SN Comprehensive Clinical Medicine (2021) 3:183–190

https://doi.org/10.1007/s42399-020-00692-4

MEDICINE

The Significance of Platelet/Lymphocyte Ratio in Relation

to Coronary Angiographic Findings in Patients with Coronary Artery
Disease
Waseem F. AlTameemi 1 & Abbas A. A. Alzirgany 2

Accepted: 7 December 2020 / Published online: 6 January 2021

# The Author(s), under exclusive licence to Springer Nature Switzerland AG part of Springer Nature 2021

Abstract
Inflammation plays a role in the initiation and propagation of the atherosclerotic process in coronary artery disease (CAD). A low
lymphocyte count has been shown to be related with worse outcome in those patients. The objective of this study is to assess the
relationship between platelet/lymphocyte ratio (PLR) and severity of CAD according to angiography findings. During the period
from May 2018 to September 2018, a cross-sectional study on 60 CAD patients was performed at two cardiac units belonging to
Imamaein Al Khadhmein Medical City—Baghdad and AL Nasiriya Cardiac Centre—Dhi Qar. In addition to demographic data,
coronary angiography findings were evaluated for the purpose of calculation of the Gensini score to indicate the severity of
atherosclerosis. Patients were classified into low-risk (< 25 points) and high-risk (≥ 25 points) groups according to their Gensini
score. PLR was calculated from patient’s laboratory data. The mean age group of the study sample was 57.98 ± 8.14 years; males
form 67%. Acute coronary syndrome (ACS) is the presentation of the majority of the patients with CAD (78%) where 70% of
them are patients at high risk according to their Gensini scores. The mean PLR in ACS patients was 107.97 ± 50.53 and for stable
angina, 117.92 ± 47.04. There is no correlation between PLR and Gensini score (p value 0.376); however, there is a positive
linear correlation (r = 0.116), although not proven statistically. There is a significant inverse relationship between BMI and PLR
(p value 0.019). It did not show a statistical relationship between PLR and severity of atherosclerosis. However, there is a linear
positive correlation between them.

Keywords Atherosclerosis . Coronary artery disease . Atheroma . Inflammation . Platelet . Lymphocyte

