Research Article

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Usefulness of monocyte to HDL-cholesterol

ratio to predict high SYNTAX score in
patients with stable coronary artery
disease

Aim: We aimed to investigate whether baseline monocyte to high-density lipoprotein Mehmet Kadri Akboga*,1,
cholesterol ratio (MHR), an easily available inflammatory and oxidative stress marker, Kevser Gulcihan Balci1, Orhan
is associated with SYNTAX score. Patients & methods: In this cross-sectional study, Maden1, Ahmet Goktug
n = 1229 consecutive patients with coronary artery disease were classified into two Ertem1, Ozgur Kirbas1, Cagri
groups, low SYNTAX score (≤22) and high SYNTAX score (≥23). Results: MHRs were Yayla1, Burak Acar1, Dursun
Aras1, Halil Kisacik1 & Sinan
significantly higher in patients with high SYNTAX score (p < 0.05). In multivariate
Aydogdu1
regression analysis, MHR remained as independent predictor of high SYNTAX 1
Turkiye Yuksek Ihtisas Training &
score together with C-reactive protein (CRP), hypertension and diabetes mellitus. Research Hospital, Department of
In correlation analysis, MHR showed significant positive correlations with SYNTAX Cardiology, Ankara, Turkey
score (r = 0.371, p < 0.001) and CRP level (r = 0.336, p < 0.001). Conclusion: This study *Author for correspondence:
Tel.: +90 312 3061134
suggests MHR is independently associated with burden of coronary atherosclerosis.
mkakboga@ yahoo.com

First draft submitted: 15 December 2015; Accepted for publication: 9 February 2016;
Published online: 21 March 2016

Keywords:  high SYNTAX score • inflammation/oxidative stress • monocyte/HDL-cholesterol

ratio

The SYNTAX score is an angiographic scor-
ing system that was developed during the
SYNTAX trial and used to quantify the
properties of lesion including complexity,
morphology and location in the coronary
tree [1] . The usefulness of the SYNTAX score
while making revascularization decisions and
in predicting adverse events in patients with
coronary artery disease has been appreciated
in several studies [2–5] . In addition to predict-
ing possible peri-procedural difficulties, the
SYNTAX score also reflects the pattern of
atheroma incorporating length, calcification
and thrombosis of the lesion [6] .
It was known that inflammation, endo-
thelial dysfunction, oxidative stress and
platelet activation play a significant role
in the formation and progression of ath-
erosclerosis  [7–9] . Alteration in white blood
cell counts and differentials were a­ ssociated
with the inflammatory condition, and
their ­ predictive and prognostic value in
cardiovascular diseases has been studied
well  [10,11] . Macrophages and monocytes are
the most important cell types for secretion
of proinflammatory and prooxidant cyto-
kines at the site of inflammation [12] . On
the contrary, high-density lipoprotein cho-
lesterol (HDL-C) defends endothelial cells
via aiding vasorelaxation, interfering low-
density lipoprotein cholesterol oxidation
and increasing endothelial nitric oxide syn-
thase expression [13,14] . Recently, monocyte
to HDL-C ratio (MHR), combining the
predictive and prognostic value of both eas-
ily available laboratory markers into a single
fraction  [15] , has emerged as a new marker
in cardiovascular diseases [16,17] . Thus, in
this study, we aimed to investigate the rela-
tion between MHR and the SYNTAX score
among patients with stable coronary artery
part of
disease (CAD) and if this simple laboratory

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Research Article  Akboga, Balci, Maden et al.

