Experimental Gerontology 139 (2020) 111019

Contents lists available at ScienceDirect

Experimental Gerontology
journal homepage: www.elsevier.com/locate/expgero

The associations between neutrophil-to-lymphocyte ratio and the Chinese T

Visceral Adiposity Index, and carotid atherosclerosis and atherosclerotic
cardiovascular disease risk
⁎
Baoli Lia,1, Xiaoying Laia,1, Chuanjie Yana, Xiaoping Jiaa, Yingjia Lib,
a
Department of Health Management Center, NanFang Hospital, Southern Medical University, Guangzhou, Guangdong, China
b
Department of Medicine Ultrasonic, NanFang Hospital, Southern Medical University, Guangzhou, Guangdong, China

A R T I C LE I N FO A B S T R A C T

Section Editor: Richard Aspinall
Keywords:
Neutrophil-to-lymphocyte ratio
Chinese Visceral Adiposity Index
Carotid atherosclerosis
Atherosclerotic cardiovascular disease
Elderly adults
Background: Inflammation and obesity are the main risk factors for the development of carotid atherosclerosis
and atherosclerotic cardiovascular disease (ASCVD). The neutrophil-to-lymphocyte ratio (NLR) is a recently
developed indicator of inflammation that can be easily calculated from blood cell counts. The Chinese Visceral
Adiposity Index (CVAI) was used to assess visceral obesity in the Chinese population.
Aims: To explore the associations between both NLR and CVAI, and carotid atherosclerosis and ASCVD risk in
elderly Chinese.
Methods: A total of 4437 participants aged ≥55 years and with no history of cardiovascular disease, were
enrolled in this retrospective study. Anthropometric measurements, laboratory results, and carotid ultra-
sonography results were extracted from a database. We used established formulas to calculate NLR and CVAI,
and the Pooled Cohort Equations to generate the 10–year ASCVD risk score. Participants were divided into two
groups according to their 10–year ASCVD scores: < 7.5% and ≥7.5%.
Results: NLR and CVAI were significantly higher in patients with carotid atherosclerosis. Regression analysis
showed that NLR (OR 1.23, 95% CI 1.05–1.43, p = 0.01) and CVAI (OR 1.39, 95% CI 1.21–1.61, p = 0.001)
were independent risk factors for carotid atherosclerosis. A combination of NLR and CVAI improved the
goodness-of-fit (p < 0.001) and discriminability of the model (p = 0.0013). NLR, CVAI and carotid plaques
showed positive associations with the 10–year ASCVD risk score (all p < 0.001).
Conclusions: NLR and CVAI are positively associated with the prevalence of carotid atherosclerosis and high risk
of ASCVD in elderly adults and could be useful in the identification of a high risk of atherosclerosis.

1. Introduction
Inflammation has been regarded as a key pathogenic mechanism in
atherosclerosis (AS), and it also plays a vital role in the initiation and
development of cardiovascular diseases (CVD) (Peter, 2006; Plutzky,
2001; Ross, 1999). Inflammatory biomarkers such as C-reactive protein
(CRP), interleukin (IL)-6, and tumor necrosis factor (TNF-α) have been
investigated as a means of monitoring AS and CVD risk. Recently, the
neutrophil-to-lymphocyte ratio (NLR) has received attention due to its
ease of calculation from blood cell counts. Unlike other inflammatory
markers, the NLR is cost-effective and can be calculated routinely.
Several studies have shown that NLR is valuable in predicting the risk of
AS and CVD (Acet et al., 2014; Balta et al., 2016).
Obesity has long been recognized as a clear risk factor for CVD
development (Guh et al., 2009). Visceral obesity has been regarded as a
more prominent CVD risk factor compared with subcutaneous adiposity
(Despres, 2012; Van Gaal et al., 2006). The visceral adiposity index
(VAI), an easily measurable indicator of visceral fat distribution and
dysfunction, has been associated with the severity of coronary heart
diseases (CHD) and AS (Amato et al., 2010; Han et al., 2014; Park et al.,
2016). However, due to the considerable differences in VAI between
populations and ethnicities, it has limitations when applied to non-
Caucasian populations (Lear et al., 2007). The Chinese Visceral Adip-
osity Index (CVAI) is a novel indicator developed to assess visceral
obesity in the Chinese population, and combines age, body mass index
(BMI), waist circumference (WC), and triglyceride (TG) and high den-
sity lipoprotein cholesterol (HDL-C) levels in the calculation. CVAI has
proved to be a reliable marker in predicting diabetes mellitus,

⁎
Corresponding author at: Nanfang Hospital, Department of Medicine Ultrasonic, Southern Medical University, Guangzhou 510515, China.
E-mail address: lyjia@smu.edu.cn (Y. Li).
1
Baoli Li and Xiaoying Lai contributed equally.

