Incremental Prognostic Value of Neutrophil-Lymphocyte Ratio in Normotensive Patients with Intermediate-Risk Acute...

Background: Risk stratification in normotensive patients with acute pulmonary embolism (APE) remains challenging, particularly within the heterogeneous intermediate-risk category. The neutrophil-lymphocyte ratio (NLR), an accessible marker of systemic inflammation, has emerged as a potential prognostic indicator. We aimed to evaluate the additional prognostic value of NLR in normotensive patients with intermediate-risk APE. Methods: We conducted a retrospective analysis of 402 consecutive normotensive patients with imaging-confirmed APE. Patients were classified according to European Society of Cardiology (ESC) risk stratification. The primary endpoint was in-hospital mortality. Laboratory, clinical, and echocardiographic parameters were analyzed. Logistic regression was performed to identify independent predictors of in-hospital death. Discriminative performance was assessed using receiver operating characteristic (ROC) analysis. Results: In-hospital mortality occurred in 13.9% of patients. NLR values were significantly higher among non-survivors. On multivariable logistic regression, NLR retained independent prognostic significance, with values exceeding one standard deviation (5.66) indicating an approximately twofold higher risk of in-hospital mortality. Echocardiographic right ventricular dysfunction and troponin I levels were not independent predictors in the adjusted model. NLR demonstrated modest discriminative ability (AUC = 0.650). A cut-off value of 5.49 provided the best balance between sensitivity and specificity. The addition of NLR to ESC risk stratification improved the identification of patients at higher risk within the intermediate category. Conclusions: In normotensive patients with intermediate-risk APE, NLR represents a simple and readily available biomarker with independent prognostic value. Its incorporation into current risk stratification algorithms may enhance early identification of patients at increased risk of in-hospital mortality. Prospective validation studies are warranted.