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Clin Exp Hypertens, Early Online: 1–5

! 2013 Informa Healthcare USA, Inc. DOI: 10.3109/10641963.2013.804547

Neutrophil to lymphocyte and platelet to lymphocyte ratio

in patients with dipper versus non-dipper hypertension
Murat Sunbul1, Fethullah Gerin2, Erdal Durmus1, Tarik Kivrak1, Ibrahim Sari1, Kursat Tigen1, and Altug Cincin1
1
Department of Cardiology and 2Department of Biochemistry, Marmara University, Faculty of Medicine, Istanbul, Turkey

Abstract Keywords
Background: Neutrophil to lymphocyte ratio (NLR) and platelet to lymphocyte ratio (PLR) are
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Neutrophil to lymphocyte ratio, platelet to

associated with worse outcome in various diseases. Non-dipping blood pressure pattern is lymphocyte ratio, dipper, non-dipper,
associated with higher cardiovascular mortality. The aim of this study was to explore the hypertension
association between NLR and PLR in patients with dipper versus non-dipper hypertension.
Methods: The study included 166 patients with hypertension. Eighty-three patients (40 male, History
mean age: 49.1 ! 10.5 years) had dipper hypertension, while 83 patients (41 male, mean age:
52.3 ! 12.7 years) had non-dipper hypertension. Received 2 March 2013
Results: Baseline demographic characteristics were similar in both groups. Patients with non- Revised 24 March 2013
dipper hypertension had significantly higher NLR compared to dipper hypertension (2.3 ! 0.9 Accepted 27 March 2013
versus 1.8 ! 0.5, p50.001). Patients with non-dipper hypertension had significantly higher PLR Published online 20 June 2013
compared to dipper hypertension (117.7 ! 35.2 versus 100.9 ! 30.5, p ¼ 0.001). In univariate
analysis, hyperlipidemia, smoking, presence of diabetes, PLR more than 107 and NLR more than
For personal use only.

1.89 were among predictors of dipper and non-dipper status. In logistic regression analyses,
only hyperlipidemia (odds ratio: 2.96, CI: 1.22–7.13) and PLR more than 107 (odds ratio: 2.62, CI:
1.13–6.06) were independent predictors of dipper and non-dipper status. A PLR of 107 or higher
predicted non-dipper status with a sensitivity of 66.3% and specificity of 68.7%.
Conclusion: We demonstrated that patients with non-dipper hypertension had significantly
higher NLR and PLR compared to dipper hypertension, which has not been reported previously.
Moreover PLR more than 107 but not NLR was independent predictor of non-dipper status.

Introduction damage (7). Although there is usually circadian variation in

blood pressure (BP), such as more than 10% decrease in
Previous studies have shown that inflammation seems to play
systolic and diastolic BP during sleep compared to daytime
an important role in the initiation and progression of
(dipper), some hypertensive subjects who have not had this
cardiovascular diseases (1,2). White blood cell count and its
circadian variation have been entitled non-dippers. Patients
subtypes are associated with increased cardiovascular risk
with non-dipper hypertension are associated with increased
factors (3–5). The neutrophil to lymphocyte ratio (NLR) has
cardiovascular risk such as myocardial infarction (MI)
been investigated as a new predictor for cardiovascular risk
(4). NLR has emerged as an important inflammatory marker,
compared to patients with dipper hypertension. Patients 13
with non-dipper hypertension had three times the risk of
20
and high level of NLR is associated with increased mortality
atherosclerotic events than dipper hypertension (8).
in non-cardiac disorders such as some malignancies. While
The etiology of essential hypertension is multifactorial,
NLR has recently been investigated as a new predictor for
and inflammation is an important factor in the pathogenesis of
cardiovascular risk, recent studies have demonstrated that
hypertension (9). Despite the importance of non-dipper
platelet to lymphocyte ratio (PLR) is associated with major
hypertension on cardiovascular outcomes, there is not
adverse cardiovascular outcomes. Increased platelet activation
enough data whether PLR and NLR are associated with
plays a major role in the initiation and progression of
non-dipper hypertension. The aim of this study was to explore
atherosclerosis (6).
the association between NLR and PLR in patients with dipper
Hypertension is a common chronic disease and associated
versus non-dipper hypertension.
with increased risk of heart attacks, strokes and target organ
Materials and method
The investigation complies with the principles outlined in the
Correspondence: Murat Sunbul, MD, Marmara University Education and Declaration of Helsinki. The study was approved by the local
Research Hospital, Fevzi Cakmak Mahallesi, Mimar Sinan Caddesi,
No: 41, Pendik/Istanbul, Turkey. Tel: 90 506 581 90 15. Fax: 90 216 657 ethics committee, and all participants gave written informed
06 95. E-mail: drsunbul@yahoo.com.tr consent before participating.
 2 M. Sunbul et al. Clin Exp Hypertens, Early Online: 1–5

