Systemic Immune-Inflammation Index Predict Lengthy-Time period Outcomes


As a definite and extreme sort of coronary artery illness (CAD), three-vessel illness (TVD) presents in almost 30% of CAD sufferers. Characterised by vital stenosis in all three main coronary arteries, TVD is without doubt one of the largest challenges in coronary intervention.1 TVD Sufferers are on the highest danger for cardiovascular opposed occasions in CAD.2 Revascularization has been discovered to result in long-term advantages amongst TVD sufferers.3

Scientific proof has depicted that irritation performs an necessary function in atherosclerotic CAD pathogenesis. Lately, rising knowledge have proven that some irritation and immune indices primarily based on the whole blood rely, equivalent to platelet-lymphocyte ratio (PLR) and neutrophil-lymphocyte ratio (NLR), present helpful info for predicting future opposed cardiovascular occasions in sufferers with CAD.4,5 Systemic immune irritation index (SII) is a brand new parameter for assessing irritation. Basically, it’s a composite inflammatory indicator that mixes three vital immune cells, specifically, neutrophils, lymphocytes, and platelets. Lately, SII has been proposed to evaluate each inflammatory and immune standing,6 is taken into account a wonderful indicator of native immune response and systemic irritation. Initially, SII was used to evaluate the prognosis of most cancers sufferers.7 Lately, a number of research have reported SII to be related to opposed outcomes in heart problems sufferers, equivalent to continual coronary heart failure, atrial fibrillation, and peripartum cardiomyopathy.8–10

In contrast with single-vessel illness, TVD sufferers have a extra outstanding inflammatory state. Moreover, TVD confers an nearly two-fold larger danger of mortality, which is a major danger issue for worse outcomes.11,12 Nevertheless, the connection between SII and scientific outcomes in TVD sufferers was nonetheless unexplored. Subsequently, this research aimed to research the prognostic worth of SII regarding long-term outcomes in TVD sufferers after revascularization in a big cohort.


Research Inhabitants

In our establishment, 13,890 sufferers underwent coronary angiography between January 2013 and December 2018. Out of those 13,890 sufferers, 4308 (31.0%) have been TVD sufferers. The exclusion standards comprised sufferers receiving medical remedy alone, sufferers with malignant tumors, immune illness, extreme liver ailments, and renal failure, in addition to clinically evident acute or continual irritation. In complete, 3561 TVD sufferers present process revascularization have been included on this research. Revascularization contains percutaneous coronary intervention (PCI) or coronary artery bypass graft surgical procedure (CABG).2 Research individuals have been categorized into 2 teams in line with preprocedural SII (694.3 × 109/L) as decided by the receiver working traits (ROC) curve evaluation.13,14 Baseline demographics, procedural traits, and in-hospital end result knowledge have been collected from medical data and compiled in a devoted database. Information on long-term scientific outcomes have been obtained by phone interviews with sufferers or their kin, outpatient visits, and hospital readmissions.


This single-center, retrospective observational research was accredited by the Ethics Committee of the First Affiliated Hospital of Dalian Medical College (Ethics No: YJ-KY-FB-2021-10). Research protocols have been in keeping with the Declaration of Helsinki. All individuals offered their written knowledgeable consent.


Coronary interventions have been carried out in line with the present customary tips. All sufferers have been pre-treated with aspirin and clopidogrel previous to catheterization. In the course of the process, unfractionated heparin (100 U/kg) was administered to all sufferers; the usage of glycoprotein IIb/IIIa inhibitors was left to the discretion of the medical group. Publish dilatation was carried out with further balloons to make sure optimum stent apposition. All deployed stents have been drug-eluting stents (DES). After DES implantation, dual-antiplatelet medicines have been administered for no less than 12 months.15,16 CABG procedures could possibly be achieved with or with out extracorporeal circulation, and use of arterial conduits was inspired.

Definition and Endpoints

TVD was outlined as angiographic stenosis of ≥ 50% in all three principal coronary arteries, together with the left anterior descending, left circumflex, and proper coronary arteries, with or with out the involvement of the left principal artery. SII was calculated as absolute peripheral neutrophil rely × platelet rely/lymphocyte rely.6 The first endpoint was set as main opposed cardiac and cerebrovascular occasions (MACCE), consisting of all-cause dying, myocardial infarction (MI), repeat revascularization, stroke, and readmission for angina pectoris or coronary heart failure. All-cause dying was the secondary end result.

