≥ II) with objective evidence of ischemia (electrocardiogram changes, troponin elevation, or perfusion defects); unplanned revascularization.
2.4. Data collection
Clinical data of patients, including general data, medical history, laboratory test indicators such as preoperative blood routine, postoperative coronary events, etc, were collected using the general data questionnaire made by the hospital, and preoperative MHR and NLR values were calculated.
2.5. Statistical methods
SPSS22.0 software (IBM Corporation, Armonk) was used to process the data, MHR, NLR and other measurement data were in line with normal distribution, expressed as mean ± standard deviation, and t test was performed for comparison between groups. For non-normally distributed continuous data, values are presented as the median with interquartile range (P25, P75). Between-group comparisons were performed using the Mann–Whitney U test. The count data were represented by n and %, and spearman rank correlation was used to analyze the correlation between MHR and NLR levels and postoperative coronary event recurrence. Logistic binary regression analysis was used to fit the prediction probability of MHR and NLR combined prediction model. Receiver operating characteristic (ROC) curve was developed using Medcalc software to analyze the value of MHR and NLR in predicting the recurrence of coronary events after coronary stent implantation in elderly patients, and the Delong test was used to compare the area under curve (AUC) between individual prediction and combined prediction of each index, P < .05 was the cutoff value for judging statistical significance.
3. Results
3.1. Baseline characteristics
No visible differences in sex, age, body mass index, basic diseases, and other baseline characteristics were observed between 2 groups (P > .05; Table 1).
Table 1.
Clinical characteristics of patients in the 2 groups [( ± s), n (%)].
| Variable | Recurrence group (n = 35) | Non-recurrence group (n = 101) | t/χ2‐values | P values |
|---|---|---|---|---|
| Sex | 0.076 | .783 | ||
| Male | 20 (57.14) | 55 (54.46) | ||
| Female | 15 (42.86) | 46 (45.54) | ||
| Age (yr) | 70.74 ± 6.78 | 71.33 ± 6.53 | 0.456 | .649 |
| Body mass index (kg/m2) | 23.23 ± 2.08 | 23.56 ± 2.34 | 0.739 | .461 |
| Basic diseases | ||||
| Hypertensive | 17 (48.57) | 36 (35.64) | 1.827 | .177 |
| Diabetes | 10 (28.57) | 31 (30.69) | 0.056 | .814 |
| Primary coronary heart disease type | 0.484 | .785 | ||
| Unstable angina pectoris | 10 (28.57) | 35 (34.65) | ||
| ST-elevation myocardial infarction | 12 (34.29) | 30 (29.70) | ||
| Non-ST elevation myocardial infarction | 13 (37.14) | 39 (35.64) | ||
| Support length (mm) | 24.85 ± 4.39 | 25.12 ± 5.26 | 0.272 | .786 |
| Educational level | 0.539 | .463 | ||
| Above high school | 12 (34.29) | 28 (37.72) | ||
| High school and below | 23 (65.71) | 73 (72.28) | ||
| Drinking history | 20 (57.14) | 38 (38.61) | 3.633 | .057 |
| Smoking history | 17 (48.57) | 43 (39.60) | 0.859 | .354 |
3.2. The serum levels of MHR and NLR in 2 group
The MHR and NLR in recurrence group were apparently higher than non-recurrence group (P < .05; Table 2).
Table 2.
Comparison of MHR and NLR between 2 groups ( ± s).
| Groups | MHR | NLR |
|---|---|---|
| Recurrence group (n = 35) | 8.62 ± 2.37 | 3.47 ± 0.89 |
| Non-recurrence group (n = 101) | 6.98 ± 1.72 | 2.64 ± 0.68 |
| t‐values | 4.387 | 5.726 |
| P‐values | <.001 | <.001 |
MHR = monocyte to high-density lipoprotein cholesterol ratio, NLR = neutrophil to lymphocyte ratio.
3.3. Correlation of MHR and NLR levels with recurrence of coronary events after coronary stent implantation in elderly patients
Spearman rank correlation analysis showed the levels of MHR and NLR were positively correlated with the recurrence of coronary events after coronary stent implantation in elderly patients (r = 0.342, 0.412, P < .05; Table 3, Figs. 1 and 2).