Patients were selected among cases referred to cardiology
outpatient clinic to evaluation of hypertension from
November 2012 to January 2013. The study included 166
patients with essential hypertension. All patients underwent a
24-h ambulatory BP monitoring for evaluation of dipper or
non-dipper status after diagnosis of the hypertension.
Ambulatory BP monitoring was performed regularly every
30 min during the 24-h period. The cuff was placed around
the non-dominant arm of the patients. Patients were ques-
tioned about their sleep quality and 24-h BP assessments were
repeated if necessary. Sleep and awake periods were assessed
based on the self-information of patients. Nocturnal BP
dipping was calculated as: (%) 100 # [1 $ (sleep systolic
BP/awake systolic BP)]. Patients with dipper hypertension
were defined as more than 10% decrease in systolic and
diastolic BP measurements. Patients with less than 10%
decrease in either systolic or diastolic BP were defined as
non-dipper hypertension (10).
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Receiver operating characteristic (ROC) curve analysis was
performed to determine the cut-off level of PLR to predict the
dipper versus non-dipper status. p Values less than 0.05 were
considered statistically significant.
Results
The study population was consisted of 166 consecutive
patients who were diagnosed with hypertension. All patients
were divided into two groups according to status of dipper or
non-dipper hypertension after 24-h ambulatory BP monitor-
ing. While 83 patients had non-dipper hypertension, 83
patients had dipper hypertension (52.3 ! 12.7 versus
49.1 ! 10.5, p ¼ 0.082). Baseline characteristics and clinical
data were similar in both groups (Table 1). The hemodynamic
data of study population was shown in Table 2. While mean
BP measurements were similar in both groups, heart rate
value was significantly higher in patients with dipper

hypertension compared to non-dipper hypertension.

Complete blood counts, which included total white blood
cells, neutrophils, lymphocytes, and platelets were obtained at
the time of admission. NLR and PLR were calculated as the
ratio of neutrophil count to lymphocyte count and as the ratio
of platelet count to lymphocyte count, respectively. All
patients were evaluated for presence of cardiovascular risk
factors such as hypertension, hyperlipidemia, diabetes
mellitus and smoking. Hypertension was defined as systolic
BP %140 mmHg and/or diastolic BP %90 mmHg, previously
For personal use only.
Laboratory findings, NLR and PLR are shown in Table 3.
Patients with non-dipper hypertension had significantly
higher NLR compared to dipper hypertension (2.3 ! 0.9
versus 1.8 ! 0.5, p50.001). Patients with non-dipper
Table 1. Baseline caharacteristics and clinical data of the study
population.
Non-dipper group Dipper group