https://doi.org/10.1016/j.exger.2020.111019
Received 9 April 2020; Received in revised form 1 July 2020; Accepted 3 July 2020
Available online 11 July 2020
0531-5565/ © 2020 Elsevier Inc. All rights reserved.
B. Li, et al.
metabolic syndrome, AS, and CVD (Wu et al., 2017; Xia et al., 2016; Xie
et al., 2018).
Atherosclerotic cardiovascular disease (ASCVD) risk scores for dif-
ferent ethnicities (black, white, or other) have been designed to im-
prove cardiovascular risk estimates. Compared with other assessment
methods, such as the Framingham Risk Score, the 10–year ASCVD risk
score includes other determining factors and has been shown to be
more accurate in predicting future cardiovascular events (D’Agostino
et al., 2001; Muntner et al., 2014).
NLR was found to be correlated with arterial stiffness and carotid
intima-media wall thickness in patients with diabetes and osteoporosis
(Ayhan et al., 2015; Wang et al., 2015; Yu et al., 2015). Only a few
studies have been conducted in healthy populations. While previous
studies have mainly focused on NLR and VAI and coronary artery dis-
eases (Ateş et al., 2016; Verdoia et al., 2016), there have been hardly
any reports on the relationship between NLR and CVAI and the early
stages of atherosclerosis in the Chinese population. This study was
designed to explore the associations between NLR and CVAI, and car-
otid atherosclerosis (CAS) and ASCVD risk in elderly adults.
2. Method
2.1. Study participants
Adults undergoing routine health check-ups at a tertiary hospital
health center from January to December 2018 were enrolled in the
investigation. Participants younger than 55 years or older than
90 years, or without complete data such as blood cell counts or ultra-
sound examination, or who had been previously diagnosed with CVD,
or who had had diseases affecting blood cell counts were excluded. A
total of 4437 participants were eventually included. Because the
10–year ASCVD risk score had already been applied to adults aged 40 to
Fig. 1. Flowchart of participants selection.
2
Experimental Gerontology 139 (2020) 111019
79 years, 4221 participants were given an ASCVD risk evaluation. The
process of participant selection is shown in Fig. 1. Patient histories of
smoking, hypertension, diabetes mellitus, dyslipidemia and medication
use were extracted from the database. Blood pressure was measured
three times after sitting for 5 min, and the average measurements were
used in the analysis. Participant's height and weight without shoes or
coats were measured. Waist circumference was measured at the umbi-
licus in a standing position, and BMI was calculated as weight divided
by height squared (kg/m2). Hypertension was recorded when blood
pressure was ≥140/90 mmHg or if patients were taking anti-hy-
pertensive drugs. The diagnostic criteria for type 2 diabetes mellitus
(T2DM) were a fasting blood glucose level above 126 mg/dL
(7.0 mmol/L), or a history of T2DM, or the use of anti-diabetic drugs.
Smoking was recorded both for current or past cigarette smoking.
Dyslipidemia was defined as a total cholesterol level (TC) ≥240 mg/dL
(6.2 mmol/L), or TG ≥200 mg/dL (2.3 mmol/L), or HDL-C < 40 mg/
dL (1.0 mmol/L), or when lipid-lowering drugs were used.
The study was approved by the Ethical Committee of NanFang
Hospital, Southern Medical University (NFEC-2019-056); informed
consent was waived because of the retrospective design.
2.2. Laboratory parameters
All laboratory examinations, including glucose, lipids, and blood
cell counts, were conducted after 12 h of overnight fasting. An auto-
analyzer (XN-10[B4], Sysmex, Japan) was used to analyze white blood
cell, neutrophil, lymphocyte, and platelet counts. Glucose was mea-
sured using the glucose oxidase method. Lipid metabolism spectra were
obtained using a biochemical autoanalyzer (AU5400 Biochemical
Autoanalyzer; Beckman Coulter, Japan).
The neutrophil-to-lymphocyte ratios were calculated as the ratio of
the absolute neutrophil counts to the absolute lymphocyte counts. The
B. Li, et al. Experimental Gerontology 139 (2020) 111019