Table 1. Baseline clinical and angiographic characteristics of the study patients (1229).
 Parameters SYNTAX score p-value
Low group High group
(≤22; n = 821) (≥23; n = 408)
Age, years 59.8 ± 10.8 62.4 ± 10.5 <0.001
Male sex, n (%) 499 (60.8) 292 (71.6) <0.001
Hypertension, n (%) 377 (45.9) 219 (53.7) 0.010
Diabetes mellitus, n (%) 181 (22.0) 114 (27.9) 0.023
Active smoker, n (%) 294 (35.8) 162 (39.7) 0.183
Family history of CAD, n (%) 151 (18.4) 88 (21.6) 0.185
LVEF (%) 61.1 ± 8.2 54.6 ± 11.6 <0.001
Prior medical therapy, n (%):
 - RAS blocker 244 (29.7) 141 (34.6) 0.085
 - Diuretic 86 (10.5) 53 (13.0) 0.190
 - Calcium channel blocker 111 (13.5) 62 (15.2) 0.426
 - β-blocker 103 (12.5) 59 (14.5) 0.350
 - Statin 89 (10.8) 51 (12.5) 0.388
 - Antiaggregant 104 (12.7) 65 (15.9) 0.118
 - Oral antidiabetic drug, n (%) 147 (17.9) 86 (21.1) 0.181
Multivessel disease 320 (39.0) 290 (71.1) <0.001
Chronic total occlusion 124 (15.1) 230 (56.4) <0.001
Location of coronary lesions:
 - LMCA 46 (5.6) 60 (14.7) <0.001
 - LAD 359 (43.7) 270 (66.2) <0.001
 - LCx 310 (37.8) 177 (43.4) 0.160
 - RCA 469 (57.1) 237 (58.1) 0.827
Management of CAD:     <0.001
 - Stenting 604 (73.5)  174 (42.6)  
 - CABG 152 (18.5) 196 (48.0)  
 - Conservative 67 (8.1) 39 (9.5)  
Data were given as mean ± standard deviation or %.
CABG: Coronary artery bypass grafting; CAD: Coronary artery disease; LAD: Left anterior descending artery; LCx: Left circumflex artery;
LMCA: Left main coronary artery; LVEF: Left ventricular ejection fraction; RAS: Renin–angiotensin system; RCA: Right coronary artery.

marker could reflect the severity and the complexity
of the CAD.
Pateints & methods
Study population
In this retrospective cross-sectional study, in between
July 2012 and November 2014, 4870 patients with
CAD who were referred to the catheter laboratory for
coronary angiogram with an initial diagnosis of stable
angina pectoris or angina equivalents were evaluated.
According to the exclusion criteria, the final study
group consisted of 1229 patients. The decision for cor-
onary angiography was made according to a positive
noninvasive stress test or high clinical suspicion for a
severe coronary artery stenosis. The angiographic data
of all patients were retrospectively retrieved and ana-
lyzed at our tertiary center angiography units. Stable
angina pectoriswas diagnosed according to the criteria
recommended by the current guidelines [18] .
Patients enrolled in present study underwent
detailed clinical examination for the assessment of the
baseline clinical characteristics of the study popula-
tion including history of hypertension, diabetes mel-
litus, smoking, family history of CAD were recorded.
Arterial hypertension was considered in patients with
repeated blood pressure measurements ≥140/90 mm
Hg or active use of antihypertensive drugs. Diabetes
mellitus was defined as fasting plasma glucose levels

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 Association of MHR with SYNTAX score  Research Article

more than 126 mg/dL in multiple measurements or
glucose level over 200 mg/dL at any measurement
or active use of antidiabetic medications. Smoking
was defined as current smoking. The family his-
tory of CAD was defined as presence of a history of
CAD or sudden cardiac death in a first-degree rela-
tive before the age of 55 years for men and before the
age of 65 years for women. The estimated glomerular
filtration rate was calculated by applying the Modifi-
cation of Diet in Renal Disease formula to the serum
­creatinine concentration.
Exclusion criteria were as following: recent acute
coronary syndrome either with or without ST-seg-
ment elevation (≤6 months before enrollment), previ-
ous revascularization history (coronary artery bypass
grafting or percutaneous coronary intervention),
decompensated heart failure, nonischemic dilated car-
diomyopathy, significant valvular heart disease, symp-
tomatic peripheral vascular disease, evidence of acute
or chronic infection, systemic inflammatory or auto-
immune disease, chronic kidney disease (­glomerular
filtration rate <60 ml/min/1.73 m2), history of any
liver disease (with liver function parameters >3x upper
normal value), chronic obstructive pulmonary disease,
and any hematologic or malignant disease. The ethical
implications regarding the study were approved by the
local Ethics Committee
Coronary angiography
Standard Judkins technique was used for coronary
artery visualization. Selective cine-angiographic
images of the coronaries were recorded using a digi-
tal angiographic system (AXIOM Artis, Siemens AG,
Munich, Germany). At least two orthogonal plane
images were taken for each coronary artery. Accord-
ing to the baseline coronary angiograms, the SYNTAX
score was calculated in all patients by two independent
experienced interventional cardiologists who were
blinded to the identities and clinical information of
the patients from baseline diagnostic coronary angio-
grams. The SYNTAX score was determined for all
coronary lesions with >50% diameter stenosis in a ves-
sel >1.5 mm, based on the SYNTAX score calculator
2.1 [19] . The patients were divided into two groups as

Table 2. Laboratory parameters of the study patients.