Statistical Evaluation

Kolmogorov–Smirnov take a look at was used to check normality. Steady variables have been expressed as imply ± customary deviation or median and interquartile ranges and in contrast utilizing Pupil’s t-test or Mann–Whitney U-test. Categorical variables have been expressed as numbers and percentages. Chi-square or Fisher’s actual exams have been used to guage the variations. Survival-free of opposed occasions was calculated by the Kaplan-Meier evaluation and in contrast utilizing the Log rank take a look at. Three fashions have been used to guage potential confounders’ results on the affiliation between SII stage and long-term outcomes. Mannequin 1 adjusted for age and intercourse; Mannequin 2 adjusted for age, intercourse, hypertension, diabetes, and continual kidney illness (CKD); and Mannequin 3 adjusted for age, intercourse, hypertension, diabetes, CKD, lipid profile, left ventricular ejection fraction (LVEF), and acute coronary syndrome (ACS). The ROC curve evaluation was used to guage the sensitivity and specificity of the SII for predicting MACCEs (Determine 1). The world beneath the curve (AUC) was utilized as a measure of the predictive accuracy of SII. To evaluate for enhancements within the accuracy of opposed cardiac occasion predictions after including SII to a baseline mannequin with conventional danger components (ie, age, intercourse, hypertension, and diabetes), the C-index, web reclassification enchancment (NRI), and built-in discrimination enchancment (IDI) have been calculated. All two-sided P values < 0.05 have been thought of statistically vital. All statistical analyses have been performed utilizing SPSS model 24.0 and R model 4.1.3.

Determine 1 A ROC curve evaluation to find out the predictive worth of SII for main opposed cardiac and cerebrovascular occasions (MACCE) with 63% sensitivity and 71% specificity.

Abbreviations: AUC, space beneath the curve; ROC, receiver working curve; SII, systemic immune-inflammation index.


Baseline and Procedural Traits

The research individuals have been divided into low SII (<694.3 × 109/L) (n = 2556, 71.8%) and excessive SII (≥694.3 × 109/L) teams (n = 1005, 28.2%). 3401 (95.5%) sufferers underwent PCI and 160 (4.5%) sufferers have been handled with CABG. Desk 1 summarizes the traits of the cohort. Sufferers with larger SII had a considerably larger incidence of CKD, ACS, and in-hospital dying, in addition to larger baseline white blood cell (WBC), neutrophil, lymphocyte, platelet ranges, NLR and PLR on admission, however a decrease incidence of smoking and a historical past of peripheral artery illness. Nevertheless, they’d decrease ranges of blood strain, glucose, LVEF, low-density lipoprotein ldl cholesterol (HDL-C), triglyceride, and hemoglobin. There have been no variations between the teams concerning the prevalence of comorbidities, together with smoking, hypertension, diabetes, and dyslipidemia. Moreover, insignificant variations have been present in C-reactive protein (CRP) and the SYNTAX rating.

Desk 1 Baseline Scientific, Angiographic, and Procedural Traits and in-Hospital Consequence in Sufferers with TVD After Revascularization In keeping with SII