Chinese Visceral Adiposity Index were calculated using the following Table 1
sex-specific formulas, following Xia et al., 2016. General characteristics of participants with and without CAS.
Males: Variable CAS (n = 2162) Non-CAS p-Value
(n = 2275)
CVAI
= −267.93 + 0.68 × age + 0.03 × BMI + 4.00 × WC + 22.00 × Age, years 67 (60, 72) 59 (56, 66) < 0.001
Male, n (%) 1782 (82.42) 1564 (68.75) < 0.001
log 10TG − 16.32 × HDL − C BMI, kg/m2 25.17 (23.30, 27.09) 24.41 (22.52, < 0.001
26.43)
Females: WC, cm 88.68 ± 9.05 84.99 ± 9.06 < 0.001
SBP, mmHg 126 (114, 137) 117 (108, 128) < 0.001
CVAI DBP, mmHg 76 (68, 74) 71 (64, 79) < 0.001
= −187.32 + 1.71 × age + 4.23 × BMI + 1.12 × WC + 39.76 × White blood cell,109/L 6.22 ± 1.73 5.93 ± 1.53 < 0.001
Neutrophil,109/L 3.54 ± 1.35 3.34 ± 1.11 < 0.001
log 10TG − 11.66 × HDL − C Lymphocyte,109/L 2.05 ± 0.60 2.00 ± 0.58 0.013
Platelet,109/L 229.83 ± 52.72 235.20 ± 53.99 0.001
The 10–year ASCVD risk scores were calculated using the Pooled NLR 1.69 (1.33, 2.14) 1.65 (1.31, 2.04) 0.011
Cohort Equations of the 2013 ACC/AHA guidelines (Goff Jr. et al., FBG, mmol/L 5.31 (4.95, 5.90) 5.12 (4.82, 5.51) < 0.001
2014). The risk scores were further divided into low risk (< 7.5%) and TC, mmol/L 2.30 ± 0.24 2.28 ± 0.21 0.004
HDL-C, mmol/L 0.068 ± 0.10 0.09 ± 0.10 < 0.001
high risk (≥7.5%), according to established guidelines (Stone et al.,
TG, mmol/L 1.39 (1.01, 2.00) 1.26 (0.91, 1.87) < 0.001
2014). LDL-C, mmol/L 1.85 ± 0.23 1.83 ± 0.20 0.001
CVAI 110.82 (87.44, 91.58 (63.43, < 0.001
2.3. Carotid artery ultrasound 136.66) 118.12)
Dyslipidemia, n (%) 1039 (48.06) 997 (43.82) 0.005
History of smoking, n 827 (38.25) 742 (32.62) < 0.001
Participants rested for a 15 min period prior to carotid ultrasound (%)
examination. Sonographers used a 4–13 MHz transducer (Esaote Mylab History of 784 (36.26) 512 (22.51) < 0.001
class C, LA523) to scan the bilateral common carotid artery (CCA), the hypertension, n (%)
History of T2DM, n (%) 385 (17.81) 254 (11.16) < 0.001
internal carotid, and the external carotid. The intima-media thickness
(IMT) was measured approximately 10 mm below the CCA bifurcation Abbreviations: CAS, carotid atherosclerosis; BMI, body mass index; WC, waist
and was defined as the distance from the intima-lumen interface to the circumference; SBP, systolic blood pressure; DBP, diastolic blood pressure; NLR,
media-adventitia interface. The average of three measurements was neutrophil-to-lymphocyte ratio; FBG, fasting blood glucose; TC, total choles-
recorded. Increased IMT was defined as ≥0.9 mm on either carotid terol; HDL-C, high density lipoprotein cholesterol; TG, triglycerides; LDL, low
artery. Plaque was defined as a structure of at least 0.5 mm that pro- density lipoprotein cholesterol; CVAI, Chinese Visceral Adiposity Index; T2DM,
truded into the lumen, or exceeded 50% of the surrounding IMT value, type 2 diabetes mellitus.
or reached a thickness of 1.5 mm. Carotid atherosclerosis was defined
as an increased IMT and/or the presence of plaque (Piepoli et al., 2016; values, and white blood cell counts, as well as lower lymphocyte counts
Touboul et al., 2012). and HDL-C values (all p < 0.05). Furthermore, the CAS group also
exhibited a higher prevalence of smoking, hypertension, T2DM, and
3. Statistical analysis dyslipidemia. There were statistically significant differences in NLR
(1.69 vs. 1.65, p = 0.011) and CVAI (110.82 vs. 90.58, p < 0.001)
Continuous variables were expressed as mean ± standard devia- values between the CAS and Non-CAS groups, indicating a higher de-
tion if the variables had a normal distribution, or median and inter- gree of inflammation and the possibility of visceral adiposity in CAS
quartile range (P25, P75) if they had a skewed distribution. Continuous patients.
variables were analyzed using independent sample t-tests or Mann-
Whitney U tests. Categorical variables were defined as number (%), and 4.2. Correlation and predictive value of NLR and CVAI with carotid
were analyzed using the Chi-square test. Univariate and multivariate atherosclerosis
logistic regressions were applied to investigate the associations between
different variables and CAS. Variables were selected for inclusion in the Using receiver-operating characteristic curve (ROC) analysis, cut-off
final model using a forward likelihood ratio method. Likelihood ratio values of NLR > 2.06 and CVAI > 96.51 were found to discriminate
tests and Delong's tests were performed to compare the goodness of fit between the CAS and Non-CAS populations. Univariate logistic re-
and discriminability of four models. Model 1 contained traditional gression analysis was used to rank the correlations of the following
atherosclerosis risk factors: age, gender, history of smoking, hyperten- variables with CAS: CVAI, gender, hypertension, T2DM, NLR, smoking,
sion, T2DM, and dyslipidemia. Model 2 added NLR to Model 1. Model 3 dyslipidemia, and age. The multivariable logistic regression showed
added CVAI to Model 1. Model 4 added NLR and CVAI to Model 1. that NLR (OR 1.23, 95% CI 1.05–1.43, p = 0.01) and CVAI (OR 1.39,
Spearman and Partial analyses were conducted between NLR, CVAI, the 95% CI 1.21–1.61, p = 0.001) were independently associated with CAS
incidence of carotid plaques and 10–year ASCVD risk scores. Statistical after adjusting for age, gender, hypertension, and T2DM (Table 2). Four
analyses were performed using SPSS22.0 and Medcalc software. The p- models were established to investigate the combined predictive value of
value was two-tailed with a statistical significance of 0.05. NLR and CVAI for CAS by comparing the areas under the curve (AUC)
(Table 3). Notably, of all the models, Model 4 showed the maximum
4. Results AUC, demonstrating that combining NLR and CVAI improved the
goodness-of-fit and discriminability of this model (differences of log
4.1. Characteristics of study participants likelihood 18.56, p < 0.001; differences of C-index 3.21, p = 0.0013)
(Fig. 2).
A total of 4437 participants were analyzed (3346 men and 1091
women). The mean age was 62.39 ± 8.11 years (range 55–89 years). 4.3. Associations between NLR, CVAI and carotid plaques, and the 10–year
The clinical characteristics are shown in Table 1. Compared with the ASCVD risk score
Non-CAS group, participants with CAS were more likely to be older
men, have higher BMI, WC, blood pressure, lipid and fasting glucose We investigated the relationships between the variables with the

3
B. Li, et al. Experimental Gerontology 139 (2020) 111019

Table 2
Predictors of the carotid atherosclerosis using logistic regression models.
Predictor Univariate Multivariable

Odds ratio 95% CI p-Value Odds ratio 95% CI p-Value

Lower Upper Lower Upper

Age 1.15 1.14 1.16 < 0.001 1.15 1.14 1.16 < 0.001
Male 2.13 1.85 2.46 < 0.001 2.24 1.88 2.67 < 0.001
NLR 1.28 1.12 1.46 < 0.001 1.23 1.05 1.43 0.010
CVAI 2.49 2.21 2.81 < 0.001 1.39 1.21 1.61 0.001
Smoking 1.28 1.13 1.45 < 0.001
T2DM 1.72 1.45 2.05 < 0.001 1.26 1.04 1.53 0.021
Hypertension 1.96 1.72 2.24 < 0.001 1.40 1.20 1.63 < 0.001
Dyslipidemia 1.19 1.05 1.34 0.005

Abbreviation: T2DM, type 2 diabetes mellitus; NLR, neutrophil-to-lymphocyte ratio; CVAI, Chinese Visceral Adiposity Index. Cutoff values used for dichotomization
were: NLR > 2.06; CVAI > 96.51.