Abbreviations Background
CAD Coronary artery disease
ACS Acute coronary syndrome Atherosclerosis is a disease of large- and medium-sized mus-
PLR Platelet/lymphocyte ratio cular arteries and is characterized by endothelial dysfunction,
NLR Neutrophil/lymphocyte ratio vascular inflammation, and buildup of lipids, cholesterol, cal-
Hb Hemoglobin cium, and cellular debris within the intima of the vessel wall
BMI Body mass index with subsequent abnormalities of blood flow with diminished
oxygen supplying the heart [1]. Coronary artery disease is the
major prototype, in which atherosclerotic changes are present
This article is part of the Topical Collection on Medicine
within the walls of the coronary arteries. The earliest patho-
logic lesion of atherosclerosis is the fatty streak [2] that prog-
* Waseem F. AlTameemi
drwaseem72@gmail.com ress to form a fibrous plaque that results from progressive lipid
accumulation and the migration and proliferation of smooth
Abbas A. A. Alzirgany muscle cells (SMCs) [3], followed by endothelial injury and
abbasalzirgany@gmail.com inflammation progression to form the plaque [4]. In fact, the
1
plaque does not begin to encroach on the lumen until it oc-
Al-Nahrain University, College of Medicine, Department of
cupies 40% of the cross-sectional area.
Medicine (Hematology Unit), P.O.Box 70044, Baghdad, Iraq
2
Atherosclerosis is an inflammatory disease, and several
Department of Medicine, Al Emmamian Al Kadhmain Medical City
inflammatory biomarkers, such as C-reactive protein, and
Hospital, Baghdad, Iraq
184
leukocytosis are associated with the presence of coronary
heart disease, peripheral arterial disease, and stroke [5].
The platelet to lymphocyte ratio (PLR) is a relatively useful
prognostic marker that gives an idea about the atherosclerosis
process as well as both the platelet aggregation and inflamma-
tory pathogenesis [6, 7]. PLR was found in addition to the
neutrophil/lymphocyte ratio (NLR) to be useful in predicting
poor prognosis in cancer population such as gastric, cervical,
and pancreatic [8–10] and in predicting critical limb ischemia
in peripheral artery disease [11], because both are associated
with an increased risk of arterial thrombosis [12]. So PLR
seems to be a simple parameter to evaluate severity of CAD
in patients undergoing elective coronary angiography, and it
could be part of cardiovascular evaluation before coronary
angiography [13].
The plaque rupture occurs due to weakening of the fi-
brous cap. Inflammatory cells localize to the shoulder re-
gion of the vulnerable plaque with T lymphocytes that
elaborate cytokine that impairs vascular smooth muscle
cell proliferation and collagen synthesis [14]. Plaque rup-
ture is the main event that causes acute presentations. In
fact, most of the atheromas that cause acute coronary syn-
drome (ACS) are less than 50% occlusive, as demonstrated
by coronary angiography [15].
Coronary angiography continues to be the standard
method of diagnosis. Conventionally, the degree of ob-
struction is estimated as the percent reduction of the lu-
minal diameter, determined by comparing the diameter at
the site of maximal reduction to that in adjacent areas
that appear either normal or only minimally diseased
[16] which is a visual influence and liable for inter-
observational variation; however, it classifies the lesion
into different grades of severity [17–20] according to di-
ameter reduction as < 50% diameter reduction, as stable
lesion (with little clinical significance), > 50% and < 70%
diameter reduction, with borderline hemodynamic and
clinical significance, > 70% but < 100% diameter reduc-
tion, with almost all lesions of hemodynamic signifi-
cance, and 100% diameter reduction. A completely oc-
cluded vessel is warranted for multiple clinical and ther-
apeutic reasons.
The Gensini score is a widely used means of quantify-
ing angiographic atherosclerosis. The Gensini considers
the geometrical severity of the lesions, the cumulative
effects of multiple obstruction, and the significance of
jeopardized myocardium. A nonlinear score is assigned
to each lesion based on the reduction of the luminal di-
ameter, and multiplied by a factor representing the impor-
tance of the lesion’s location in the coronary arterial sys-
tem [21].
Objectives To assess the relationship between PLR and sever-
ity of CAD according to angiography findings.
SN Compr. Clin. Med. (2021) 3:183–190
Patients and Methods
Study Design and Setting
This is a cross-sectional study performed during the period
from May 2018 to September 2018 at coronary care units in
two different hospitals (Imamaein Al Khadhmein Medical
City—Baghdad and AL Nasiriya Cardiac Centre—Dhi Qar).
Population and Workup
It is designed to enroll 60 patients randomly with a diagnosis
of coronary artery disease (based on clinical findings, ECGs,
echocardiography, and cardiac enzymes or documented by
previous coronary angiography) in order to evaluate the se-
verity of coronary artery stenosis.
The study had excluded all those with other underlying
valvular heart disease or those complicated by congestive
heart failure or cardiogenic shock, as well as those patients
with comorbidities like malignancy, hematological disorder,
severe renal or hepatic insufficiency, or undergoing active
infection.
Every patient had been evaluated by direct interview to
register the demographic data and risk factors. All patients
were categorized according to the presenting diagnosis into
3 groups (stable angina, unstable angina, or myocardial infarc-
tion). All patients were informed about the study and written
consent was taken from each concerning the coronary inter-
vention according to hospital guidelines as well as verbal con-
sent was taken for registration of patients’ data.
Data Collection
Angiographic Analysis
All patients had undergone coronary angiography. The proce-
dure was performed and interpreted by an interventional car-
diologist. The coronary arteries were displaced in different
views under screen. Angiogram of each patient was thorough-
ly reviewed by AXIOM Sensis XP information system soft-
ware, in order to establish the lesion location and the percent-
age of luminal stenosis among all coronary artery lesions.
In this study, the Gensini scoring system was used to iden-
tify the severity of CAD [21]. This method classifies and
scores the degree and extent of the stenosis of the coronary
arteries. This system scores [22]:
& 1 point for 1% to 25% stenosis.
& 2 points for 26% to 50% stenosis.
& 4 points for 51% to 75% stenosis.
& 8 points for 76% to 90% stenosis.
& 16 points for 91% to 99% stenosis.
& 32 points for total occlusion.
SN Compr. Clin. Med. (2021) 3:183–190
The score is then multiplied by a factor representing the
importance of the lesion’s location in the coronary arterial
system. For the location, scores are multiplied by:
& 5 for a left main stem lesion.
& 2.5 for the proximal left anterior descending (LAD) or left
circumflex (LCX) artery.
& 1.5 for the mid-segment LAD and LCX.
& 1 for the distal segment of the LAD and LCX, first diag-
onal branch, first obtuse marginal branch, right coronary
artery, posterior descending artery, and intermediate
artery.
& 0.5 for the second diagonal and second obtuse marginal
branches. As shown in Fig. 1.
This score is applied to patients’ angiography and they are
divided into two groups, high-risk group (score ≥ 25) and low-
risk group (score > 25).
Biochemical and Hematological Parameters
At the morning of the day of coronary angiography, peripheral
venous blood samples were drawn from each patient and sent
for the following parameters: complete blood count including
total and differential leukocyte, hemoglobin level, platelet
count, and mean platelet volume count, measured by an
Fig. 1 Gensini scoring system [22]
185
automated hematology analyzer (CELL_DYN Ruby in
Imamaein Al Khadhmein Medical City—Baghdad and
Sysmex XP-300 in AL Nasiriya Cardiac Centre—Dhi Qar),
in addition to lipid profile. PLR was calculated
mathematically.
Data Statistical Analysis
All data are represented by range, mean, value, and frequency
using demographic data, patient’s presentation, hematological
parameters, and the results of coronary angiography looking
for the relationship between the PLR and severity of coronary
atherosclerosis. Statistical Package for the Social Sciences
(SPSS, version 20) was used for data analysis, and
Microsoft Excel was used to generate graphs. The Student test
(t test) was used to compare means of continuous variables,
and Pearson’s chi-square to compare the dichotomous vari-
ables as well as correlation analysis.
Results
Demographic Data
Patient samples consist of 60; the majority are males (67%)
with male to female ratio of 2:1; the age group of the patient
sample ranges from 38 to 76 years old with a mean of 57.98 ±
186 SN Compr. Clin. Med. (2021) 3:183–190