Affiliation Between SII and Outcomes

The median follow-up interval was 2.4 (1.1 to 4.1) years. Within the larger SII group, there have been 268 (26.7%) MACCEs, comprising 25 (2.5%) all-cause deaths, 101 (10%) MI, 170 (16.9%) repeat revascularizations, 117 (11.6%) angina pectoris readmissions, 86 (8.6%) coronary heart failure readmissions, and 14 (1.4%) nonfatal strokes. The Cox proportional hazard regression mannequin evaluation revealed that top SII was independently related to elevated danger of growing future MACCE (hazard ratio [HR] 1.65, 95% confidence interval [CI] 1.23–2.21, p = 0.001), all-cause dying (HR: 2.96; 95% CI: 1.19–7.32, p = 0.019), repeat revascularization (HR: 1.95; 95% CI: 1.38–2.76, p < 0.001), pectoris readmission (HR: 1.77; 95% CI: 1.19–2.63, p = 0.004), coronary heart failure readmission (HR: 1.78; 95% CI: 1.02–3.10, p = 0.041) and stroke (HR: 5.81; 95% CI: 1.69–19.97, p = 0.005) aside from MI (HR: 1.27; 95% CI: 0.71–2.27, p = 0.420) after adjusting for age, gender, hypertension, diabetes, CKD, lipid profile, LVEF, and the presence of ACS throughout enrolment in line with the multivariable Mannequin 3 (Desk 2). Moreover, the affiliation between MACCE and SII remained vital in multivariable Mannequin 1 and Mannequin 2. Furthermore, Kaplan-Meier evaluation revealed that sufferers with excessive SII had larger MACCE charges than sufferers with low SII within the long-term follow-up (Desk 2, Determine 2).

Desk 2 Affiliation Between SII and Antagonistic Occasions in Sufferers with TVD After Revascularization

Determine 2 Kaplan–Meier evaluation for main opposed cardiac and cerebrovascular occasions (MACCE) (A) and all-cause dying (B) in sufferers with TVD after revascularization.

Abbreviations: SII, systemic immune-inflammation index; TVD, three-vessel illness.

Including SII to Baseline Mannequin for Prediction of Outcomes

The addition of SII to a baseline mannequin with conventional danger components led to enhancements within the prediction of MACCE (p < 0.001), all-cause dying (p < 0.001), MI (p < 0.001), repeat revascularization (p = 0.003) and coronary heart failure readmission (p < 0.001), as demonstrated by the considerably elevated C-index. The addition of SII considerably improved reclassification past the baseline mannequin with conventional danger components (MACCE: NRI, 0.115; p = 0.0001; all-cause dying: NRI, 0.369; p = 0.0001). Reclassification including SII additionally indicated an IDI of 0.0022 (p = 0.006) in MACCE and 0.0033 (p = 0.014) in all-cause dying, suggesting that the addition of SII results in a considerably improved predictive worth than conventional danger components in TVD sufferers after revascularization (Desk 3).

Desk 3 Analysis of Predictive Fashions for Antagonistic Occasions Utilizing the C-Index, NRI and IDI


To the perfect of our information, that is the primary research analyzing the power of SII to foretell scientific outcomes amongst sufferers with TVD after revascularization. Primarily based on the findings, elevated SII is straight associated to the incidence of MACCEs and long-term mortality charges in these sufferers.

Persistent irritation is understood to be a serious contributor to atherosclerotic CAD. As the primary inflammatory cell concerned in plaque formation, neutrophils appeal to leukocytes and promote foam cell formation.17 Moreover, peripheral lymphopenia throughout MI has been famous as an indication of extreme response to MI. Larger platelet counts could also be associated to worse outcomes by demonstrating the elevated launch of inflammatory mediators. Elevated platelet activation results in damaging inflammatory responses and a prothrombotic state.18 Specifically, neutrophil extracellular traps can induce quite a few prothrombotic results, together with platelet adhesion, activation, and aggregation,19 which can result in thrombosis and enhance the chance of acute issues equivalent to stroke. Proof reveals that platelet adhesion to vessel partitions enhances leukocyte recruitment and precedes atherosclerotic plaque invasion by leukocytes, initiating atheroprogression.20

The NLR and the PLR have been launched as novel markers. NLR has been reported as an unbiased predictor of cardiovascular occasions and mortality in ST-segment elevation myocardial infarction (STEMI).4 A meta-analysis demonstrated that in STEMI sufferers who have been handled with PCI, larger PLR earlier than the process was related to poor in-hospital and long-term prognosis.21 Along with the NLR and PLR, platelets play an necessary function within the pathogenesis of CAD and ACS. Neutrophils, platelets and the cytokines they produce are primarily associated to non-specific immune responses, whereas lymphocytes are thought of to be primarily associated to particular immune pathways. Remarkably, the SII, a comparatively novel inflammatory marker combining platelet, neutrophil, and lymphocyte counts, can higher replicate the immune and inflammatory state of the physique than NLR and PLR that are sometimes developed from two cells or any one in all these different markers in isolation.6 Subsequently, SII is superior to different systemic irritation index in prognostic evaluation of CAD. CRP has been confirmed to be related to elevated relative dangers of cardiovascular occasions in ACS sufferers.22 Nevertheless, CRP isn’t particular and is affected by many components. The SII is considered extra particular than CRP.7 As well as, the SII has been extensively reported to be related to poor outcomes in sufferers with numerous malignancies.

