- Department of Neurology, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China
Objective: To assess the prognostic value of
lipid profiles and their ratios, particularly the white blood cell to
high-density lipoprotein (WBC/HDL) ratio, for predicting 28-day and
1-year all-cause mortality in ischemic stroke patients admitted to the
ICU.
Methods: A retrospective cohort study was
conducted using the MIMIC-IV ICU database, including 2,894 ischemic
stroke patients. Lipid profiles—including total cholesterol,
triglycerides, low-density lipoprotein, and high-density lipoprotein—and
derived ratios were analyzed. Associations with mortality were assessed
using Cox proportional hazards models adjusted for demographic and
clinical factors. Restricted cubic spline and Kaplan–Meier survival
analyses were utilized to explore the relationship between the WBC/HDL
ratio and mortality risk.
Results: Traditional lipid profiles and their
ratios were not significantly associated with 28-day or 1-year
mortality. Conversely, an elevated WBC/HDL ratio was independently
associated with increased mortality risk at both 28 days (hazard ratio:
2.198; 95% confidence interval: 1.864–3.225) and 1 year (hazard ratio:
3.163; 95% confidence interval: 2.947–3.334). Restricted cubic spline
analysis demonstrated a linear relationship between the WBC/HDL ratio
and mortality risk, while Kaplan–Meier analyses indicated significantly
poorer survival outcomes for patients with higher WBC/HDL ratios.
Interpretation: The WBC/HDL ratio is a superior
prognostic marker for mortality in ischemic stroke patients admitted to
the ICU, outperforming traditional lipid profiles. Incorporating this
measure into clinical practice may enhance early risk stratification and
guide targeted interventions.
1 Introduction
Ischemic stroke (IS) is a leading cause of disability
and mortality worldwide, imposing a significant burden on patients,
families, and healthcare systems (1).
Thrombolysis and endovascular embolectomy have significantly improved
the prognosis of ischemic stroke patients; however, many patients
continue to experience poor outcomes, particularly those requiring
intensive care unit (ICU) admission due to severe neurological deficits
or medical complications (2).
Identifying high-risk patients early remains essential to enhance
postoperative management, optimize therapeutic strategies, and allocate
resources effectively within the ICU setting.
Lipid metabolism and inflammation are pivotal in the
pathogenesis and progression of IS. Dyslipidemia contributes to
atherosclerosis and thrombosis, fundamental mechanisms underlying
ischemic events (3).
Elevated levels of low-density lipoprotein (LDL) and triglycerides
(TG), along with decreased high-density lipoprotein (HDL), have been
associated with an increased risk of stroke occurrence (4).
In parallel, systemic inflammation plays a critical role in neuronal
injury and post-stroke recovery, with elevated inflammatory markers
correlating with worse outcomes (5, 6).
Given the interconnected roles of lipid metabolism and
inflammation in IS, ratios that integrate these parameters have been
proposed as comprehensive prognostic markers. Ratios like LDL/HDL,
TC/HDL (total cholesterol to HDL ratio), and TG/HDL aim to reflect the
balance between pro-atherogenic lipids and protective HDL (7).
The white blood cell to HDL ratio (WBC/HDL), in particular, combines
systemic inflammation with lipid status, potentially offering a more
holistic assessment of risk (8).
Prior studies suggest that these composite ratios may hold stronger
prognostic value than individual lipid measures in cardiovascular
disease (9, 10),
yet their predictive utility in ICU-admitted IS patients remains
uncertain. Therefore, critical illness and the body’s acute response can
change lipid levels and inflammation markers, which may influence their
usefulness for predicting outcomes (11, 12).
Understanding whether traditional lipid profiles and their ratios can
still reliably predict outcomes in this setting is crucial for
identifying effective markers to assess risk and guide treatment in the
ICU.
Prior studies suggest that these composite ratios may
hold stronger prognostic value than individual lipid measures in
cardiovascular disease (9, 10),
yet their predictive utility in ICU-admitted IS patients remains
uncertain. This study therefore aimed to evaluate two critical questions
using the MIMIC-IV database (13):
first, whether traditional lipid ratios (LDL/HDL, TC/HDL, TG/HDL)
retain prognostic value in critically ill stroke patients experiencing
acute metabolic disturbances; and second, whether novel ratios
integrating systemic inflammation with lipid profiles (e.g., WBC/HDL)
could provide enhanced risk stratification in this population. Through
this investigation, we sought to establish evidence-based guidance for
prognostic marker selection in neurocritical care settings.
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