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ISSN: 1064-1963 (print), 1525-6006 (electronic)
Abstract Keywords
Background: Neutrophil to lymphocyte ratio (NLR) and platelet to lymphocyte ratio (PLR) are
Clin Exp Hypertens Downloaded from informahealthcare.com by 78.176.66.211 on 06/20/13
1.89 were among predictors of dipper and non-dipper status. In logistic regression analyses,
only hyperlipidemia (odds ratio: 2.96, CI: 1.22–7.13) and PLR more than 107 (odds ratio: 2.62, CI:
1.13–6.06) were independent predictors of dipper and non-dipper status. A PLR of 107 or higher
predicted non-dipper status with a sensitivity of 66.3% and specificity of 68.7%.
Conclusion: We demonstrated that patients with non-dipper hypertension had significantly
higher NLR and PLR compared to dipper hypertension, which has not been reported previously.
Moreover PLR more than 107 but not NLR was independent predictor of non-dipper status.
Patients were selected among cases referred to cardiology Receiver operating characteristic (ROC) curve analysis was
outpatient clinic to evaluation of hypertension from performed to determine the cut-off level of PLR to predict the
November 2012 to January 2013. The study included 166 dipper versus non-dipper status. p Values less than 0.05 were
patients with essential hypertension. All patients underwent a considered statistically significant.
24-h ambulatory BP monitoring for evaluation of dipper or
non-dipper status after diagnosis of the hypertension. Results
Ambulatory BP monitoring was performed regularly every The study population was consisted of 166 consecutive
30 min during the 24-h period. The cuff was placed around patients who were diagnosed with hypertension. All patients
the non-dominant arm of the patients. Patients were ques- were divided into two groups according to status of dipper or
tioned about their sleep quality and 24-h BP assessments were non-dipper hypertension after 24-h ambulatory BP monitor-
repeated if necessary. Sleep and awake periods were assessed ing. While 83 patients had non-dipper hypertension, 83
based on the self-information of patients. Nocturnal BP patients had dipper hypertension (52.3 ! 12.7 versus
dipping was calculated as: (%) 100 # [1 $ (sleep systolic 49.1 ! 10.5, p ¼ 0.082). Baseline characteristics and clinical
BP/awake systolic BP)]. Patients with dipper hypertension data were similar in both groups (Table 1). The hemodynamic
were defined as more than 10% decrease in systolic and data of study population was shown in Table 2. While mean
diastolic BP measurements. Patients with less than 10% BP measurements were similar in both groups, heart rate
decrease in either systolic or diastolic BP were defined as value was significantly higher in patients with dipper
non-dipper hypertension (10).
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Non-dipper Dipper
group group
(n ¼ 83) (n ¼ 83) p
$3
Leukocytes (mm ) 7608 ! 1859 7825 ! 1795 0.446
Neutrophils (mm$3) 4612 ! 1397 4470 ! 1261 0.492
Lymphocyes (mm$3) 2176 ! 671 2539 ! 719 0.001
NLR 2.3 ! 0.9 1.8 ! 0.5 50.001
(neutrophil/lymphocyte ratio)
Platelets (103/mm$3) 244.2 ! 62.7 243.8 ! 62.4 0.970
PLR 117.7 ! 35.2 100.9 ! 30.5 0.001
(platelet/lymphocyte ratio)
Hemoglobin (g/dl) 13.6 ! 1.5 13.9 ! 1.5 0.245
Fasting glocose (mg/dl) 108.5 ! 46.8 97.8 ! 24.5 0.132
Creatinine (mg/dl) 0.86 ! 0.24 0.82 ! 0.28 0.393
Total cholesterol (mg/dl) 197.5 ! 51.7 212.4 ! 41.8 0.068
Triglycerides (mg/dl) 144.5 ! 80.7 149.5 ! 74.8 0.713
Low dencity lipoprotein (mg/dl) 118.4 ! 45.6 126.4 ! 38.1 0.276
High dencity lipoprotein (mg/dl) 52.0 ! 14.3 50.5 ! 14.4 0.547
2.1 ! 1.8 2.0 ! 1.3
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hypertension had significantly higher PLR compared to levels of endothelial progenitor cells, which play an important
dipper hypertension (117.67 ! 35.15 versus 100.89 ! 30.46, role in the endothelial homeostasis and vascular repair, was
p ¼ 0.001). In univariate analysis, hyperlipidemia, smoking,
For personal use only.
