Neutrophil-to-Lymphocyte Ratio for Risk Stratification in Acute Myocarditis Across the Left Ventricular Ejection Fraction Spectrum
Year: 2025
Type: article
Study design: Observational Study
Abstract: AIMS: Acute myocarditis (AM) is a heterogeneous clinical condition. Several classification models have been proposed to predict adverse clinical outcomes, but risk stratification remains challenging, particularly for patients presenting with preserved left ventricular ejection fraction (LVEF). Neutrophil-to-lymphocyte ratio (NLR) is a useful tool for risk stratification in patients with AM. This study aimed to compare the predictive accuracy of available risk stratification models, including NLR, for identifying patients with AM at increased risk of adverse events. METHODS AND RESULTS: The study included 1150 patients with biopsy- or cardiac magnetic resonance (CMR)-proven AM from 10 hospitals in six countries. Baseline clinical, laboratory, echocardiographic and CMR data, and clinical outcomes, were collected. The population was divided into four groups based on published models of high-risk AM (complicated, fulminant, high-risk, and NLR ≥4). The primary outcome was all-cause mortality and heart transplantation. During a median follow-up of 228 weeks (interquartile range 114-339), 63 events occurred in 60 patients (5.2%) who experienced the primary outcome. NLR (area under the curve [AUC] 0.72) performed similarly to complicated (AUC 0.73) and high-risk definitions (AUC 0.73) for the prediction of adverse events, while the fulminant classification showed significantly inferior predictive accuracy (AUC 0.62, p = 0.02). Moreover, among patients with preserved LVEF (≥50%) at presentation, NLR showed superior prognostic value (AUC 0.73; complicated: 0.52, p = 0.001; high-risk: 0.52, p = 0.002). Multivariable analysis confirmed that each classification was independently associated with the primary outcome. However, the NLR model showed better predictive performance compared to the other models among patients with LVEF ≥50%. CONCLUSIONS: While traditional definitions of high-risk AM remain valuable, NLR ≥4 is a simple and cost-effective marker that aids in risk stratification. NLR ≥4 is particularly robust in patients with preserved LVEF, supporting its use across the LVEF spectrum.
DOI: 10.1002/ejhf.70072
Authors: Cristina Madaudo, Amitai Segev, Emanuele Bobbio, Chiara Baggio, Jonathan Schütze, Piero Gentile, Marta Sanguineti, Luca Monzo, Matteo Schettino, Emma Ferone, Ahmed Elsanhoury, Anan Younis, Matteo Palazzini, Adriana Ferroni, Valentina Giani, Matthew Sadler, Mohammad Albarjas, Leonardo Calò, Christian Lars Polte, Andrea Garascia, Stefano Figliozzi, Paul A. Scott, Ajay M. Shah, Alfredo Ruggero Galassi, Mauro Giacca, Gianfranco Sinagra, Entela Bollano, Theresa McDonagh, Carsten Tschöpe, Giuseppina Novo, Enrico Ammirati, Roy Beigel, Christoph Gräni, Marco Merlo, Pietro Ameri, Antonio Cannata, Daniel I. Bromage
Institutions: King's College London, British Heart Foundation, University of Palermo, Tel Aviv University, Sheba Medical Center, Sahlgrenska University Hospital, University of Gothenburg, Azienda sanitaria universitaria Giuliano Isontina, University of Bern, University Hospital of Bern, Azienda Socio Sanitaria Territoriale Grande Ospedale Metropolitano Niguarda, University of Genoa, Inserm, Centre Hospitalier Régional et Universitaire de Nancy, Policlinico Casilino, Défaillance Cardiovasculaire Aiguë et Chronique, Université de Lorraine, Deutsches Herzzentrum der Charité, Berlin-Brandenburger Centrum für Regenerative Therapien, German Centre for Cardiovascular Research, Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Charité - Universitätsmedizin Berlin, King's College Hospital NHS Foundation Trust, Princess Royal University Hospital, Humanitas University, IRCCS Humanitas Research Hospital, University of Wrocław, Wroclaw Medical University, Ospedale Policlinico San Martino
Language: English
Subfield: Cardiology and Cardiovascular Medicine
Field: Medicine
Domain: Health Sciences
Open Access status: hybrid
Estimated APC paid: $5,300
OpenAlex ID: W4415238712