8.14, with male mean age of 56.52 ± 8.25 years and with fe-
male mean age of 60.9 ± 7.26 years, with relatively younger
presentation in males compared to females; and the majority
of patients were between 41 and 60 years, representing 55%
(Table 1).
Regarding risk factors, hypertension, diabetes, and
smoking in order of frequency were the most frequent risk
factors.
Clinical Presentation
Forty-seven patients (78%) were considered as ACS while the
rest (22%) were cases of stable angina. High Gensini risk
score constituted 70% of total patient, ACS represented 81%
of patients with high-risk Gensini, and 72% those with low
score (Table 1). The mode of presentation as ACS had shown
a statistical significant association with male predominance (p
value 0.027), as shown in Table 2.
There is no relationship between other risk factors and clin-
ical presentation, neither with hypertension, diabetes,
smoking, family history, nor hyperlipidemia as well as age
and BMI (p values of 0.617, 0.469, 0.152, 0.756, 0.483,
0.726, and 0.711, respectively) (Table 2).
Angiographic Data
Statistically speaking, there is no significant relationship be-
tween gender and Gensini score (p value 0.073), but females
were at high risk of severe atherosclerosis forming 85% of pre-
senting females who had more complicated coronary stenosis.
There is no significant relationship between other risk fac-
tors and severity of coronary atherosclerosis which are hyper-
tension, smoking, family history, and hyperlipidemia as well
as age and BMI (p values of 0.827, 0.866, 0.827, 1, 0.458, and
0.787, respectively) apart from a significant association be-
tween diabetes and coronary atherosclerosis (p value 0.027).
Similarly, the clinical presentation shows no statistical sig-
nificant association with Gensini scoring (p value 0.420).
Hematological and Biochemical Data
There is no statistical relationship between any of the hema-
tological parameters and the clinical presentation including
Hb, WBC, lymphocyte, platelet, and mean platelet volume
(MPV) as well as PLR (p values of 0.480, 0.914, 0.120,
0.790, 0.412, and 0.527, respectively) (Table 3). Similarly,
the lipid profile shows no statistical relationship with clinical
presentation including LDL, cholesterol, and triglycerides (p-
values of 0.333, 0.496, and 0.487, respectively) (Table 3).
In terms of coronary angiographic Gensini scoring, the
same results are reported where there is no statistical associa-
tion between Hb, WBC, lymphocyte, platelet, MPV, and PLR
and severity of coronary atherosclerosis (p values of 0.405,
0.219, 0.916, 0.469, 0.927, 0.269, respectively).
It is also found that there is no correlation between
PLR and Gensini score (p value 0.376) (Fig. 2); how-
ever, there is positive linear correlation (r = 0.116) but it
did not reach a statistical significance. However, there
was a significant inverse correlation between BMI and
PLR (p value 0.019, r = − 0.303*) (Fig. 3) and a signif-
icant positive linear correlation between cholesterol and
PLR (p value 0.009, r = 0.773**).
It is shown that there is no correlation between age and PLR
(p value 0.831, r = 0.028) being independent factors. Similarly,
no correlations were found between Gensini score and Hb (p
value 0.063, r = − 242) but with a negative linear correlation.