reflect to inflammation, low lymphocyte counts reflect poor revascularisation. A systematic review on more than 34 000
subjects. Thromb Haemost 2011;106:591–9.
general health and physiologic stress (28). Blood NLR is an 4. Tamhane UU, Aneja S, Montgomery D, et al. Association between
indicator of the overall inflammatory and stress status of the admission neutrophil to lymphocyte ratio and outcomes in patients
body, and an alteration in NLR may be found in hypertensive with acute coronary syndrome. Am J Cardiol 2008;102:653–7.
patients. Recently published trials established that NRL was 5. Uthamalingam S, Patvardhan EA, Subramanian S, et al. Utility of
the neutrophil to lymphocyte ratio in predicting long-term
associated with increased mortality and poor prognosis in
outcomes in acute decompensated heart failure. Am J Cardiol
acute coronary syndromes especially ST segment elevation 2011;107:433–8.
MI (29). NRL was also increased in patients with diabetes 6. Tsiara S, Elisaf M, Jagroop IA, Mikhailidis DP. Platelets as
mellitus and hypertension. NLR can be a useful and cost- predictor of vascular risk: is there a practical index of platelet
effective method to evaluate inflammatory state. activity? Clin Appl Thromb Hemost 2003;9:177–90.
7. Kannel WB. Blood pressure as a cardiovascular risk factor:
Previous studies have demonstrated that higher platelet and prevention and treatment. JAMA 1996;275:1571–6.
lower lymphocyte counts were associated with adverse 8. Seo HS, Kang TS, Park S, et al. Non-dippers are associated with
cardiovascular outcomes. Azab et al. showed that higher adverse cardiac remodeling and dysfunction. In J Cardiol 2006;112:
value of PLR as a marker of long-term mortality in patients 171–7.
9. Turak O, Ozcan F, Tok D, et al. Serum uric acid, inflammation, and
with non-ST segment elevation MI (30). In patients with nondipping circadian pattern in essential hypertension. J Clin
various malignancies such as ovarian cancer and pancreatic Hypertens (Greenwich) 2013;15:7–13.
ductal adenocarcinoma, it has been demonstrated that eleva- 10. Pickering TG. The clinical significance of diurnal blood pressure
tion of neutrophils, platelets, NLR or PLR were associated variations. Dippers and nondippers. Circulation 1990;81:700–2.
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11. Birkenhäger AM, van den Meiracker AH. Causes and consequences
with some adverse clinico-pathologic events (31,32). of a non-dipping blood pressure profile. Neth J Med 2007;65:
Although the association between NLR and cardiovascular 127–31.
disease has been demonstrated in numerous studies, the 12. Zacharieva S, Orbetzova M, Stoynev A, et al. Circadian blood
association between PLR and cardiovascular diseases pressure profile in patients with Cushing’s syndrome before and
after treatment. J Endocrinol Invest 2004;27:924–30.
remained unclear except a few clinical studies (30,33). To 13. Sasaki N, Ozono R, Yamauchi R, et al. Age-related differences in
date, there is no study investigating the relationship between the mechanism of nondipping among patients with obstructive
PLR and dipper versus non-dipper status. Our study, for the sleep apnea syndrome. Clin Exp Hypertens 2012;34:270–7.
first time demonstrated that PLR was not only higher in the 14. Liu M, Takahashi H, Morita Y, et al. Non-dipping is a potent
predictor of cardiovascular mortality and is associated with
non-dipper group than the dipper group it also emerged as an autonomic dysfunction in haemodialysis patients. Nephrol Dial
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