Table 3.
Correlation of MHR and NLR levels with recurrence of coronary events.
| Recurrence of coronary events | Indexes | r | P values |
|---|---|---|---|
| MHR | 0.342 | <.001 | |
| NLR | 0.412 | <.001 |
MHR = monocyte to high-density lipoprotein cholesterol ratio, NLR = neutrophil to lymphocyte ratio.
Figure 1.
Correlation of MHR levels with recurrence of coronary events. MHR = monocyte to high-density lipoprotein cholesterol ratio.
Figure 2.
Correlation of NLR levels with recurrence of coronary events. NLR = neutrophil to lymphocyte ratio.
3.4. Predictive value of MHR and NLR in the recurrence of coronary events after coronary stent implantation in elderly patients
Taking the recurrence of coronary artery events as the dependent variable and MHR, NLR, age, sex, and hypertension as independent variables, logistic regression analysis was conducted to construct a predictive model: logit(P) = −10.175 + .517 × MHR + 1.664 × NLR (Table 4). Based on the prediction probability of the constructed prediction model, the ROC curve of the combined prediction of MHR and NLR levels for the recurrence of coronary artery events after coronary stent implantation was plotted. As can be seen from the ROC curve, the AUC of MHR and NLR combined prediction of recurrence of coronary events after coronary stent implantation in elderly patients was 0.972, which was significantly higher than that of individual indicator diagnosis (P < .05; Table 5 and Fig. 3).
Table 4.
Model construction for the combined prediction of MHR and NLR for the recurrence of coronary artery events after coronary stent implantation.
| Variables | B | SE | Walds | P values | OR | (95% CI) |
|---|---|---|---|---|---|---|
| MHR | 0.517 | 0.139 | 13.924 | <.001 | 1.678 | 1.278–2.202 |
| NLR | 1.664 | 0.370 | 20.239 | <.001 | 5.278 | 2.557–10.895 |
| Age | 0.092 | 0.161 | 0.327 | .568 | 1.096 | 0.800–1.503 |
| Sex | −0.164 | 0.120 | 1.868 | .172 | 0.849 | 0.671–1.074 |
| Hypertension | 0.156 | 0.135 | 1.335 | .249 | 1.169 | 0.897–1.523 |
| Constant | −10.175 | 1.860 | 29.929 | <.001 | – | – |
CI = confidence interval, MHR = monocyte to high-density lipoprotein cholesterol ratio, NLR = neutrophil to lymphocyte ratio, OR = odds ratio, SE = standard error.
Table 5.
Predictive value of MHR and NLR in the recurrence of coronary events.
| Variables | AUC | Associated criterion | Standard error | P values | Sensitivity | Specificity | 95% CI | Youden index |
|---|---|---|---|---|---|---|---|---|
| MHR | 0.726 | 8.2 | 0.057 | <.001 | 68.57 | 74.26 | 0.643–0.799 | 0.428 |
| NLR | 0.772 | 3.7 | 0.048 | <.001 | 45.71 | 94.06 | 0.692–0.839 | 0.398 |
| MHR combined with NLR | 0.972 | – | 0.012 | <.001 | 97.14 | 90.10 | 0.928–0.992 | 0.872 |
AUC = area under curve, MHR = monocyte to high-density lipoprotein cholesterol ratio, NLR = neutrophil to lymphocyte ratio.
Figure 3.
ROC curve of MHR and NLR for prediction of recurrence of coronary events after coronary stent implantation in elderly patients. MHR = monocyte to high-density lipoprotein cholesterol ratio, NLR = neutrophil to lymphocyte ratio, ROC = receiver operating characteristic.