Parameters SYNTAX Score p-value
Low group High group
(≤22; n = 821) (≥23; n = 408)
Hemoglobin, g/dL 14.2 ± 1.2 14.3 ± 1.2 0.392
RDW (%) 13.8 ± 1.6 14.0 ± 1.6 0.153
Platelet, 10³/mm³ 251 ± 49 261 ± 58 0.028
Mean platelet volume, fL 8.5 ± 1.3 8.7 ± 1.4 0.056
White blood cell, μL 7566 ± 1694 7881 ± 1601 0.002
Neutrophil, μL 4555 ± 1410 4846 ± 1424 0.001
Lymphocyte, μL 2296 ± 680 2246 ± 747 0.239
Monocyte, μL† 510 (400–700) 600 (420–740) 0.001
Creatinine, mg/dL 0.84 ± 0.17 0.85 ± 0.18 0.304
eGFR, mL/min/1.73 m2  94.5 ± 23.9 92.2 ± 21.6 0.296
Uric acid, mg/dL† 5.0 (4.2–6.9) 5.6 (4.9–6.3) 0.118
ALT, U/l 22.6 ± 6.4 22.7 ± 6.7 0.973
AST, U/l 22.4 ± 7.9 23.2 ± 8.7 0.132
C-reactive protein, mg/L †
6.2 (3.5–11.1) 10.0 (5.1–18.4) <0.001
Total cholesterol, mg/dL 198 ± 43 196 ± 48 0.491
HDL-cholesterol, mg/dL †
43.0 (37.0–52.0) 38.5 (33.0–45.0) <0.001
LDL-cholesterol, mg/dL 122 ± 37 126 ± 43 0.117
Triglyceride, mg/dL† 137 (102–197) 143 (99–205) 0.709
Monocyte/HDL-C ratio †
12.1 (8.5–16.9) 14.6 (11.1–20.4) <0.001
Data are given as mean ± standard deviation, or %.
†
Median (interquartile range).
ALT: Alanine aminotransferase; AST: Aspartate aminotransferase; eGFR: estimated glomerular filtration rate; HDL-C: High-density lipoprotein
cholesterol; LDL-C: Low-density lipoprotein cholesterol; RDW: Red cell distribution width.

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Research Article  Akboga, Balci, Maden et al.

Table 3. Baseline characteristics and laboratory parameters of the study groups according to SYNTAX score tertiles.
Parameters SYNTAX score p-value
Low group Intermediate group High group
(≤22; n = 821) (23–32; n = 226) (≥33; n = 182)
Age, years 59.8 ± 10.8 61.6 ± 10.9 63.4 ± 10.3 <0.001
Male sex, n (%) 499 (60.8) 154 (68.1) 138 (75.8) <0.001
Hypertension, n (%) 377 (45.9) 115 (50.9) 104 (57.1) 0.017
Diabetes mellitus, n (%) 181 (22.0) 56 (24.8) 58 (31.9) 0.019
LVEF (%) 61.1 ± 8.2 55.3 ± 11.2 53.6 ± 12.1 <0.001
Hemoglobin, g/dL 14.2 ± 1.2 14.2 ± 1.3 14.3 ± 1.5 0.894
RDW (%) 13.8 ± 1.6 13.9 ± 1.5 14.1 ± 1.8 0.299
Platelet, 10³/mm³ 251 ± 49 257 ± 51 266 ± 62 0.030
Mean platelet volume, fL 8.5 ± 1.3 8.7 ± 1.4 8.8 ± 1.4 0.096
White blood cell, μL 7566 ± 1694 7728 ± 1538 8071 ± 1660 0.001
Neutrophil, μL 4555 ± 1410 4754 ± 1312 4960 ± 1549 0.001
Monocyte, μL† 510 (400–700) 545 (400–742) 600 (477–725) 0.001
eGFR, mL/min/1.73 m2  94.5 ± 23.9 92.9 ± 21.1 91.1 ± 22.4 0.515
C-reactive protein, mg/L †
6.2 (3.5–11.1) 8.4 (4.4–16.1) 12.1 (6.1–20.1) <0.001
Total cholesterol, mg/dL 198 ± 43 197 ± 47 195 ± 50 0.712
HDL-cholesterol, mg/dL† 43.0 (37.0–52.0) 40.0 (34.0–47.3) 37.0 (31.0–44.0) <0.001
LDL-cholesterol, mg/dL 122 ± 37 124 ± 40 128 ± 45 0.167
Triglyceride, mg/dL †
137 (102–197) 143 (104–205) 142 (94–203) 0.633
Monocyte/HDL-C ratio† 12.1 (8.5–16.9) 13.9 (10.5–18.9) 16.1 (11.6–21.3) <0.001
†
Data were given as mean ± standard deviation or %.
Median (interquartile range).
eGFR: Estimated glomerular filtration rate; HDL-C: High-density lipoprotein cholesterol; LDL-C: Low-density lipoprotein cholesterol; LVEF: Left ventricular ejection
fraction; RDW: Red cell distribution width.

