• Nelson Chavarria New York Hospital Queens, Flushing, New York
  • Cyrus Wong New York Hospital Queens, Flushing, New York
  • Hafiz Hussain New York Hospital Queens, Flushing, New York
  • Habib ullah Jooiya New York Hospital Queens, Flushing, New York
  • Seth Goldbarg New York Hospital Queens, Flushing, New York
  • Andrew Buda New York Hospital Queens, Flushing, New York


Background: Increasing evidence suggests that inflammation plays an important role in initiation and maintaining of atrial fibrillation (AF). The Neutrophil to Lymphocyte (N/L) Ratio is an easily derived and readily available parameter that has emerged as marker of inflammation with predictive and prognostic value. We investigated the association between N/L ratio and incidence of atrial fibrillation in patients undergoing cardiac catheterization for acute ST-segment elevation myocardial infarction (STEMI). Methods: This cross sectional descriptive study was carried out at New York Hospital Queens. We retrospectively analysed clinical, hematologic and angiographic data of 290 patients who underwent coronary angiography with stent placement for acute ST-segment elevation myocardial infarction between 2008–2011. Results: Study cohort of 290 patients had mean age 63.3±13.0 years consisting of 81.4% male. The N/L ratio was measured at time points: <6 hours pre-catheterization, <12, 48 and 96 hours post catheterization. Patients who developed AF (n=40, 13.8%), had higher post catheterization N/L ratios at 48hours (median 5.23 vs 3.00, p=0.05) and 96 hours (median 4.67 vs 3.56, p=0.03), with no differences in the immediate pre and post procedural measurements, <6 hours pre catheterization (median 2.49 vs 2.82, p=0.467) and <12 hours post catheterization (median 5.93 vs 5.03, p=0.741) respectively. Conclusion: In conclusion, these findings support an inflammatory aetiology contributing to new onset AF following percutaneous coronary intervention for acute STEMI. Further studies are warranted to elucidate these findings.Keywords: Neutrophil/Lymphocyte ratio, Atrial Fibrillation Coronary Angiography, Myocardial Infarction


Falk RH. Etiology and complications of atrial fibrillation: insights from pathology studies. Am J Cardio 1998;82(8A):10–17.

Frustaci A, Chimenti C, Bellocci F, Morgante E, Russo MA, Maseri A. Histological substrate of atrial biopsies in patients with lone atrial fibrillation. Circulation 1997;96(4):1180–4.

Ommen SR, Odell JA. Atrial Arrhythmias after Cardiothoracic Surgery. N Engl J Med 1997;336(20):1429–34.

Frustaci A, Caldarulo M, Buffon A, Bellocci F, Fenici R, Melina D. Cardiac biopsy in patients with “primary” atrial fibrillation. Histologic evidence of occult myocardial diseases. Chest 1991;100(2):303–6.

Issac TT, Dokainish H, Lakkis NM. Role of Inflammation in Initiation and Perpetuation of Atrial Fibrillation. A systematic Review of the Published Data. J Am Coll Cardiol 2007;50(21):2021–8.

Schnabel RB, Larson MG, Yamamoto JF, Kathiresan S, Rong J, Levy D, et al. Benjamin EJ. Relation of multiple inflammatory biomarkers to incident atrial fibrillation. Am J Cardiol 2009;104(1):92–6.

Aviles RJ, Martin DO, Apperson-Hansen C, Houghtaling PL, Rautaharju P, Kronmal RA, et al. Clinical Investigation and Reports: Inflammation as a Risk Fator for Atrial Fibrillation. Circulation 2003;108(24):3006–10.

Conen D, Ridker PM, Everett BM, Tedrow UB, Rose L, Cook NR, et al. A multimarker approach to assess the influence of inflammation on the incidence of atrial fibrillation in women. Eur Heart J 2010;31(14):1730–6.