Amongst CAD sufferers, these with TVD have the best danger for cardiovascular opposed occasions. Primarily based on multivariable evaluation, our earlier research have reported that scientific descriptors equivalent to diabetes mellitus, low LVEF of 40%, and left principal coronary artery illness have been unbiased predictors of MACCE in TVD sufferers. Lately, a number of research have reported that SII was independently related to contrast-induced nephropathy improvement after PCI in sufferers with non-STEMI, coronary collateral circulation formation in steady CAD or mortality in sufferers with continual coronary heart failure.10,23,24 Nevertheless, within the present literature, there isn’t any prior scientific research demonstrating the prognostic worth of SII for long-term outcomes in TVD sufferers after revascularization. An early, easy, cheap scientific or laboratory marker should be recognized for these high-risk sufferers.

On this research, numerous multivariable Cox regression evaluation fashions have been generated to evaluate the unbiased results of the SII and outcomes of TVD sufferers after revascularization after adjusting for different potential confounders. The addition of SII to the scientific mannequin improved the predictive energy for opposed cardiovascular occasions in TVD sufferers after revascularization by way of the C-index. Moreover, it improved the reclassification of the themes into totally different danger classes by performing the NRI and IDI. Primarily based on our findings, the inflammatory standing indicated by SII is an efficient parameter in predicting MACCEs in TVD sufferers after revascularization. The current research may be the primary to reveal the nice predictive worth of SII for MACCEs in TVD sufferers present process revascularization.

Aspirin and statins have been exhibited to lower thrombosis and irritation not directly. Subsequently, these are sometimes used earlier than procedures to scale back cardiovascular occasions.25 Lately, Ridker et al reported that anti-inflammatory remedy focusing on interleukin-1β considerably lowered the speed of cardiovascular occasions in sufferers with earlier MI.26 Additional research are required to find out whether or not anti-inflammatory remedy can scale back the prevalence of scientific opposed occasions in TVD sufferers with a excessive stage of SII after revascularization.

As a easy and cheap index that may be simply calculated from full blood rely (CBC) parameters, SII is a sensible and dependable indicator. Subsequently, it may be extensively used to foretell restoration charges and help clinicians in quickly figuring out high-risk sufferers with worse prognoses for opposed cardiovascular occasions. Our research means that TVD sufferers with a excessive SII rely after revascularization must be fastidiously evaluated for additional scientific monitoring and remedy.


First, the main limitation of this research was its single-center observational design. Regardless of the usage of multivariable evaluation, there could have been sure unmeasured confounders that would have affected the research outcomes. Second, we calculated SII solely as soon as at admission and didn’t monitor modifications of SII throughout the research interval.


In TVD sufferers after revascularization, elevated SII is an unbiased prognostic issue for long-term outcomes of MACCE and dying. In comparison with conventional danger components, SII improved the chance prediction of main cardiovascular occasions in TVD sufferers who underwent revascularization. Subsequently, as a straightforward and sensible indicator, SII has the potential to assist clinicians establish high-risk sufferers.


SII, systemic immune-inflammation index; TVD, three-vessel illness; PCI, percutaneous coronary intervention; MACCE, main opposed and cerebrovascular occasions; CAD, coronary artery illness.

Information Sharing Assertion

The info used and/or analyzed throughout the present research can be found from the corresponding creator on affordable request.


The authors acknowledge all individuals of the research and the interventional cardiologists and surgeons from the First Affiliated Hospital of Dalian Medical College.


This research was supported by the the Nationwide Pure Science Basis of China (82170252), Dalian Medical Science Analysis Venture (2112002) and Dalian Youth Science and Expertise Star Assist program (2021RQ006).


The authors report no conflicts of curiosity on this work.


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