CARDIOVASCULAR JOURNAL OF AFRICA • Volume 35, No 2, May – August 2024 86 AFRICA Discussion The main finding of the study was that SII independently predicted in-hospital and long-term MACE in ACS patients. Although increased levels of NLR and PLR were associated with worse outcomes in ACS patients, they were not found to be independent predictors for MACE. These results show that SII was a much stronger predictor of MACE than NLR and PLR in these ACS patients. To the best of our knowledge, there is no study that compares these three ratios in ACS patients. Many complicated risk scores with multiple parameters have been developed for early and late risk assessment after myocardial infarction. Instead of these challenging risk scores, easily accessible parameters obtained from complete blood counts can be used.11 SII is thought to be an excellent indicator of the immune response and systemic inflammation, consisting of neutrophils, platelets and lymphocytes. To date, there are few studies showing that SII is associated with a poor prognosis in cardiovascular diseases. The relationship between SII and short- and long-term mortality in patients with ACS was first reported by Su et al. They indicated that SII was a promising prognostic biomarker in patients with ACS.12 In their study, Fan et al. showed that NLR with SII was an independent predictor of MACE in ACS patients who underwent PCI.13 In a study by Yang et al. in 5 602 patients with chronic coronary artery disease who underwent PCI, SII was a better predictor for major cardiovascular events than traditional risk factors.14 In another study, SII was found to be associated with isolated coronary ectasia.15 In a study of 510 patients, it was shown that SII independently predicted the no-reflow phenomenon in STEMI patients.16 Except for coronary artery disease in 120 patients who underwent transcatheter aortic valve implantation (TAVI), the SII was shown to have predictive value for major adverse cardiac events and six-month short-termmortality.17 In a study conducted with 4 606 patients with heart failure, the workers showed that increased SII predicted short-term mortality.18 In addition, in patients with NSTEMI, increased SII level was shown to be an independent predictor of contrast-induced nephropathy.19 All these studies indicate that increased SII levels are related to poor cardiovascular events in different cardiac pathologies. The effect of SII level on prognosis rather than cardiovascular diseases has been shown foremost in malignancies. The inflammatory response plays an important role in malignancy development as well as in atherosclerosis. Based on this hypothesis, it has been shown in many studies and meta-analyses in patients with malignancy that SII can be used to predict a poor prognosis.20-22 We found only one study in the field of malignancies in which SII 1 – Specificity 0.0 0.2 0.4 0.6 0.8 1.0 Sensitivity 1.0 0.8 0.6 0.4 0.2 0.0 AUC ± SE WBC 0.77 ± 0.02 CRP 0.76 ± 0.02 NLR 0.77 ± 0.02 PLR 0.67 ± 0.02 SII 0.88 ± 0.02 reference line SII NLR CRP WBC PLR Number at risk SII ≤ 955.8 835 739 685 659 623 606 675 503 417 355 319 255 193 130 79 40 0 0 SII > 955.8 266 139 122 113 105 100 94 88 71 62 51 45 33 26 21 15 0 0 Follow-up (months) 0 3 6 9 12 15 18 21 24 27 30 33 36 39 42 45 48 51 Survival probability (%) 100 90 80 70 60 50 40 30 20 10 0 HR = 48.7 95% CI = 33.8–69.9 Logrank p < 0.001 SII ≤ 955.8 SII > 955.8 Number at risk SII ≤ 916.7 285 253 234 227 217 214 207 193 171 151 137 115 83 57 38 15 0 SII > 916.7 118 62 56 56 54 51 50 46 45 42 36 34 24 19 15 10 0 Follow-up (months) 0 3 6 9 12 15 18 21 24 27 30 33 36 39 42 45 48 51 Survival probability (%) 100 90 80 70 60 50 40 30 20 10 0 HR = 24.6 95% CI = 14.4–42.1 Logrank p < 0.001 SII ≤ 916.7 SII > 916.7 Number at risk SII ≤ 986 551 487 451 431 405 391 367 308 243 201 179 137 107 71 39 24 0 0 SII > 986 147 76 66 58 52 50 46 44 29 23 18 14 12 9 8 6 0 0 Follow-up (months) 0 3 6 9 12 15 18 21 24 27 30 33 36 39 42 45 48 51 Survival probability (%) 100 90 80 70 60 50 40 30 20 10 0 HR = 97.1 95% CI = 59.2–159.1 Logrank p < 0.001 SII ≤ 986 SII > 986 Fig. 1. (A) SII diagnostic performance assessment in predicting MACE, (B) Predictive value for MACE risk in all patients, (C) in STEMI patients, and (D) in NSTEMI patients. A C B D
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