Sabatine MS, Morrow DA, Cannon CP, Murphy SA, Demopoulos LA, DiBattiste PM, et al. Relationship between baseline white blood cell count and degree of coronary artery disease and mortality in patients with acute coronary syndromes: a TACTICS-TIMI 18 substudy. J Am Coll Cardiol 2002;40(10):1761–8.

Furman MI, Gore JM, Anderson FA, Budaj A, Goodman SG, Avezum A, et al. Elevated leukocyte count and adverse hospital events in patient with acute coronary syndromes: findings from the Global Registry of Acute Coronary Events(GRACE). Am Heart J 2004;147(1):42–8.

Prasad A. Stone GW, Stuckey TD, Constantini CO, Mehran R, Garcia E, et al. Relation between leucocyte count, myonecrosis, myocardial perfusion, and outcomes following primary angioplasty. Am J Cardiol 2007;99(8):1067–71.

Horne BD, Anderson JL, John JM, Weaver A, Bair TL, Jensen KR, et al. Which white blood cell subtypes predict increased cardiovascular risk? J Am Coll Cardiol 2005;45(10):1638–43.

Duffy BK, Gurm HS, Rajagopal V, Gupta R, Ellis SG, Bhatt DL. Usefulness of an elevated neutrophil to lymphocyte ratio in predicting long-term mortality after percutaneous coronary intervention. Am J Cardiol 2006;97(7):993–6.

Papa A, Emdin M, Passino C, Michelassi C, Battaglia D, Cocci F. Predictive value of elevated neutrophil-lymphocyte ratio on cardiac mortality in patients with stable coronary artery disease. Clin Chim Acta 2008;395(1–2):27–31.

Park JJ, Jang HJ, Oh IY, Yoon CH, Suh JW, Cho YS, et al. Prognostic Value of Neutrophil to Lymphocyte Ratio in Patients Presenting with ST-elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention. Am J Cardiol 2013;111(5):636–42.

Kaya MG, Akpek M, Lam YY, Yarlioglues M, Celik T, Gunebakmaz O, et al. Prognostic Value of neutrophil/lymphocyte ratio in patients with ST-elevated myocardial infarction undergoing primary coronary intervention: A prospective, multicenter study. Int J Cardiol 2013;168(2):1154–9.

Gibson PH, Cuthbertson BH, Croal BL, Rae D, El-Shafei H, Gibson G, et al. Usefulness of Neutrophil/Lymphocyte Ratio As Predictor of New-Onset Atrial Fibrillation After Coronary Artery Bypass Grafting. Am J Cardiol 2010;105(2):186–91.

Sugiura T, Iwasaka T, Takahashi N, Yuasa F, Takeuchi M, Hasegawa T, et al. Factors associated with atrial fibrillation and Q wave anterior myocardial infarction. Am Heart J 1991;12195):1409–12.

Rivard L, Sinno H, Shiroshita-Takeshita A, Schram G, Leung TK, Nattel S. The pharmacological response of ischemia-related atrial fibrillation in dogs: evidence for substrate-specific efficacy. Cardiovasc Res 2007;74(1):104–13.

Sakabe M, Shiroshita-Takeshita A, Maguy A, Brundel BJ, Fujiki A, Inoue H, et al. Effects of a heat shock protein inducer on the atrial fibrillation substrate caused by acute atrial ischaemia. Cardiovasc Res 2008;78(1):63–70.

Shiroshita-Takeshita A, Sakabe M, Haugan K, Hennan JK, Nattel S. Model-dependent effects of the gap junction conduction-enhancing antiarrhythmic peptide rotigaptide (ZP123) on experimental atrial fibrillation in dogs. Circulation 2007;115(3):310–8.

Rechavia E, Strasberg B, Mager A, Zafrir N, Kusniec J, Sagie A, et al. The incidence of atrial arrhythmias during inferior wall myocardial infarction with and without right ventricular involvement. Am Heart J 1992;124(2):387–91.