diagnosed hypertension, or use of any antihypertensive (n ¼ 83) (n ¼ 83) p

medications. Diabetes mellitus was defined as fasting Age (years) 52.3 ! 12.7 49.1 ! 10.5 0.082
plasma glucose levels more than 126 mg/dL in multiple Sex (male – n) 41 40 0.937
measurements, previously diagnosed diabetes mellitus or use Height (cm) 167.6 ! 10.3 166.1 ! 7.6 0.531
of antidiabetic medications such as oral anti-diabetic agents or Weight (kg) 76.7 ! 19.3 81.8 ! 13.9 0.253
Smoking (n) 16 21 0.351
insulin. Hyperlipidemia was defined as serum total choles- Diabetes mellitus (n) 12 10 0.642
terol %240 mg/dl, serum triglyceride %200 mg/dl, low-density Hyperlipidemia (n) 30 38 0.269
lipoprotein cholesterol %130 mg/dl, previously diagnosed
Data are expressed as mean ! SD or as number of patients.
hyperlipidemia, or use of lipid-lowering medication.
Smoking status was defined as the history of tobacco use at
admission or in the 6 months prior to visit. Patients with Table 2. Hemodynamic data of the study population.
systemic disease and using of medical treatment to affect the
white blood cell counts, such as hematopoietic system Non-dipper Dipper
group group
disorders, history of malignancies and/or treatment with (n ¼ 83) (n ¼ 83) p
chemotherapy, evidence of any concomitant inflammatory
Systolic blood pressure 128.6 ! 15.7 126.5 ! 13.1 0.355
disease, acute infection, and chronic inflammatory status, (total) – mmHg
acute coronary syndrome and percutaneous coronary inter- Systolic blood pressure 129.3 ! 15.6 130.8 ! 13.6 0.529
vention within the past 6 months, history of using the (awake) – mmHg
glucocorticoid therapy within the past 3 months, secondary Systolic blood pressure 125.6 ! 16.4 112.6 ! 11.9 50.001
(sleep) – mmHg
hypertension, heart failure, history of chronic renal or hepatic Diastolic blood pressure 80.4 ! 11.7 79.9 ! 10.3 0.778
disease and cerebrovascular disease were excluded from (total) – mmHg
the study. Diastolic blood pressure 81.8 ! 11.9 83.2 ! 11.1 0.424
(awake) – mmHg
Diastolic blood pressure 76.0 ! 11.8 69.1 ! 9.7 50.001
Statistical analysis (sleep) – mmHg
Mean blood pressure 102.4 ! 12.7 101.2 ! 10.8 0.503
Statistical analyses were performed using SPSS 20.0 statis- (total) – mmHhg
tical package for Windows (Somers, NY). Continuous data Mean blood pressure 103.6 ! 12.8 104.9 ! 11.5 0.485
(awake) – mmHg
were expressed as mean ! standard deviation, while categor- Mean blood pressure 98.8 ! 13.2 88.9 ! 10.3 50.001
ical data were presented as number of patients. Chi-square test (sleep) – mmHg
was used for comparison of categorical variables, while Pulse rate (total) – beat/min 73.0 ! 11.8 76.6 ! 10.5 0.037
student-t test was used to compare continuous variables. Pulse rate (awake) – beat/min 75.1 ! 12.3 79.3 ! 11.0 0.026
Pulse rate (sleep) – beat/min 65.9 ! 10.8 65.1 ! 9.9 0.584
Logistic regression analysis was performed to determine the
independent predictors of dipper versus non-dipper status. Data are expressed as mean ! SD.
 DOI: 10.3109/10641963.2013.804547 Neutrophil and platelet to lymphocyte ratio in hypertension 3
Table 3. Comparison of laboratory findings of dipper and non-dipper
patients.

Non-dipper Dipper
group group
(n ¼ 83) (n ¼ 83) p
$3
Leukocytes (mm ) 7608 ! 1859 7825 ! 1795 0.446
Neutrophils (mm$3) 4612 ! 1397 4470 ! 1261 0.492
Lymphocyes (mm$3) 2176 ! 671 2539 ! 719 0.001
NLR 2.3 ! 0.9 1.8 ! 0.5 50.001
(neutrophil/lymphocyte ratio)
Platelets (103/mm$3) 244.2 ! 62.7 243.8 ! 62.4 0.970
PLR 117.7 ! 35.2 100.9 ! 30.5 0.001
(platelet/lymphocyte ratio)
Hemoglobin (g/dl) 13.6 ! 1.5 13.9 ! 1.5 0.245
Fasting glocose (mg/dl) 108.5 ! 46.8 97.8 ! 24.5 0.132
Creatinine (mg/dl) 0.86 ! 0.24 0.82 ! 0.28 0.393
Total cholesterol (mg/dl) 197.5 ! 51.7 212.4 ! 41.8 0.068
Triglycerides (mg/dl) 144.5 ! 80.7 149.5 ! 74.8 0.713
Low dencity lipoprotein (mg/dl) 118.4 ! 45.6 126.4 ! 38.1 0.276
High dencity lipoprotein (mg/dl) 52.0 ! 14.3 50.5 ! 14.4 0.547
2.1 ! 1.8 2.0 ! 1.3
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TSH (mIU/ml) 0.837

AST (U/l) 22.6 ! 11.0 20.4 ! 5.9 0.253
ALT (U/l) 22.8 ! 13.4 23.3 ! 9.7 0.840
Na (mmol/l) 140.1 ! 2.7 140.7 ! 2.4 0.240
K (mmol/l) 4.4 ! 0.5 4.4 ! 0.5 0.749
Figure 1. ROC analysis for PLR to predict non-dipper status (area under
Data are expressed as mean ! SD. curve is 0.661).

