Plaque characteristics and inflammatory markers for the prediction of major cardiovascular events in patients with ST-segment elevation myocardial infarction

  • Ae-Young Her
  • Kyoung Im Cho
  • Gillian Balbir Singh
  • Dae Seong An
  • Young-Hoon Jeong
  • Bon-Kwon Koo
  • Eun-Seok Shin
Original Paper


To investigate the clinical utility of culprit plaque characteristics and inflammatory markers for the prediction of future cardiovascular events in patients with ST-segment elevation myocardial infarction (STEMI) with successful drug-eluting stent (DES) implantation. We evaluated 172 STEMI patients with successful primary percutaneous coronary intervention (PCI) with DES using pre-PCI high-sensitivity C-reactive protein (hs-CRP), neutrophil-to-lymphocyte ratio (NLR) and pre-PCI intravascular ultrasound virtual histology (IVUS-VH) of culprit lesions. The incidence of major adverse cardiovascular events (MACE) including all-cause mortality, non-fatal MI, stroke and late revascularization were recorded during hospitalization and follow-up. During follow-up (median 41 months), the incidence of MACE did not significantly differ among patients with or without all 3 high-risk plaque features on IVUS-VH (15.1 vs. 16.2%; p = 0.39). In contrast, patients with elevated hs-CRP and NLR levels were at significant risk for MACE [32.7 vs. 5.8%; hazard ratio (HR) 7.85; p < 0.001 and 43.9 vs. 6.9%; HR 8.44; p < 0.001, respectively]. High-risk plaque features had no incremental usefulness to predict future MACE. However, the incorporation of hs-CRP and NLR into a model with conventional clinical and procedural risk factors significantly improved the C-statistic for the prediction of MACE (0.76–0.89; p = 0.04). High-risk plaque features identified by IVUS-VH in culprit lesions were not associated with future MACE in patients with STEMI receiving DES. However, elevated hs-CRP and NLR levels were significantly associated with poorer outcomes and had incremental predictive values over conventional risk factors.


Plaque characteristics High-sensitivity C-reactive protein Neutrophil to lymphocyte ratio Intravascular ultrasound virtual histology ST-segment elevation myocardial infarction Outcomes 



Acute myocardial infarction


Drug-eluting stent


High sensitivity C-reactive protein


Intravascular ultrasound virtual histology


Major adverse cardiovascular events


Neutrophil to lymphocyte ratio


Percutaneous coronary intervention


ST-segment elevation myocardial infarction


Thin-cap fibroatheroma


Compliance with ethical standards

Conflict of interest

The author(s) declare that they have no competing interests.

Supplementary material

10554_2017_1135_MOESM1_ESM.docx (15 kb)
Supplementary material 1 (DOCX 14 KB)