low SYNTAX score group (≤22) and high SYNTAX
score group (≥23) [20] . Transthoracic echocardiography
was performed in all patients, and left ventricular ejec-
tion fraction (LVEF) was calculated using ­modified
Simpson method.
Laboratory analysis
Blood samples were collected from the antecubital
vein before the index coronary angiography after
an overnight fast. Laboratory parameters (includ-
ing complete blood count, SA, biochemistry panel
and lipid panel that were taken before the index
coronary angiography) of all the participants were
recorded. Samples for the complete blood count
(CBC) analysis (with differential analysis) were col-
lected in EDTA anticoagulated Monovette tubes
(Sarstedt, Leicester, UK). Monocyte count was cal-
culated using data obtained from the CBC differen-
tial analysis (using an automated blood cell counter).
The reference value for monocyte in our laboratory is
0.2–1.2 × 103 /dL and for HDL-C is 40–60 mg/dL.
HDL-C levels were measured using a Beckman
Coulter AU680 (Beckman Coulter Inc, CA, USA).
Statistical analysis
In all statistical analysis SPSS 20.0 Statistical Pack-
age Program for Windows (SPSS Inc., IL, USA) was
used. Kolmogorov–Smirnov test was used to test nor-
mality of distribution. Quantitative variables with a
normal distribution were specified as the mean ± stan-
dard deviation, and those with non-normal distri-
bution were specified with median (minimum and
maximum); categorical variables were specified with
number and percentage values. To compare paramet-
ric continuous variables, Student’s t test or analysis of
variance (ANOVA) was used; to compare nonpara-
metric continuous variables, Mann–Whitney U test
or ­K ruskal–Wallis test was used as appropriate. Cat-
egorical variables were compared with Chi-square test.
Spearman’s correlation coefficient was computed to
examine the relationship between MHR and SYN-
TAX score and C-reactive protein (CRP). Multiple