Table 3 Table 4
Comparison of the goodness of fit and discriminability of logistic regression Correlation between clinical parameters, NLR, CVAI and 10-year ASCVD risk
models. score.
Likelihood ratio test Discriminability 10-year ASCVD risk score (%)

LogLik Diff. (%) p-Value C-index Diff. (%) p-Value Unadjusted coefficients Age-adjusted coefficients
(%)
r p-Value r p-Value
Model 1 −2524.67 38.72
Model2 −2522.47 38.82 BMI, kg/m2 0.302 < 0.001 0.230 < 0.001
Model 3 −2507.40 39.70 WC, cm 0.464 < 0.001 0.341 < 0.001
Model 4 −2506.11 39.77 SBP, mmHg 0.457 < 0.001 0.383 < 0.001
Model 1 vs. 18.56 < 0.001 3.21 0.0013 DBP, mmHg 0.397 < 0.001 0.351 < 0.001
Model 4 NLR 0.085 < 0.001 0.063 < 0.001
FBG, mmol/L 0.348 < 0.001 0.310 < 0.001
Model 1: age + gender + smoking + T2DM + hypertension; Model 2: Model TC, mmol/L 0.144 < 0.001 0.150 < 0.001
1 + NLR; Model 3: Model 1 + CVAI; Model 4: Model 1 + NLR + CVAI. HDL-C, mmol/L −0.374 < 0.001 −0.357 < 0.001
Abbreviation: LogLik, loglikelihood; Diff., difference; C-index, Harrell's con- TG, mmol/L 0.356 < 0.001 0.405 < 0.001
LDL-C, mmol/L 0.178 < 0.001 0.134 < 0.001
cordance index; T2DM, type 2 diabetes mellitus; NLR, neutrophil-to-lympho-
CVAI 0.431 < 0.001 0.363 < 0.001
cyte ratio; CVAI, Chinese Visceral Adiposity Index.
Number of carotid 0.409 < 0.001 0.286 < 0.001
plaques

Abbreviation: ASCVD, atherosclerotic cardiovascular disease; BMI, body mass

index; WC, waist circumference; SBP, systolic blood pressure; DBP, diastolic
blood pressure; TC, total cholesterol; TG, triglycerides; HDL, high density li-
poprotein cholesterol; LDL, low density lipoprotein cholesterol; FBG, fasting
blood glucose; NLR, neutrophil-to-lymphocyte ratio; CVAI, Chinese Visceral
Adiposity Index; FBG, fasting blood glucose.

Fig. 2. Comparison of ROC according to logistic regression models.
Model 1: age + gender + smoking + T2DM + hypertension; Model 4: Model
1 + NLR + CVAI.
Abbreviation: ROC, receiver–operating characteristic curve; AUC, area under
curve; T2DM, type 2 diabetes mellitus; NLR, neutrophil-to-lymphocyte ratio;
CVAI, Chinese Visceral Adiposity Index.
risk (all p < 0.001). CVAI (adjusted r 0.363, p < 0.001) and the
number of carotid plaques (adjusted r 0.286, p < 0.001) showed sig-
nificantly positive associations with the 10–year ASCVD risk score,
while NLR exhibited a weak correlation (adjusted r 0.063, p < 0.001).
Established cutoffs, according to the guidelines, defined 10–year
ASCVD risk scores below 7.5% as low risk and above 7.5% as high risk.
Significantly, participants with high risk tended to be male (1395,
94.1%), older (66 vs. 58), and smokers (67.1% vs. 18.7%), and had a
high prevalence of hypertension (41.9% vs. 14.8%), diabetes (22.9% vs.
4.4%), and dyslipidemia (60.3% vs. 34.2%) (Table 5). The high risk
group had higher NLR (1.70 vs. 1.64, p = 0.002) and CVAI (121.86 vs.
89.68, p < 0.001) values and more carotid plaques (1.57 vs. 0.49,
p < 0.001) than the low risk group. Individuals with carotid plaques,
high inflammatory states, and visceral obesity had a greater chance of
developing ASCVD in the future.
5. Discussion

This study demonstrated that NLR and CVAI were significantly

10–year ASCVD risk score and adjusted for age as the main influencing correlated with CAS and ASCVD risk. NLR and CVAI were independent
variable (Table 4). Variables used to calculate the ASCVD risk score risk factors for CAS after adjusting for confounding variables, and the
(e.g. SBP, TC, HDL-C) had strong correlations with the 10–year ASCVD combination of these two indicators improved the predictive value of