  1. 1.
    Roger VL, Go AS, Lloyd-Jones DM et al (2012) Heart disease and stroke statistics–2012 update. Circulation 125:e2–e220CrossRefPubMedGoogle Scholar
  2. 2.
    Arbab-Zadeh A, Fuster V (2015) The myth of the “vulnerable plaque”: transitioning from a focus on individual lesions to atherosclerotic disease burden for coronary artery disease risk assessment. J Am Coll Cardiol 65:846–855CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Vink MA, Vos NS, Dirksen MT et al (2015) Recurrent myocardial infarction after primary percutaneous coronary intervention in multivessel coronary disease is primarily related to stent failure. J Interv Cardiol 28:523–530CrossRefPubMedGoogle Scholar
  4. 4.
    Stone GW, Maehara A, Lansky AJ et al (2011) A prospective natural-history study of coronary atherosclerosis. N Engl J Med 364:226–235CrossRefPubMedGoogle Scholar
  5. 5.
    Bourantas CV, Garcia-Garcia HM, Farooq V et al (2013) Clinical and angiographic characteristics of patients likely to have vulnerable plaques: analysis from the PROSPECT study. JACC Cardiovasc Imaging 6:1263–1272CrossRefPubMedGoogle Scholar
  6. 6.
    Fleg JL, Stone GW, Fayad ZA et al (2012) Detection of high-risk atherosclerotic plaque: report of the NHLBI Working Group on current status and future directions. JACC Cardiovasc Imaging 5:941–955CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Tian J, Ren X, Vergallo R et al (2014) Distinct morphological features of ruptured culprit plaque for acute coronary events compared to those with silent rupture and thin-cap fibroatheroma. J Am Coll Cardiol 63:2209–2216CrossRefPubMedGoogle Scholar
  8. 8.
    Hlatky MA, Douglas PS, Cook NL et al (2012) Future directions for cardiovascular disease comparative effectiveness research: report of a workshop sponsored by the National Heart, Lung, and Blood Institute. J Am Coll Cardiol 60:569–580CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Zairis MN, Manousakis SJ, Stefanidis AS et al (2002) C-reactive protein levels on admission are associated with response to thrombolysis and prognosis after ST-segment elevation acute myocardial infarction. Am Heart J 144:782–789CrossRefPubMedGoogle Scholar
  10. 10.
    Zebrack JS, Anderson JL, Maycock CA, Horne BD, Bair TL, Muhlestein JB (2002) Usefulness of high-sensitivity C-reactive protein in predicting long-term risk of death or acute myocardial infarction in patients with unstable or stable angina pectoris or acute myocardial infarction. Am J Cardiol 89:145–149CrossRefPubMedGoogle Scholar
  11. 11.
    Hoffman M, Blum A, Baruch R, Kaplan E, Benjamin M (2004) Leukocytes and coronary heart disease. Atherosclerosis 172:1–6CrossRefPubMedGoogle Scholar
  12. 12.
    Fowler AJ, Agha RA (2013) Neutrophil/lymphocyte ratio is related to the severity of coronary artery disease and clinical outcome in patients undergoing angiography: the growing versatility of NLR. Atherosclerosis 228:44–45CrossRefPubMedGoogle Scholar
  13. 13.
    Cho KI, Ann SH, Singh GB, Her AY, Shin ES (2015) Combined usefulness of the platelet-to-lymphocyte ratio and the neutrophil-to-lymphocyte ratio in predicting the long-term adverse events in patients who have undergone percutaneous coronary intervention with a drug-eluting stent. PLoS ONE 10:e0133934CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Kurtul A, Yarlioglues M, Murat SN et al (2014) Usefulness of the platelet-to-lymphocyte ratio in predicting angiographic reflow after primary percutaneous coronary intervention in patients with acute ST-segment elevation myocardial infarction. Am J Cardiol 114:342–347CrossRefPubMedGoogle Scholar
  15. 15.
    Park JJ, Jang HJ, Oh IY et al (2013) Prognostic value of neutrophil to lymphocyte ratio in patients presenting with ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention. Am J Cardiol 111:636–642CrossRefPubMedGoogle Scholar
  16. 16.
    O’Gara PT, Kushner FG, Ascheim DD et al (2013) ACCF/AHA guideline for the management of ST-elevation myocardial infarction: executive summary. Catheter Cardiovasc Interv 82(2013):E1–E27PubMedGoogle Scholar
  17. 17.
    Schoenhagen P, Ziada KM, Kapadia SR, Crowe TD, Nissen SE, Tuzcu EM (2000) Extent and direction of arterial remodeling in stable versus unstable coronary syndromes. Circulation 101:598–603CrossRefPubMedGoogle Scholar
  18. 18.