Sinno H, Derakhchan K, Libersan D, Merhi Y, Leung TK, Nattel S. Atrial ischemia promotes atrial fibrillation in dogs. Circulation 2003;107(14):1930–6.

Nishida K, Qi XY, Wakili R, Comtois P, Chartier D, Harada M, et al. Mechanisms of atrial tachyarrhythmias associated with coronary artery occlusion in a chronic canine model. Circulation 2011;123(2):137–46.

Kim D. Novel cation-selective mechanosensitive ion channel in the atrial cell membrane. Circ Res 1993;72(1):225–31.

Hu H, Sachs F. Stretch-activated ion channels in the heart. J Mol Cell Cardiol 1997;29(6):1511–23.

Hatem SN, Coulombe A, Balse E. Specificities of atrial electrophysiology: Clues to a better understanding of cardiac function and the mechanisms of arrhythmias. J Mol Cell Cardiol 2010;48(1):90–5.

Satoh T, Zipes DP. Unequal atrial stretch in dogs increases dispersion of refractoriness conducive to developing atrial fibrillation. J Cardiovasc Electrophysiol 1996;7(9):833–42.

Stilli D, Aimi B, Sgoifo A, Ciarlini P, Regoliosi G, Lagrasta C, et al. Dependence of temporal variability of ventricular recovery on myocardial fibrosis. Role of mechnoelectric feedback? Cardiovasc Res 1998;37(1):58–65.

Burstein B, Nattel S. Atrial Fibrosis: mechanisms and clinical relevance in atrial fibrillation. J Am Coll Cardiol 2008;51(8):802–9.

Friedrichs K, Klinke A, Baldus S. Inflammatory pathways underlying atrial fibrillation. Trends Mol Med 2011;17(10):556–63.

Engelmann MD, Svendsen JH. Inflammation in the genesis and perpetuation of atrial fibrillation. Eur Heart J 2005;26(20):2083–92.

Novo G, Guttilla D, Fazio G, Cooper D, Novo S. The role of the renin-angiotensin system in atrial fibrillation and the therapeutic effects of ACE-Is and ARBS. Br J Clin Pharmacol 2008;66(3):345–51.

Qu YC, Du YM, Wu SL, Chen QX, Wu HL, Zhou SF. Activated nuclear factor-kappaβ and increased tumor necrosis factor-alpha in atrial tissue of atrial fibrillation. Scand Cardiovasc J 2009;43(5):292–7.

Liew R, Khairunnisa K, Gu Y, Tee N, Yin NO, Naylynn TM, Moe KT. Role of Tumor Necrosis Factor-α in the Pathogenesis of Atrial Fibrosis and Development of an Arrhythmogenic Substrate. Circ J 2013;77(5):1171–9.

Marcus GM, Whooley MA, Glidden DV, Pawlikowska L, Zaroff JG, Olgin JE. Interleukin-6 and atrial fibrillation in patients with coronary artery disease: data from the Heart and Soul Study. Am Heart J 2008;155(2):303–9.

Melenovsky V, Lip GY. Interleukin-8 and atrial fibrillation. Europace 2008;10(7):784–5.

Frangogiannis NG. Regulation of the inflammatory response in cardiac repair. Circ Res 2012;110(1):159–73.

Wilber DJ. Fibroblasts, focal triggers, and persistent atrial fibrillation: is there a connection? Circ Arrhythm Electrophysiol 2012;5(2):249–51.

Rohr S. Arrhythmogenic implications of fibroblast and myocyte interactions. Circ Arrhythm Electrophysiol 2012;5(2):442–52.

Guo Y, Lip GY, Apostolakis S. Inflammation in Atrial Fibrillation. J Am Coll Cardiol 2012;60(22):2263–70.

Schnabel RB, Larson MG, Yamamoto JF, Sullivan LM, Pencina MJ, Meigs JB, et al. Relations of biomarkers of distinct pathophysiological pathways and atrial fibrillation incidence in the community. Circulation 2010;121(2):200–7.