4
B. Li, et al. Experimental Gerontology 139 (2020) 111019

Table 5 inflammatory process. Visceral adipose generates various pro-in-

Differences in clinical parameters, NLR and CVAI between risk groups. flammatory hormones and cytokines, such as TNF-α, IL-6, and pigment
10-year ASCVD risk score (%) p-Value epithelium-derived factor (PEDF), which might increase the risk of
atherosclerosis and CVD (Romacho et al., 2014; Smitka and Maresova,
< 7.5% (low risk) ≥7.5% (high risk) 2015). We used CVAI to assess obesity rather than other indicators
because many studies have indicated that visceral adiposity exerts a
Age, years 58 (55, 64) 66 (60, 70) < 0.001
Male, n (%) 1801 (65.8%) 1395 (94.1%) < 0.001 greater influence on CVD risk than other anthropometric parameters
BMI, kg/m2 24.39 (22.51, 25.62 (23.75, < 0.001 (e.g. weight, BMI, and WC) (Despres, 2012; Park et al., 2016; Yusuf
26.29) 27.47) et al., 2004). Indeed, obesity and metabolic syndrome have previously
WC, cm 84.6 ± 8.79 90.75 ± 8.51 < 0.001 been recognized as common vascular risk factors for atherosclerotic
SBP, mmHg 117 (108, 127) 129 (118, 140) < 0.001
diseases.
DBP, mmHg 71 (64, 79) 78 (71, 86) < 0.001
NLR 1.64 (1.30, 2.05) 1.70 (1.34, 2.14) 0.002 Despite carotid atherosclerosis, our participants had few serious
FBG, mmol/L 5.11 (4.81, 5.48) 5.44 (5.04, 6.21) < 0.001 clinical complications. Therefore, the NLR values found in this study
TC, mmol/L 5.23 ± 0.88 5.49 ± 0.99 < 0.001 were lower than other studies due to the low incidence of inflammation
HDL-C, mmol/L 1.29 ± 0.29 1.13 ± 0.25 < 0.001
in this healthy population. Although NLR did differ significantly be-
TG, mmol/L 1.22 (0.89, 1.73) 1.59 (1.15, 2.33) < 0.001
LDL-C, mmol/L 3.4 ± 0.7 3.62 ± 0.77 < 0.001
tween the CAS and Non-CAS groups, the independent predictive value
CVAI 89.68 (64.04, 121.86 (99.42, < 0.001 for carotid atherosclerosis was weak. In addition, the cut-off values of
113.39) 144.29) NLR and CVAI were significantly different due to the heterogeneity of
Dyslipidemia, n (%) 936 (34.2%) 894 (60.3%) < 0.001 the study population. A significant challenge for future investigations
History of smoking, n (%) 512 (18.7%) 995 (67.1%) < 0.001
will be to determine the appropriate cutoff values of NLR and CVAI for
History of hypertension, n 406 (14.8%) 622 (41.9%) < 0.001
(%) clinical practice. A combination of NLR and CVAI provides slightly
History of T2DM, n (%) 121 (4.4%) 339 (22.9%) < 0.001 greater predictive value compared with the use of traditional athero-
Average number of 0.49 ± 0.96 1.57 ± 1.84 < 0.001 sclerosis risk factors. Most importantly, NLR and CVAI are simple,
plaques
cheap, routine measures that can have a beneficial impact on the cost of
health care, are particularly suited to widespread population screening.
Abbreviation: ASCVD, atherosclerotic cardiovascular disease; BMI, body mass
index; WC, waist circumference; SBP, systolic blood pressure; DBP, diastolic NLR and CVAI could be useful tools for identifying patients at high risk
blood pressure; TC, total cholesterol; TG, triglycerides; HDL, high density li- of atherosclerotic diseases.
poprotein cholesterol; LDL, low density lipoprotein cholesterol; FBG, fasting One of the strengths of our study was its relatively large sample size
blood glucose; NLR, neutrophil-to-lymphocyte ratio; CVAI, Chinese Visceral compared with other similar studies. We have clearly illustrated the
Adiposity Index; FBG, fasting blood glucose. combined predictive value of NLR and CVAI for CAS, and provided a
new means of clinically evaluating the risk of atherosclerosis. We have
CAS. The neutrophil-to-lymphocyte ratio and CVAI were significantly not only verified the relationship between NLR and CVAI, and athero-
higher in patients with high ASCVD risk compared to those with low sclerosis in an elderly population, but also assessed the impact of these
risk. As biomarkers of inflammatory and visceral obesity, NLR and CVAI two indicators on the risk of future ASCVD. But our study did have some
appear to be reliable indicators of the risk of developing atherosclerotic limitations. It was a retrospective, single-center study that may not be
disease. representative of the entire elderly Chinese population. Also, because
Our results were consistent with other studies showing correlations not every individual underwent laboratory examinations and carotid
between NLR, atherosclerosis and CVD (Hyun et al., 2015; Mayer et al., ultrasound, selection bias cannot be ruled out entirely. Without follow-
2013). Wang et al. (2017) reported that NLR could be an effective up data, we were unable to verify the predictive efficacy of NLR and
predictor of sub-clinical arteriosclerosis in a hypertense population. CVAI for ASCVD. Our findings need further investigation in a multi-
Yurtdas et al. (2014) showed that NLR was a predictor of athero- center and prospective cohort study.
sclerosis in patients with psoriasis. Yang et al. (2018) found a positive In conclusion, as biomarkers of inflammation and visceral adiposity,
correlation between NLR and atherosclerosis in Chinese patients with NLR and CVAI were positively associated with the prevalence of CAS
systemic lupus erythematosus. Balta et al. (2013) reported the asso- and a high risk of ASCVD in an elderly population. The advantages of
ciation between NLR and coronary artery ectasia, and NLR was sig- this easily applicable and inexpensive screening process may be bene-
nificantly increased in patients with atherosclerotic coronary artery ficial in predicting atherosclerotic disease in clinical practice.
ectasia. To our knowledge, our study is the first to explore the asso-
ciations between NLR and CVAI, and carotid atherosclerosis and Author statement
atherosclerotic disease risk in a relatively large sample from a healthy
population and provides new insights into the significant correlations Baoli Li: Conceptualization, Methodology, Investigation, Writing-
between NLR and CVAI, and atherosclerosis in healthy individuals. Original Draft preparation, Funding acquisition.
These significant associations could be explained by the action of Xiaoying Lai: Methodology, Investigation, Formal analysis, Funding
chronic inflammations. The neutrophil-to-lymphocyte ratio is the ratio acquisition.
of the neutrophil counts to lymphocyte counts. Elevated neutrophils Chuanjie Yan: Data Curation, Software.
secrete various inflammatory mediators, proteolysis enzymes, and re- Xiaoping Jia: Validation, Visualization.
active oxygen radicals, which promote an inflammatory response to Yingjia Li: Conceptualization, Methodology, Writing-Review &
tissue injury (Eriksson et al., 2001; Tamhane et al., 2008). Furthermore, Editing, Supervision.
a reduction in lymphocytes, due to lymphocyte redistribution and
apoptosis, decrease anti-inflammatory cytokine secretions (e.g. IL-10
Declaration of competing interest
and IL-4) (Koklu et al., 2016; Tamhane et al., 2008). The neutrophil-to-
lymphocyte ratio indicates the balance between the two important, and
opposing, immune pathways (inflammation and stress response) The authors declare no conflict of interest.
(Weber et al., 2008). Higher NLR indicates increased inflammation and
a higher risk of atherosclerosis. CVAI has been identified as an effective Acknowledgements
biomarker to estimate visceral adiposity. The relationship between
CVAI and atherosclerosis and ASCVD risk could represent a pro- NA.