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logistic regression analysis was used to determine the
independent predictors of high SYNTAX score (≥23).
Possible confounding factors for which the unadjusted
p-value was <0.10 in univariate regression analysis
(age, male sex, hypertension, diabetes mellitus, LVEF,
platelet, mean platelet volume, white blood cell, neu-
trophil, CRP and MHR) were identified as potential
risk markers and included in multivariate logistic
regression model. A p-value of <0.05 was considered
statistically ­significant.
Results
Baseline clinical and angiographic characteristics of
the study patients were presented in Table 1. There
were 408 (33.1%) patients with high (≥23) SYN-
TAX score (mean age was 62.4 ± 10.5 years, 71.6%
males), and 821 (66.9%) patients low (≤22) SYN-
TAX score (mean age was 59.8 ± 10.9 years, 60.8%
males). Patients with high SYNTAX score were older,
more likely to be male and more often had hyperten-
sion and diabetes mellitus. There were no significant
differences between two groups with respect to num-
ber of current smokers and prehospital treatments.
However, LVEF was significantly lower in the high
SYNTAX score group than in the low SYNTAX score
group (p < 0.05). ­Multivessel disease, chronic total
occlusions, the left main coronary artery lesions and
the left anterior descending coronary artery lesions
were more often present in the high SYNTAX score
group. The rate of patients who underwent coronary
artery bypass grafting was also significantly higher in
the high SYNTAX score group, whereas the rate of
40.0
Monocyte/HDL-C ratio
30.0
20.0
10.0
0 p < 0.001
1.0 10.0 20.0 30.0
SYNTAX score
Figure 1. Correlation analysis showing statistically significant positive correlation between monocyte/HDL-C ratio with SYNTAX
score and C-reactive protein.
HDL-C: High-density lipoprotein cholesterol.
future science group
Association of MHR with SYNTAX score  Research Article
stent implantation for the coronary lesions was sig-
nificantly higher in the low SYNTAX score group
(Table 1) . The laboratory data of the study groups
were demonstrated in Table 2. Platelet, white blood
cell (WBC), neutrophil, monocyte, MHR and CRP
values were significantly higher in the high SYNTAX
score group whereas HDL-C level was significantly
lower in the high SYNTAX score group as compared
with the low SYNTAX score group (p < 0.05). We
also presented the baseline clinical characteristics and
laboratory findings of the study population accord-
ing to SYNTAX score tertiles in Table 3. In addition,
demographic and clinical characteristics of the study
population based on MHR tertiles were given in
Table 4. From tertile 1 (with the lowest MHR) to ter-
tile 3 (with the highest MHR), direct i­nflammatory
markers including CRP, WBC and neutrophil values
showed a significant increase whereas LVEF showed a
significant decrease (p < 0.05).
Univariate regression analysis showed that age,
male sex, hypertension, diabetes mellitus, LVEF,
platelet, mean platelet volume, WBC, neutrophil,
CRP and MHR were possible confounding factors
for the high SYNTAX score. After multi­variate logis-
tic regression analysis, MHR (odds ratio [OR]: 1.083
[1.060–1.108]; p < 0.001) remained as indepen-
dent predictor of high SYNTAX score as well as
CRP (OR: 1.062 [1.043–1.080]; p < 0.001), LVEF
(OR: 0.942 [0.929–0.954]; p < 0.001), hyper­tension
(OR: 1.397 [1.056–1.847]; p = 0.019) and ­diabetes
mellitus (OR: 1.464 [1.062–2.019]; p = 0.020)
(Table 5) . Namely, one unit increment in both MHR
40.0
Monocyte/HDL-C ratio
30.0
20.0
10.0
r = 0.371 r = 0.336
0 p < 0.001
40.0 1.0 10.0 20.0 30.0 40.0
C-reactive protein (mg/l)
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Research Article  Akboga, Balci, Maden et al.

and CRP was associated with an 8.3% and 6.2%
increased the risk of high SYNTAX score, whereas one
unit d
­ ecrement in LVEF was associated 5.8% increased
the risk of high SYNTAX score. Finally, in correlation
analysis, MHR showed significant positive correlations
with SYNTAX score (r = 0.371; p < 0.001) and CRP
(r = 0.336; p < 0.001) (Figure 1A & B) .
Discussion
In the present study, we showed that baseline MHR
is significantly associated with the extent and com-
plexity of coronary artery disease, as estimated by the
SYNTAX score in patients with stable coronary artery
disease. Also, MHR is correlated positively with high
SYNTAX score and CRP level.
Atherosclerosis is a maladaptive, nonresolving
chronic inflammatory disease occurring at sites of
blood flow disturbance [21,22] . The subendothelial
retention of cholesterol-containing plasma lipoproteins
at these sites and flow-mediated inflammatory changes
in endothelial cells are thought to trigger the athero-
genic process [23,24] . In the center of this atheroscle-
rotic plaque, macrophages derived from monocytes
take an active role by ingesting oxidized LDL and
forming the dangerous foamy cells. It has been shown
that monocyte count was an independent and signifi-
cant predictor of plaque formation and progression in
atherosclerosis  [25] . Contrary to monocytes, HDL-C
interferes LDL oxidation and has anti-inflammatory,
antioxidant, antithrombotic and beneficial vascular
effects  [13,14] . These activities are exerted by both the
quality and quantity of HDL-C [17] .
Lately, Kanbay et al. described a novel ­inflammatory
marker that combined the predictive values of the
­circulating monocyte count and serum HDL ­cholesterol
into a single proportion [15] . They showed that MHR
was associated cardiovascular prognosis in patients with
chronic kidney disease. In addition to that, another
study showed that higher MHR was associated with
the presence and severity of isolated coronary artery
ectasia [17] . In our study, we observed higher MHRs in
patients with SYNTAX score ≥23, also high MHRs
and CRP levels were independently related to higher
SYNTAX score. When patients were classified accord-
ing to the MHR tertiles, CRP levels were significantly
higher, and the LVEF was significantly lower in the
highest tertile. Previously, Canpolat et al. reported that
MHR correlated positively with high-sensitivity CRP
in slow coronary flow [16] . ­Similarly, we also observed
a positive correlation between MHR and CRP that
MHR may indirectly reflect the underlying inflamma-
tory condition. Higher MHRs in patients with stable
coronary artery disease and higher SYNTAX scores
(≥23) support that increased MHR may be a predictor
for atherosclerosis development and progression, and
resultant cardiovascular events.
SYNTAX score is an anatomic scoring system that
reflects both the lesion characteristics and cardiovascu-
lar morbidity and mortality [1–3] . In different clinical
conditions, irrespective of the disease severity, higher
SYNTAX score predicts early and late mortality and
morbidity including major adverse cardiac events,
all-cause death, cardiac death, myocardial infarction,
and target vessel revascularization [1–6] . The SYN-