4. Discussion
Coronary heart disease is caused by lipid deposition, fibrous tissue hyperplasia and calcosis in the intima of the coronary artery, leading to thickening of the vascular wall and narrowing of the lumen, thus leading to insufficient myocardial blood supply, which involves complex inflammatory reactions, abnormal lipid metabolism, impaired vascular endothelial function and other links.[11,12] As an important means for the treatment of coronary heart disease, coronary stent implantation is based on the principle that metal stents are sent into the narrow coronary artery segment through interventional means, and the support of the stent is used to dilate the narrow vascular wall, restore the patency of the lumen, and thus improve the blood perfusion of the myocardium.[13] However, there is still a risk of recurrence of coronary events after coronary stent implantation, which is mainly due to the fact that stent restenosis, thrombosis, intimal hyperplasia and patients’ own risk factors have not been effectively controlled.[14] In view of the serious consequences of recurrence of postoperative coronary events, early prediction is particularly important to guide clinical prevention and treatment strategies.
Traditional risk prediction models remain fundamentally constrained by their reactive nature-relying on clinically evident manifestations, late-stage imaging findings, and standard biochemical markers that often only capture established pathology. This inherent lag creates a critical prevention gap: actionable identification of high-risk patients occurs after significant disease progression, particularly problematic in elderly populations where compensatory mechanisms mask early deterioration. While MHR and NLR offer theoretical promise as proactive inflammatory biomarkers for cardiovascular risk stratification,[15,16] their translation into reliable clinical tools faces unaddressed hurdles: current evidence predominantly establishes association rather than causality or specific pathophysiological roles for MHR/NLR in post-stent event recurrence. In Toprak’s study,[17] the influence of inflammatory indicators such as MHR and NLR on coronary circulation in patients with stable coronary heart disease was analyzed. The results showed that serum MHR and NLR levels in patients with poor coronary collateral circulation were significantly higher than those in patients with good coronary collateral circulation, suggesting that MHR and NLR could be used as prognostic indicators for patients with coronary heart disease. Mohanty et al analyzed the relationship between novel hematological indicators (MHR, NLR) and the severity of coronary artery disease in patients with coronary heart disease, and the results showed that MHR and NLR were predictors of the severity of coronary artery disease in patients with coronary heart disease.[18]
In this study, we analyzed the relationship between MHR and NLR and the recurrence of coronary events in elderly patients after coronary stent implantation, and the results showed that the levels of MHR and NLR in recurrence group were apparently higher than those in non-recurrence group, suggesting that MHR and NLR may be closely related to the recurrence of coronary events in elderly patients after coronary stent implantation. Further correlation analysis showed that the levels of MHR and NLR were positively correlated with the recurrence of postoperative coronary events, revealing that the higher the level of MHR and NLR, the higher the risk of recurrence of postoperative coronary events. The recurrence mechanism of coronary events in elderly patients with coronary stent implantation includes endothelial cell injury and repair, inflammatory response and thrombosis. This may be attributed to the fact that the increase in MHR reflects the decrease in the amount of high density lipoprotein cholesterol and the increase in monocytes in the body. High density lipoprotein cholesterol plays a key role in reversing cholesterol transport and preventing lipid deposition in the blood vessel wall. Thus, the decrease in the amount of high density lipoprotein cholesterol can weaken the regulation of lipid metabolism and promote the progression of atherosclerosis.[19] High levels of monocytes may damage the function of vascular endothelial cells through the release of inflammatory mediators, resulting in increased vascular permeability and enhanced platelet adhesion and aggregation ability, thus promoting thrombosis and plaque rupture.[20] However, the increased level of NLR means the increase of neutrophils and the decrease of lymphocytes. In atherosclerotic plaques, the increase of neutrophils can aggravate the inflammatory response in plaques and increase the instability of plaques. Lymphocytes play a regulatory role in the immune response, and a decrease in their number may mean that the body’s ability to regulate the inflammatory response is reduced, leading to overactivation and persistence of the inflammatory response.