Comments to “Neutrophil-to-lymphocyte ratio compared to N-terminal pro-brain natriuretic peptide as a prognostic marker of adverse events in elderly patients with chronic heart failure”

We have read the article which entitled “Neutrophil-tolymphocyte ratio compared to N-terminal pro-brain natriuretic peptide as a prognostic marker of adverse events in elderly patients with chronic heart failure” published in Journal of Geriatric Cardiology with great interest. However, we have some comments regarding this study. First of all, it has not been stated that any inflammatory marker was analyzed in study patients. The authors reported that patients with known evidence of infection, chronic inflammatory conditions were excluded. But there is no data to support it in any way. At least C-reactive protein (CRP) or hypersensitive CRP could have been examined. Thus, the relationship between neutrophil-to-lymphocyte (N/L) ratio ratio and CRP could be investigated. Secondly, in the study, it is highlighted that heart failure and AF often coexist and each condition can promote the other, with an associated increase in overall morbidity and mortality. So a higher N/L ratio was associated with an increased risk of AF which may make the prognosis of heart failure become worser in the elderly with CHF. Although the N/L ratio was higher in the major cardiovascular events (MCEs) group, AF was reported as lower at this study. How do you explain this contradiction? At the same time, the contribution of N/L ratio to NYHA III-IV group is limited because it is known that there is already more MCE in NYHA III-IV patients. In addition NYHA class IV patients are still considered unsuitable for survival studies and have been systematically excluded from clinical trials because of the expectation of a much shortened lifespan. In the present study 51.9% of the major cardiovascular events (MCEs) group was composed of NYHA III-IV patients. It might be better to investigate the predictive power of N/L ratio for MCE in patients with NYHA I-II. As the third NYHA was mistakenly written as HYHA in all parts of the text. Future studies should be directed towards larger randomized trials with more emphasis on long term clinical endpoints.