Patel P, Dokainish H, Tsai P, Lakkis N. Update on the association of inflammation and atrial fibrillation. J Cardiovasc Electrophysiol 2010;21(9):1064–70.

Dixit S. Atrial Fibrillation and inflammation: quest for the missing link in the etiopathogenesis of AF. Heart Rhythm 2010;7(2):155–6.

Leftheriotis DI, Fountoulaki KT, Flevari PG, Parissis JT, Panou FK, Andreadou IT, et al. The predicitive value of inflammatory and oxidative markers following the successful cardioversion of persistent lone atrial fibrillation. Int J Cardiol 2009;135:361–9.

Madjid M, Awan I, Willerson JT, Casscells SW. Leukocyte count and coronary heart disease: implications for risk assessment. J Am Coll Cardiol 2004;44(10):1945–56.

Ommen SR, Gibbons RJ, Hodge DO, Thomson SP. Usefulness of the lymphocyte concentration as a prognostic marker in coronary artery disease. Am J Cardiol 1997;79(6):812–4.

Adamsson Eryd S, Smith JG, Melander O, Hedblad B, Engstrom G. Incidence of coronary events and case fatality rate in relation to blood lymphocyte and neutrophil counts. Arterioscler Thromb Vasc Biol 2012;32(2):533–9.

Park BJ, Shim JY, Lee HR, Lee JH, Jung DH, Kim HB, et al. Relationship of neutrophil-lymphocyte ratio with arterial stiffness and coronary calcium score. Clin Chim Acta. 2011;412:925–9.

Akpek M, Kaya MG, Lam YY, Sahin O, Elcik D, Celik T, et al. Relation of neutrophil/lymphocyte ratio to coronary flow to in-hospital major adverse cardiac events in patients with ST-elevated myocardial infarction undergoing primary coronary intervention. Am J Cardiol 2012;110(5):621–7.

Chong KH, Jeong MH, Ahmed K, Hachinohe D, Choi HS, Chang SY, Kim MC, et al. Value of early risk stratification using hemoglobin level and neutrophil-to-lymphocyte ratio in patients with ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention. Am J Cardiol 2011;107(6):849–56.

Chatterjee S, Chandra P, Guha G, Kalra V, Chakraborty A, Frankel R. Pre-procedural Elevated White Blood Cell Count and Neutrophil-Lymphocyte (N/L) Ratio are Predictors of Ventricular Arrhythmias During Percutaneous Coronary Intervention. Cardiovasc Hematol Disord Drug Targets 2011.

Poludasu S, Cavusoglu E, Khan W, Marmur JD. Neutrophil to lymphocyte ratio as a predictor of long-term mortality in African Americans undergoing percutaneous coronary intervention. Clin Cardiol 2009;32(12):6–10.

Ertas G, SOnmez O, Turfan M, Kul S, Erdogan E, Tasal A, et al. Neutrophil/lymphocyte ratio is associated with thromboembolic stroke in patients with non-valvular atrial fibrillation. J Neurol Sci 2013;324:49–52.

Aribas A, Akilli H, Gul EE, Kayrak M, Demir K, Duman C, et al. Can neutrophil/lymphocyte ratio predict recurrence after electrical cardioversion in non-valvular atrial fibrillation? Anadolu Kardiyol Derg 2013;13(2):123–30.

Liuba L, Ahlomroth H, Jonasson L, Englund A, Jonsoon A, Safstrom K, et al. Source of inflammatory markers in patients with atrial fibrillation. Europace 2008;10(7):848–53.

Marcus GM, Smith LM, Ordovas K, Scheinman MM, Kim AM, Badhwar N, Lee RJ, et al. Intracardiac and extracardiac markers of inflammation during atrial fibrillation. Heart Rhythm 2010;7(2):149–54.

Keywords: Neutrophil/Lymphocyte ratio, Atrial Fibrillation Coronary Angiography, Myocardial Infarction