[21] Therefore, the high level of NLR indicates that the body is in a state of continuous inflammatory response and the regulation of immune response is unbalanced, thus increasing the risk of recurrence of postoperative coronary events. In Chung’s[22] study also confirmed that NLR was closely related to adverse coronary events after coronary stenting, which was similar to the results of this study. In this study, ROC curve was used to evaluate the predictive value of MHR and NLR for the recurrence of coronary events after coronary stenting in elderly patients. The results showed that the AUC of MHR and NLR for predicting the recurrence of coronary events after coronary stenting in elderly patients was 0.726 and 0.772, respectively, the sensitivity was 68.57% and 45.71%, respectively, and the specificity was 74.26% and 94.06%, respectively. While the AUC of the combined prediction of MHR and NLR was 0.972, the sensitivity and specificity were 97.14%, 90.10%, suggesting that the combined prediction efficiency of MHR and NLR was better than that of each index alone. Based on these findings, clinicians should fully recognize the importance of MHR and NLR in predicting the risk of recurrence of coronary events after coronary stenting in elderly patients. During postoperative follow-up, patients’ MHR and NLR levels should be regularly monitored to detect potential risks in a timely manner. Meanwhile, a personalized treatment strategy should be developed based on the patient’s MHR and NLR levels. While our 1-year follow-up period captures early stent-related complications (e.g., acute/subacute thrombosis, neointimal hyperplasia), it may miss late adverse events occurring beyond 12 months, including: very late stent thrombosis (incidence peak at 2–3 years), neoatherosclerosis (typically develops > 1 year postimplantation), late catch-up restenosis (especially with drug-eluting stents). This limitation stems from difficulties in clinical follow-up, limitations in research periods, etc. Future studies with extended follow-up (3–5 years) are warranted to evaluate long-term performance.
5. Conclusion
In summary, we initially discovered elderly patients with coronary stent implantation have a higher risk of recurrence of coronary events after surgery, which is closely related to the levels of MHR and NLR. Early determination of MHR and NLR levels may provide reference value for predicting the recurrence of coronary events in elderly patients with coronary stent implantation after surgery. However, the AUC value of the prediction model in this study was as high as 0.972. In the case of a small sample size and the lack of external validation, we cannot easily accept the conclusion of its high predictive value. On the contrary, we should maintain a cautious attitude and regard this research as a preliminary exploratory study to provide clues and directions for subsequent in-depth research. In the future, external validation cohorts should be actively sought for independent validation to confirm the true predictive performance of this biomarker.
Despite these findings, the study is not without flaws. This study was a single-center retrospective analysis with limited sample size. In addition, the follow-up time of this study may not be long enough to fully assess the long-term occurrence of coronary events, so follow-up time can be extended in subsequent studies to provide more comprehensive and accurate data. And a large number of multi-center prospective studies with large sample size are still needed to verify and promote the results of this study, so as to provide a more scientific basis for the early prediction of the recurrence of coronary events after coronary stent implantation in elderly patients, and further improve the prognosis of elderly patients.
Acknowledgments
We would like to acknowledge the everyone for their helpful contributions on this paper.
Author contributions
Conceptualization: Chunxiao Zhang.
Data curation: Chunxiao Zhang.
Formal analysis: Chunxiao Zhang, Sai Wang.
Funding acquisition: Sai Wang.
Investigation: Chunxiao Zhang.
Methodology: Chunxiao Zhang.
Project administration: Sai Wang.
Resources: Chunxiao Zhang, Sai Wang.
Software: Chunxiao Zhang.
Supervision: Chunxiao Zhang, Sai Wang.
Validation: Chunxiao Zhang.
Visualization: Chunxiao Zhang, Sai Wang.
Writing – original draft: Chunxiao Zhang.
Writing – review & editing: Chunxiao Zhang, Sai Wang.
Abbreviations:
- AUC
- area under curve
- HDL-C
- high-density lipoprotein cholesterol
- MHR
- monocyte to high-density lipoprotein cholesterol ratio
- NLR
- neutrophil to lymphocyte ratio
- ROC
- receiver operating characteristic.
All of the authors have consented to publish this research.
The ethic approval was reviewed and approved from Shengli Oilfield Central Hospital and informed written consent from all of the patients.
The authors have no funding and conflicts of interest to disclose.
The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.
How to cite this article: Zhang C, Wang S. A retrospective study on the correlation between serum MHR, NLR and recurrence of coronary events after coronary stent implantation in elderly patients. Medicine 2025;104:46(e44675).
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