5
B. Li, et al.
Funding
This research was supported by the Clinical Research Program of
Nanfang Hospital, Southern Medical University, China (grant number:
2018CR009) and President Foundation of Nanfang Hospital, Southern
Medical University, China (grant number: 2017C039).
References
Acet, H., Ertas, F., Akil, M.A., Oylumlu, M., Polat, N., Yildiz, A., Bilik, M.Z., Yuksel, M.,
Kaya, Z., Ulgen, M.S., 2014. New inflammatory predictors for non-valvular atrial
fibrillation: echocardiographic epicardial fat thickness and neutrophil to lymphocyte
ratio. Int J Cardiovasc Imaging. https://doi.org/10.1007/s10554-013-0317-4.
Amato, M.C., Giordano, C., Galia, M., Criscimanna, A., Vitabile, S., Midiri, M., Galluzzo,
A., 2010. Visceral Adiposity Index: a reliable indicator of visceral fat function asso-
ciated with cardiometabolic risk. Diabetes Care. https://doi.org/10.2337/dc09-1825.
Ateş, A.H., Aytemir, K., Koçyiğit, D., Yalcin, M.U., Gürses, K.M., Yorgun, H., Canpolat, U.,
Hazırolan, T., Özer, N., 2016. Association of neutrophil-to-lymphocyte ratio with the
severity and morphology of coronary atherosclerotic plaques detected by multi-
detector computerized tomography. Acta Cardiol Sin. https://doi.org/10.6515/
acs20160225a.
Ayhan, H., Kasapkara, H.A., Aslan, A.N., Durmaz, T., Keles, T., Akcay, M., Akar Bayram,
N., Bastug, S., Bilen, E., Sari, C., Bozkurt, E., 2015. Relationship of neutrophil-to-
lymphocyte ratio with aortic stiffness in type 1 diabetes mellitus. Can. J. Diabetes.
https://doi.org/10.1016/j.jcjd.2015.01.004.
Balta, S., Demirkol, S., Celik, T., Kucuk, U., Unlu, M., Arslan, Z., Balta, I., Iyisoy, A.,
Kocak, N., Haqmal, H., Yokusoglu, M., 2013. Association between coronary artery
ectasia and neutrophil-lymphocyte ratio. Angiology. https://doi.org/10.1177/
0003319713480424.
Balta, S., Celik, T., Mikhailidis, D.P., Ozturk, C., Demirkol, S., Aparci, M., Iyisoy, A., 2016.
The relation between atherosclerosis and the neutrophil-lymphocyte ratio. Clin. Appl.
Thromb. Hemost. https://doi.org/10.1177/1076029615569568.
D’Agostino Sr., R.B., Grundy, S., Sullivan, L.M., Wilson, P., 2001. Validation of the
Framingham coronary heart disease prediction scores: results of a multiple ethnic
groups investigation. Jama 286 (2), 180–187. https://doi.org/10.1001/jama.286.2.
180.
Despres, J.P., 2012. Body fat distribution and risk of cardiovascular disease: an update.
Circulation. https://doi.org/10.1161/circulationaha.111.067264.
Eriksson, E.E., Xie, X., Werr, J., Thoren, P., Lindbom, L., 2001. Direct viewing of ather-
osclerosis in vivo: plaque invasion by leukocytes is initiated by the endothelial se-
lectins. FASEB J. 15 (7), 1149–1157. https://doi.org/10.1096/fj.00-0537com.
Goff Jr., D.C., Lloyd-Jones, D.M., Bennett, G., Coady, S., D’Agostino Sr., R.B., Gibbons, R.,
Greenland, P., Lackland, D.T., Levy, D., O’Donnell, C.J., Robinson, J.G., Schwartz,
J.S., Shero, S.T., Smith Jr., S.C., Sorlie, P., Stone, N.J., Wilson, P.W.F., 2014. 2013
ACC/AHA guideline on the assessment of cardiovascular risk: a report of the
American College of Cardiology/American Heart Association Task Force on Practice
Guidelines. J. Am. Coll. Cardiol. https://doi.org/10.1016/j.jacc.2013.11.005.
Guh, D.P., Zhang, W., Bansback, N., Amarsi, Z., Birmingham, C.L., Anis, A.H., 2009. The
incidence of co-morbidities related to obesity and overweight: a systematic review
and meta-analysis. BMC Public Health. https://doi.org/10.1186/1471-2458-9-88.
Han, L., Fu, K.L., Zhao, J., Wang, Z.H., Tang, M.X., Wang, J., Wang, H., Zhang, Y., Zhang,
W., Zhong, M., 2014. Visceral adiposity index score indicated the severity of coronary
heart disease in Chinese adults. Diabetol. Metab. Syndr. https://doi.org/10.1186/
1758-5996-6-143.
Hyun, S., Kwon, S., Cho, S., Park, S., Jung, W., Moon, S., Park, J., Ko, C., Cho, K., 2015.
Can the neutrophil-to-lymphocyte ratio appropriately predict carotid artery stenosis
in patients with ischemic stroke?—a retrospective study. J. Stroke Cerebrovasc. Dis.
