Prognostic value of c-reactive protein to albumin ratio in patients with valvular heart disease: nationwide prospective cohort study

Bin Zhang; Ziang Li; Yunqing Ye; Zhe Li; Zhenyan Zhao; Haitong Zhang An; Bincheng Wang; Qingrong Liu; Junxing Lv; Huiqiao Han; Yanyan Zhao; Marie-Annick Clavel; Philippe Pibarot; Runlin Gao; Haiyan Xu; Yongjian Wu; Hongliang Zhang An

doi:10.1097/JS9.0000000000002576

Prognostic value of c-reactive protein to albumin ratio in patients with valvular heart disease: nationwide prospective cohort study

Int J Surg. 2025 May 28. doi: 10.1097/JS9.0000000000002576. Online ahead of print.

Authors

Bin Zhang^{1

2}, Ziang Li^{1

2}, Yunqing Ye¹, Zhe Li¹, Zhenyan Zhao¹, Haitong Zhang An¹, Bincheng Wang¹, Qingrong Liu¹, Junxing Lv¹, Huiqiao Han¹, Yanyan Zhao³, Marie-Annick Clavel², Philippe Pibarot², Runlin Gao¹, Haiyan Xu¹, Yongjian Wu¹, Hongliang Zhang An¹

Affiliations

¹ Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, People's Republic of China.
² Research Center, Institut universitaire de cardiologie et de pneumologie de Québec (Quebec Heart & Lung Institute), Université Laval, Québec city, Canada.
³ Medical Research & Biometrics Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.

PMID: 40434743
DOI: 10.1097/JS9.0000000000002576

Abstract

Background: The C-reactive to albumin ratio (CAR) integrates the pro-inflammatory and nutritional status of patients, which may provide superior prognostic information over either parameter alone in valvular heart disease (VHD). The study aims to examine the association between CAR and mortality and its ability as biomarker to guide risk stratification in VHD patients.

Materials and methods: A total of 5519 patients (age ≥ 18 years) with moderate or severe VHD from a multicenter prospective cohort underwent echocardiography and CAR measurement. VHD examined included aortic stenosis, aortic regurgitation, mitral stenosis, mitral regurgitation; tricuspid regurgitation, and multivalvular heart disease. An optimal threshold of 0.15 was defined based on penalized splines and receiver operating characteristic curves. The primary outcome was all-cause mortality.

Results: The cohort had a mean age of 61.9 ± 13.7 years, and 2997 (54.3%) were men. At two-year follow-up, 482 (8.7%) deaths occurred. Penalized splines showed a monotonic increase of relative hazards with greater CAR for death. Higher CAR was independently associated with mortality (overall adjusted hazard ratio [aHR]: 1.89; 95% confidence interval [CI]: 1.56 to 2.28; p < 0.001) and major adverse cardiovascular events (aHR: 1.40; 95% CI: 1.30 to 1.82; p < 0.001). Different subtypes of VHD incurred excess mortality with elevated CAR. Results remained consistent in patients under medical care. The CAR threshold combined with NT-proBNP amplified the stratification of patients at risk (log-rank, p < 0.001). The addition of CAR to a prediction algorithm including traditional risk factors improved outcome prediction (continuous net reclassification index [NRI]: 0.57; likelihood ratio test p < 0.001) and reclassified better in patients both with and without events (absolute NRI: 4.3%).

Conclusions: CAR provides incremental prognostic information for mortality in various VHD. It could aid in risk stratification as a dependable and accessible tracking tool of prognosis in VHDs.

Keywords: C-reactive protein to albumin ratio; biomarker; mortality; valvular heart disease.