Table 1 General demographic variables in the study sample

Variables Description
Age (years) Range Mean ± SD
38–76 57.98 ± 8.14
Gender (frequency) Male, no. (%) Female, no. (%)
40 (67%) 20 (33%)
Clinical presentation (frequency) Stable angina, no. (%) ACS, no. (%)
13 (22%) 47 (78%)
Body mass index (kg/m2) Underweight (less than 18.5) nil
Healthy weight (18.5–24.9) nil
Overweight (25–29.9) 33
Obese (30 or more) 27
Gensini score High risk, no. (%) ACS, no. (%) 34 (81%) Male, no. (%) 25 (60%)
Low risk >25 42 (70%) Stable angina, no. (%) 8 (19%) Female, no. (%) 17 (40%)
High risk ≥ 25
Low risk, no. (%) ACS, no. (%) 13 (72%) Male, no. (%) 15 (83%)
18 (30%) Stable angina, no. (%) 5 (28%) Female, no. (%) 3 (17%)
SN Compr. Clin. Med. (2021) 3:183–190 187

Table 2 Relationship between

hematological and biochemical Stable ACS p value
data with clinical presentation
Range Mean ± SD Range Mean ± SD

Hb (g/dL) 11.2–16.9 13.62 ± 1.70 9.9–16.2 13.25 ± 1.61 0.480 NS

6
WBC (10 /μL) 4.9–16.9 8.79 ± 2.94 4.13–14.8 8.89 ± 2.61 0.914 NS
Lymphocyte (106/μL) 1.2–2.8 2.15 ± 0.45 1.09–6.36 2.64 ± 1.09 0.120 NS
Platelets (106/μL) 106–416 246.08 ± 94.66 138–603 253.87 ± 92.80 0.790 NS
MPV (fL) 6.07–10.2 8.06 ± 1.10 4.58–11 7.67 ± 1.58 0.412 NS
PLR 50–207.5 117.92 ± 47.04 32.7–243.5 107.97 ± 50.53 0.527 NS
LDL (mg/dL) 66–152 109.00 ± 60.81 69.4–210 146.93 ± 45.54 0.333 NS
Cholesterol (mg/dL) 138–188 163.00 ± 35.36 110–270 194.78 ± 58.74 0.496 NS
Triglycerides (mg/dL) 149–199 174.00 ± 35.36 78–284 204.44 ± 57.93 0.487 NS

Hb hemoglobin, WBC white blood cell, MPV mean platelet volume, PLR platelet/lymphocyte ratio, LDL low-
density lipoprotein