    Nair A, Kuban BD, Tuzcu EM, Schoenhagen P, Nissen SE, Vince DG (2002) Coronary plaque classification with intravascular ultrasound radiofrequency data analysis. Circulation 106:2200–2206CrossRefPubMedGoogle Scholar
  19. 19.
    Pencina MJ, D’Agostino RB (2004) Overall C as a measure of discrimination in survival analysis: model specific population value and confidence interval estimation. Stat Med 23:2109–2123CrossRefPubMedGoogle Scholar
  20. 20.
    Franco M, Cooper RS, Bilal U, Fuster V (2011) Challenges and opportunities for cardiovascular disease prevention. Am J Med 124:95–102CrossRefPubMedGoogle Scholar
  21. 21.
    Virmani R, Burke AP, Farb A, Kolodgie FD (2006) Pathology of the vulnerable plaque. J Am Coll Cardiol 47:C13–C18CrossRefPubMedGoogle Scholar
  22. 22.
    Virmani R, Burke AP, Kolodgie FD, Farb A (2003) Pathology of the thin-cap fibroatheroma: a type of vulnerable plaque. J Interv Cardiol 16:267–272CrossRefPubMedGoogle Scholar
  23. 23.
    Zannad F, Dallongeville J, Macfadyen RJ et al (2012) Prevention of cardiovascular disease guided by total risk estimations—challenges and opportunities for practical implementation. Eur J Prev Cardiol 19:1454–1464CrossRefPubMedPubMedCentralGoogle Scholar
  24. 24.
    Tanaka A, Shimada K, Sano T et al (2005) Multiple plaque rupture and C-reactive protein in acute myocardial infarction. J Am Coll Cardiol 45:1594–1599CrossRefPubMedGoogle Scholar
  25. 25.
    Tamhane UU, Aneja S, Montgomery D, Rogers EK, Eagle KA, Gurm HS (2008) Association between admission neutrophil to lymphocyte ratio and outcomes in patients with acute coronary syndrome. Am J Cardiol 102:653–657CrossRefPubMedGoogle Scholar
  26. 26.
    Han YC, Yang TH, Kim DI et al (2013) Neutrophil to lymphocyte ratio predicts long-term clinical outcomes in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention, Korean. Circ J 43:93–99Google Scholar
  27. 27.
    Ozcan Cetin EH, Cetin MS, Aras D et al (2016) Platelet to lymphocyte ratio as a prognostic marker of in-hospital and long-term major adverse cardiovascular events in ST-segment elevation myocardial infarction. Angiology 67:336–345CrossRefPubMedGoogle Scholar
  28. 28.
    Barron HV, Cannon CP, Murphy SA, Braunwald E, Gibson CM (2000) Association between white blood cell count, epicardial blood flow, myocardial perfusion, and clinical outcomes in the setting of acute myocardial infarction. Circulation 102:2329–2334CrossRefPubMedGoogle Scholar
  29. 29.
    Arbel Y, Finkelstein A, Halkin A et al (2012) Neutrophil/lymphocyte ratio is related to the severity of coronary artery disease and clinical outcome in patients undergoing angiography. Atherosclerosis 225:456–460CrossRefPubMedGoogle Scholar
  30. 30.
    Azab B, Zaher M, Weiserbs KF et al (2010) Usefulness of neutrophil to lymphocyte ratio in predicting short- and long-term mortality after non-ST-elevation myocardial infarction. Am J Cardiol 106:470–476CrossRefPubMedGoogle Scholar
  31. 31.
    Ommen SR, Gibbons RJ, Hodge DO, Thomson SP (1997) Usefulness of the lymphocyte concentration as a prognostic marker in coronary artery disease. Am J Cardiol 79:812–814CrossRefPubMedGoogle Scholar
  32. 32.
    Ray KK, Cannon CP, McCabe CH et al (2005) Early and late benefits of high dose atorvastatin in patients with acute coronary syndrome. J Am Coll Cardiol 46:1405–1410CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media Dordrecht 2017

Authors and Affiliations

  • Ae-Young Her
    • 1
  • Kyoung Im Cho
    • 2
  • Gillian Balbir Singh
    • 3
  • Dae Seong An
    • 4
  • Young-Hoon Jeong
    • 5
  • Bon-Kwon Koo
    • 6
  • Eun-Seok Shin
    • 3
  1. 1.Division of Cardiology, Department of Internal MedicineKangwon National University School of MedicineChuncheonSouth Korea
  2. 2.Department of CardiologyKosin University School of MedicineBusanSouth Korea
  3. 3.Department of CardiologyUlsan University Hospital, University of Ulsan College of MedicineUlsanSouth Korea
  4. 4.Division of BiostatisticsResearch Institute of Convergence for Biomedical Science and Technology, Pusan National University YangSan HospitalYangsanSouth Korea
  5. 5.Department of CardiologyGyeongsang National University Hospital and Gyeongsang National University School of MedicineJinjuSouth Korea
  6. 6.Department of Internal Medicine and Cardiovascular CenterSeoul National University HospitalSeoulSouth Korea

Personalised recommendations