Table 4. Demographic and clinical characteristics of the study groups according to monocyte/high-
density lipoprotein cholesterol ratio tertiles.
Parameters Monocyte/HDL-C ratio tertiles p-value
Tertile 1 (n = 410) Tertile 2 (n = 410) Tertile 3 (n = 409)
Age, years 60.3 ± 10.8 60.7 ± 10.5 61.1 ± 11.1 0.560
Male sex, n (%) 255 (62.2) 263 (64.1) 273 (66.7) 0.394
Hypertension, n (%) 184 (44.9) 199 (48.5) 213 (52.1) 0.119
Diabetes mellitus, n (%) 86 (21.0) 96 (23.4) 113 (27.6) 0.079
LVEF (%) 60.3 ± 8.5 58.8 ± 10.3 57.5 ± 10.7 <0.001
RDW (%) 13.8 ± 1.4 13.9 ± 1.7 13.9 ± 1.6 0.905
Platelet, 10³/mm³ 251.6 ± 47 254.3 ± 55 258.5 ± 56 0.394
Mean platelet volume, fL 8.6 ± 1.2 8.6 ± 1.4 8.7 ± 1.4 0.655
White blood cell, μL 7.1 ± 1.5 7.5 ± 1.6 8.3 ± 1.6 <0.001
Neutrophil, μL 4.2 ± 1.2 4.6 ± 1.4 5.1 ± 1.4 <0.001
C-reactive protein, mg/L †
5.6 (3.2–9.6) 7.1 (3.8–13.2) 9.5 (5.4–18.2) <0.001
Data were given as mean ± standard deviation or %.
†
Median (interquartile range).
HDL-C: High-density lipoprotein cholesterol; LVEF: Left ventricular ejection fraction; RDW: Red cell distribution width.