https://doi.org/10.1016/j.jstrokecerebrovasdis.2015.07.024.
Koklu, E., Yuksel, I.O., Arslan, S., Bayar, N., Cagirci, G., Gencer, E.S., Alparslan, A.S., Cay,
S., Kus, G., 2016. Is elevated neutrophil-to-lymphocyte ratio a predictor of stroke in
patients with intermediate carotid artery stenosis? J. Stroke Cerebrovasc. Dis.
https://doi.org/10.1016/j.jstrokecerebrovasdis.2015.10.031.
Lear, S.A., Humphries, K.H., Kohli, S., Chockalingam, A., Frohlich, J.J., Birmingham, C.L.,
2007. Visceral adipose tissue accumulation differs according to ethnic background:
results of the Multicultural Community Health Assessment Trial (M-CHAT). Am. J.
Clin. Nutr. https://doi.org/10.1093/ajcn/86.2.353.
Mayer, F.J., Gruenberger, D., Schillinger, M., Mannhalter, C., Minar, E., Koppensteiner,
R., Arbesu, I., Niessner, A., Hoke, M., 2013. Prognostic value of neutrophils in pa-
tients with asymptomatic carotid artery disease. Atherosclerosis. https://doi.org/10.
1016/j.atherosclerosis.2013.10.002.
Muntner, P., Colantonio, L.D., Cushman, M., Goff Jr., D.C., Howard, G., Howard, V.J.,
Kissela, B., Levitan, E.B., Lloyd-Jones, D.M., Safford, M.M., 2014. Validation of the
atherosclerotic cardiovascular disease Pooled Cohort risk equations. Jama. https://
doi.org/10.1001/jama.2014.2630.
Park, H.J., Kim, J., Park, S.E., Park, C.Y., Lee, W.Y., Oh, K.W., Park, S.W., Rhee, E.J.,
2016. Increased risk of subclinical atherosclerosis associated with high visceral
adiposity index in apparently healthy Korean adults: the Kangbuk Samsung Health
Study. Ann. Med. https://doi.org/10.1080/07853890.2016.1183258.
Peter, L., 2006. Inflammation and cardiovascular disease mechanisms. Am. J. Clin. Nutr.
83 (2), 456S–460S. https://doi.org/10.1093/ajcn/83.2.456S.
Experimental Gerontology 139 (2020) 111019
Piepoli, M.F., Hoes, A.W., Agewall, S., Albus, C., Brotons, C., Catapano, A.L., Cooney,
M.T., Corra, U., Cosyns, B., Deaton, C., Graham, I., Hall, M.S., Hobbs, F.D.R., Lochen,
M.L., Lollgen, H., Marques-Vidal, P., Perk, J., Prescott, E., Redon, J., Richter, D.J.,
Sattar, N., Smulders, Y., Tiberi, M., van der Worp, H.B., van Dis, I., Verschuren,
W.M.M., Binno, S., 2016. 2016 European guidelines on cardiovascular disease pre-
vention in clinical practice: the Sixth Joint Task Force of the European Society of
Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical
Practice (constituted by representatives of 10 societies and by invited experts) de-
veloped with the special contribution of the European Association for Cardiovascular
Prevention & Rehabilitation (EACPR). Eur. Heart J. https://doi.org/10.1093/
eurheartj/ehw106.
Plutzky, J., 2001. Inflammatory pathways in atherosclerosis and acute coronary syn-
dromes. Am. J. Cardiol. 88 (8A), 10K–15K. https://doi.org/10.1016/s0002-9149(01)
01924-5.
Romacho, T., Elsen, M., Rohrborn, D., Eckel, J., 2014. Adipose tissue and its role in organ
crosstalk. Acta Physiol (Oxf). https://doi.org/10.1111/apha.12246.
Ross, R., 1999. Atherosclerosis — an inflammatory disease. N. Engl. J. Med. https://doi.
org/10.1056/nejm199901143400207.
Smitka, K., Maresova, D., 2015. Adipose tissue as an endocrine organ: an update on pro-
inflammatory and anti-inflammatory microenvironment. Prague Med Rep. https://
doi.org/10.14712/23362936.2015.49.
Stone, N.J., Robinson, J.G., Lichtenstein, A.H., Bairey Merz, C.N., Blum, C.B., Eckel, R.H.,
Goldberg, A.C., Gordon, D., Levy, D., Lloyd-Jones, D.M., McBride, P., Schwartz, J.S.,
Shero, S.T., Smith Jr., S.C., Watson, K., Wilson, P.W., Eddleman, K.M., Jarrett, N.M.,
LaBresh, K., Nevo, L., Wnek, J., Anderson, J.L., Halperin, J.L., Albert, N.M., Bozkurt,
B., Brindis, R.G., Curtis, L.H., DeMets, D., Hochman, J.S., Kovacs, R.J., Ohman, E.M.,
Pressler, S.J., Sellke, F.W., Shen, W.K., Smith Jr., S.C., Tomaselli, G.F., 2014. 2013
ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic
cardiovascular risk in adults: a report of the American College of Cardiology/