There is significant correlation between WBC, lympho- has been investigated as a new predictor for worse car-
cyte, and platelet (p value 0.007, r = 0.343; p value 0.000, diovascular outcome.
r = − 0.578) respectively; as well as with PLR (p value 0.000, ACS was the predominant group in this study (78%) since
r = 0.575) (Fig. 4). the indication of coronary angiography is limited in some
tertiary centers for this group of patients compared with those
having stable angina whom medical treatments are main mo-
Discussion dality, which may be due to limited resources and lack of
equipment that restrict an invasive intervention for the high-
Inflammation has been proven to have a role in athero- risk patients in favor of patients with stable angina.
sclerosis process, and inflammatory biomarkers can pre- This study revealed that 70% of patients had high-risk
dict the prognosis of its consequences like acute coro- Gensini score which is an objective method to determine the
nary syndrome. The platelet to lymphocyte ratio (PLR) severity of CAD according to angiographic findings. It was
originally developed to quantify the severity of CAD; howev-
Table 3 Correlations between platelet /lymphocyte ratio (PLR) and er, subsequent studies have demonstrated its ability to identify
Gensini score with some demographic and hematological data patients who are at high risk of adverse events treated with
PLR Gensini score
PCI [23].
In this study, no relationship is found between Gensini
Age r 0.028 0.055 score and WBC and lymphocyte count (p values of 0.833
p 0.831 0.675 and 0.530, respectively) which is not in agreement with
BMI r − 0.303* 0.008 Muhammet et al.’s assumption [24] that leukocytosis is an
p 0.019 0.952 independent predictor of future cardiovascular events, in both
Hb r − 0.242 − 0.241 healthy individuals free of CAD and in subjects with CAD
p 0.063 0.063 [25]. WBCs play a major role in the development of CAD
WBC r 0.343** − 0.028 through different mechanisms, such as mediation of inflam-
p 0.007 0.833 mation, induction of proteolysis and oxidative damage to the
Lymphocyte r − 0.578** − 0.083 endothelial cells, plugging the microvasculature, induction of
p 0.000 0.530 hypercoagulability, and infarct expansion [26].
Platelets r 0.575** 0.039 Lymphocytes also play an important role in the early path-
p 0.000 0.770 ogenesis of atherosclerotic lesions, but with time (e.g., once a
MPV r − 0.048 − 0.012 critical mass of inflammatory cells has accumulated), other
p 0.714 0.925 atherogenic stresses take over [27].
PLR r 1.000 0.116 Thrombus formation is triggered either by the rupture or the
p 0.376 ulceration of the atherosclerotic plaque; hence, the role of plate-
Cholesterol r 0.773** − 0.193 let is well demonstrated. In the subsequent process, the platelets
p 0.009 0.593 (and especially in the thrombogenic state, due to the increased
reactivity of circulating platelets) are very important. Platelets
188
Fig. 2 Correlation between
Gensini score and platelet/
lymphocyte ratio (PLR)
are heterogeneous in size and density, where many platelet
indices have been evaluated including MPV, which is the most
commonly used measure of platelet size and is a potential
marker of platelet reactivity [28]. In this study, there is no
relationship between platelet count and MPV with the
Gensini score (p values of 0.770 and 0.925 respectively) that
agrees with Karan et al. [29] but not with others [30, 31] who
demonstrate an association between an increased MPV in acute
coronary syndromes.
The platelets and their functional cursor MPV are impor-
tant indicators of the presence and the prevalence of CAD
[32].
This study could not prove any correlation between
Gensini score and PLR (p value 0.376) unlike Yüksel
et al. [7] who showed that pre-procedural PLR value cor-
related positively with the amount of coronary atheroscle-
rotic burden in CAD patients and that high PLR appears to
be additive to conventional risk factors and can be used as
biomarkers in predicting severe atherosclerosis. Also,
Kurtul et al. stated that PLR at admission is significantly
associated with the severity and complexity of coronary
atherosclerosis in patients with ACS [33]. This contradic-
ting results can be attributed to inter-individual variations
between those interventional cardiologists who interpret
the subjective description of stenosis percentage as well
as the possible anti-inflammatory effect of medical
Fig. 3 Correlation between body
mass index (BMI) and platelet/
lymphocyte ratio (PLR)
SN Compr. Clin. Med. (2021) 3:183–190
treatment offered to all patients before they got the due
time of coronary angiography since the waiting list may
take longer than expected in addition to the effect of small
sample size. However, these non-compatible results were
also reported by other authors like Kundi et al. [34] who
stated that it is not clear to highlight the pathogenesis role
of PLR in the severity of coronary artery disease, and fur-
ther larger studies are needed to show and clarify this
situation.
All the above inconsistencies with other studies can be
attributed to different sample sizes and different inclusion
criteria taking into consideration different machines to assess
CBC parameters with possibilities of imprecise result as well
as time of blood count aspiration.
Conclusion
This study could not prove the assumed relationship between
PLR and severity of atherosclerosis, despite the presence of
linear positive correlation between them that did not reach a
statistical significance. It does not seem appropriate to consid-
er this laboratory measure as a reliable indicator for the ad-
vancement of atherosclerotic plaque as there are multiple fac-
tors contributing in this issue.
SN Compr. Clin. Med. (2021) 3:183–190
Fig. 4 Correlation between white
blood cells (WBCs) and platelet/
lymphocyte ratio (PLR)
Acknowledgments The authors thank all the patients and the team of
interventional cardiologists (Dr. Rafid. Al Taweel and Dr. Mouayed
Basheer).
Authors’ Contributions Both authors shared in data collection, analyses,
and interpretation. All authors have read and approved the manuscript and
ensure that this is the case.
Data Availability All data belong to both authors.
Compliance with Ethical Standards
Conflict of Interest The authors declare that they have no conflict of
interest.
Ethics Approval This is an academic research licensed under authoriza-
tion and approval of the committee of the Arab Board of Internal
Medicine.
Consent to Participate All patients were informed about the study and
written consent was taken from each concerning the coronary interven-
tion according to hospital guidelines as well as verbal consent was taken
for registration of patients’ data.
Consent for Publication We hereby transfer, assign, or otherwise con-
vey all copyright ownership, including any and all rights incidental there-
to, exclusively to the journal, if such work is published by the journal. All
authors have read and approved the manuscript and ensure that this is the
case.
Code Availability N/A.
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