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Table 5. Univariate and multivariate logistic regression analysis for assessment of independent
predictors of high SYNTAX score.
Variables
OR (95% CI)
Age 1.022 (1.011–1.034)
Male sex 1.624 (1.257–2.100)
Hypertension 1.365 (1.075–1.732)
Diabetes mellitus 1.381 (1.052–1.813)
LVEF 0.937 (0.925–0.949)
Platelet 1.002 (1.000–1.003)
Mean platelet volume 1.086 (0.998–1.183)
White blood cell 1.119 (1.042–1.202)
Neutrophil 1.154 (1.061–1.254)
C-reactive protein 1.075 (1.059–1.091)
Monocyte/HDL-C ratio 1.085 (1.065–1.105)
HDL-C: High-density lipoprotein cholesterol; LVEF: Left ventricular ejection fraction; OR: Odds ratio.
TAX score not only reflects the technical difficulty
of ­percutaneous coronary intervention and also gives
information about the pattern of atheroma [6] . The
association between SYNTAX score and MHR sup-
ports that the patients having high levels of circulating
monocytes and devoid of HDL beneficial effects may
have more severe and complex coronary artery disease.
However, none of the inflammatory markers includ-
ing high sensitivity-CRP have been involved in any
clinical and angiographic scoring system incorporating
GRACE, SYNTAX, TIMI, STS, Euroscore [26–28] . In
this context adding inflammatory markers into a scor-
ing system may improve the predictive and prognostic
value of the applied score.
Limitations
The first limitation of this study is inherent to its retro-
spective design and absence of follow-up data about the
patient group. Second, coronary angiogram assessment
was limited to visual interpretation. Third, rather than
follow-up values only a single measurement of MHR
was used. At last, only white blood cell counts with
differentials and CRP were used to assess inflamma-
tory condition because the other markers were not used
routinely in clinical practice.
Conclusion
Our study showed that higher MHR levels were signifi-
cantly and independently associated with higher SYN-
TAX score in patient with stable CAD. Add to this,
according to the MHR tertiles, we observed higher
CRP levels in the highest tertile, and there was a posi-
tive correlation between CRP and MHR. MHR that
can be easily derived from routine laboratory tests may
future science group
Association of MHR with SYNTAX score  Research Article
Univariate Multivariate
p-value OR (95% CI) p-value
<0.001 – –
<0.001 – – 
0.011 1.397 (1.056–1.847) 0.019
0.020 1.464 (1.062–2.019) 0.020
<0.001 0.942 (0.929–0.954) <0.001
0.022 – –
0.056 – –
0.002 – –
0.001 – –
<0.001 1.062 (1.043–1.080) <0.001
<0.001 1.083 (1.060–1.108) <0.001
simply and indirectly show underlying inflammatory
status. Furthermore, adding ­inflammatory markers to
a scoring system may be useful in predicting adverse
events by improving its predictive ability.
Future perspective
MHR combining the predictive and prognostic value
of both readily available inflammatory and oxidative
stress markers has emerged a new marker in cardio-
vascular diseases. In our study higher MHR values in
patients with higher SYNTAX scores supported that
increased MHR may be a predictor for atherosclerosis
development and progression, and resultant cardio­
vascular events. In order to understand this ­relationship
in detail, further studies are needed.
Financial & competing interests disclosure
The authors have no relevant affiliations or financial in-
volvement with any organization or entity with a financial
interest in or financial conflict with the subject matter or
materials discussed in the manuscript. This includes employ-
ment, consultancies, honoraria, stock ownership or options,
expert testimony, grants or patents received or pending, or
­royalties.
No writing assistance was utilized in the production of this
manuscript.
Ethical conduct of research
The authors state that they have obtained appropriate institu-
tional review board approval or have followed the principles
outlined in the Declaration of Helsinki for all human or animal
experimental investigations. In addition, for investigations in-
volving human subjects, informed consent has been obtained
from the participants involved.
www.futuremedicine.com10.2217/bmm-2015-0050
Research Article  Akboga, Balci, Maden et al.

Executive summary
Background
• It was known that inflammation, endothelial dysfunction, oxidative stress and platelet activation play a
significant role in the formation and progression of atherosclerosis.
• Recently, monocyte to high-density lipoprotein-C ratio (MHR), combining the predictive and prognostic value
of both easily available laboratory markers into a single fraction has emerged a new marker in cardiovascular
diseases.
Results
• Inflammation, endothelial dysfunction and oxidative stress play a significant role in the formation and
progression of atherosclerosis.
• MHR an easily available inflammatory and oxidative stress marker.
• SYNTAX score is an anatomic scoring system that reflects both the lesion characteristics and cardiovascular
morbidity and mortality.
• MHR were significantly higher in patients with high SYNTAX score.
• MHR showed significant positive correlations with SYNTAX score and C-reactive protein level.
• MHR was independently associated with burden of coronary atherosclerosis assessed by SYNTAX score.
Conclusion
• Our study showed that higher MHR levels as readily available inflammatory and oxidative stress markers were
significantly and independently associated with higher SYNTAX score in patient with stable coronary artery
disease.
• Furthermore, adding inflammatory markers to a scoring system may be useful in predicting adverse events by
improving its predictive ability.

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