American Heart Association Task Force on Practice Guidelines. Circulation. https://
doi.org/10.1161/01.cir.0000437738.63853.7a.
Tamhane, U.U., Aneja, S., Montgomery, D., Rogers, E.K., Eagle, K.A., Gurm, H.S., 2008.
Association between admission neutrophil to lymphocyte ratio and outcomes in pa-
tients with acute coronary syndrome. Am. J. Cardiol. https://doi.org/10.1016/j.
amjcard.2008.05.006.
Touboul, P.J., Hennerici, M.G., Meairs, S., Adams, H., Amarenco, P., Bornstein, N., Csiba,
L., Desvarieux, M., Ebrahim, S., Hernandez Hernandez, R., Jaff, M., Kownator, S.,
Naqvi, T., Prati, P., Rundek, T., Sitzer, M., Schminke, U., Tardif, J.C., Taylor, A.,
Vicaut, E., Woo, K.S., 2012. Mannheim carotid intima-media thickness and plaque
consensus (2004-2006-2011). An update on behalf of the advisory board of the 3rd,
4th and 5th watching the risk symposia, at the 13th, 15th and 20th European Stroke
Conferences, Mannheim, Germany, 2004, Brussels, Belgium, 2006, and Hamburg,
Germany, 2011. Cerebrovasc. Dis. https://doi.org/10.1159/000343145.
Van Gaal, L.F., Mertens, I.L., De Block, C.E., 2006. Mechanisms linking obesity with
cardiovascular disease. Nature. https://doi.org/10.1038/nature05487.
Verdoia, M., Barbieri, L., Di Giovine, G., Marino, P., Suryapranata, H., De Luca, G., 2016.
Neutrophil to lymphocyte ratio and the extent of coronary artery disease: results from
a large cohort study. Angiology. https://doi.org/10.1177/0003319715577529.
Wang, R.T., Zhang, J.R., Li, Y., Liu, T., Yu, K.J., 2015. Neutrophil-lymphocyte ratio is
associated with arterial stiffness in diabetic retinopathy in type 2 diabetes. J. Diabetes
Complicat. https://doi.org/10.1016/j.jdiacomp.2014.11.006.
Wang, H., Hu, Y., Geng, Y., Wu, H., Chu, Y., Liu, R., Wei, Y., Qiu, Z., 2017. The re-
lationship between neutrophil to lymphocyte ratio and artery stiffness in subtypes of
hypertension. J Clin Hypertens (Greenwich). https://doi.org/10.1111/jch.13002.
Weber, C., Zernecke, A., Libby, P., 2008. The multifaceted contributions of leukocyte
subsets to atherosclerosis: lessons from mouse models. Nat Rev Immunol. https://doi.
org/10.1038/nri2415.
Wu, J., Gong, L., Li, Q., Hu, J., Zhang, S., Wang, Y., Zhou, H., Yang, S., Wang, Z., 2017. A
novel visceral adiposity index for prediction of type 2 diabetes and pre-diabetes in
Chinese adults: a 5-year prospective study. Sci. Rep. https://doi.org/10.1038/
s41598-017-14251-w.
Xia, M.F., Chen, Y., Lin, H.D., Ma, H., Li, X.M., Aleteng, Q., Li, Q., Wang, D., Hu, Y., Pan,
B.S., Li, X.J., Li, X.Y., Gao, X., 2016. A indicator of visceral adipose dysfunction to
evaluate metabolic health in adult Chinese. Sci. Rep. https://doi.org/10.1038/
srep38214.
Xie, X., Li, Q., Zhang, L., Ren, W., 2018. Lipid accumulation product, visceral adiposity
index, and Chinese visceral adiposity index as markers of cardiometabolic risk in
adult growth hormone deficiency patients: a cross-sectional study. Endocr. Pract.
https://doi.org/10.4158/ep-2017-0007.
Yang, X.F., Ding, F.M., Ye, Y.C., Zhang, S.Y., 2018. Relationship between neutrophil-to-
lymphocyte ratio and pulse wave velocity in young patients with systemic lupus
erythematosus. Chin. Med. J. https://doi.org/10.4103/0366-6999.221272.
Yu, X.Y., Li, X.S., Li, Y., Liu, T., Wang, R.T., 2015. Neutrophil-lymphocyte ratio is asso-
ciated with arterial stiffness in postmenopausal women with osteoporosis. Arch.
Gerontol. Geriatr. https://doi.org/10.1016/j.archger.2015.03.011.
Yurtdas, M., Yaylali, Y.T., Kaya, Y., Ozdemir, M., Ozkan, I., Aladag, N., 2014. Neutrophil-
to-lymphocyte ratio may predict subclinical atherosclerosis in patients with psoriasis.
Echocardiography. https://doi.org/10.1111/echo.12511.
Yusuf, S., Hawken, S., Ounpuu, S., Dans, T., Avezum, A., Lanas, F., McQueen, M., Budaj,
A., Pais, P., Varigos, J., Lisheng, L., 2004. Effect of potentially modifiable risk factors
associated with myocardial infarction in 52 countries (the INTERHEART study): case-
control study. Lancet. https://doi.org/10.1016/s0140-6736(04)17018-9.