hypertension had significantly higher PLR compared to levels of endothelial progenitor cells, which play an important
dipper hypertension (117.67 ! 35.15 versus 100.89 ! 30.46, role in the endothelial homeostasis and vascular repair, was
p ¼ 0.001). In univariate analysis, hyperlipidemia, smoking,
For personal use only.

decreased in patients with non-dipper BP compared with

presence of diabetes, PLR more than 107 and NLR more than
1.89 were among predictors of dipper and non-dipper status.
In logistic regression analyses, only hyperlipidemia (odds
ratio: 2.96, CI: 1.22–7.13) and PLR more than 107 (odds
ratio: 2.62, CI: 1.13–6.06) were independent predictors of
non-dipper status. ROC analysis was performed to determine
the cut-off value of PLR to predict the dipper versus non-
dipper status. A PLR of 107 or higher predicted non-dipper
status with a sensitivity of 66.3% and specificity of 68.7%
(Figure 1).
Discussion
In this study, we demonstrated that patients with non-dipper
hypertension had significantly higher NLR and PLR com-
pared to dipper hypertension. Moreover, PLR more than 107
but not NLR was independent predictors of non-dipper status.
Clinical use of 24-h ambulatory BP monitoring gives
information about BP during the night. BP falling during the
night time compared with day time, which is more than 10%,
is called as dipper BP pattern. If BP drop is less than 10%, it is
called non-dipper BP pattern (11). Non-dipper BP pattern is
always associated with autonomic dysfunction.
Endocrinologic disorders such as hypercortisolism (12),
pheochromocytoma, sleep apnea syndrome (13) and chronic
kidney disease (14) may be associated with non-dipper
hypertension. Non-dipper BP pattern has been proven to be
associated with target end-organ damages and increased
cardiovascular mortality (15). Adverse effects of non-dipper
BP pattern on cardiovascular risk were observed independent
of BP level that was normal or higher than normal limits (16).
Adverse effect of non-dipper BP may be related with
endothelial damage. In a previous study, it was shown that
dipper hypertensive patients (17). Hypertension cause left
ventricle hypertrophy (LVH) and diastolic dysfunction (DD).
Compared with dipper hypertensive patients, non-dipper
hypertensive patients had higher incidence of LVH and DD
(18). Non dipping BP pattern was associated higher cardio-
vascular mortality, poor long-term survival and autonomic
dysfunction (19,20).
Chronic inflammation is associated with lots of chronic
disease such as malignancy, diabetes mellitus, hypertension,
connective tissue disease, chronic kidney disease and coron-
ary artery disease (21–24). White blood cell count, C reactive
protein and neutrophil lymphocyte ratio (NLR) are some of
the predictors of chronic inflammation. Leukocytes play a
major role in inflammatory processes. Neutrophils are the
most abundant type of the white blood cells. They take
important roles in inflammatory response. Neutrophils are the
first cells responding to inflammation especially due to
bacterial infection, cancer and environmental exposure.
They release many kinds of cytokines and activate other
cells of the immune system to trigger and amplify inflam-
matory reactions. The relationship between white blood cell
count and increased cardiovascular risk is well known. NLR,
which can be derived from the white blood cell count is an
inexpensive, routinely used, reproducible test and has shown
up as a marker of systemic inflammatory response. Previous
studies have shown that NLR is associated with poor clinical
outcomes in cardiac diseases and several malignancies
(25,26). Kruk et al. showed that increased level of inflam-
mation was associated with poor prognosis in coronary artery
disease (27). NLR is a parameter that gives us information not
only about the systemic inflammation but also the stress
response of the patient. While mainly high neutrophil counts
 4 M. Sunbul et al.
reflect to inflammation, low lymphocyte counts reflect poor
general health and physiologic stress (28). Blood NLR is an
indicator of the overall inflammatory and stress status of the
body, and an alteration in NLR may be found in hypertensive
patients. Recently published trials established that NRL was
associated with increased mortality and poor prognosis in
acute coronary syndromes especially ST segment elevation
MI (29). NRL was also increased in patients with diabetes
mellitus and hypertension. NLR can be a useful and cost-
effective method to evaluate inflammatory state.
Previous studies have demonstrated that higher platelet and
lower lymphocyte counts were associated with adverse
cardiovascular outcomes. Azab et al. showed that higher
value of PLR as a marker of long-term mortality in patients
with non-ST segment elevation MI (30). In patients with
various malignancies such as ovarian cancer and pancreatic
ductal adenocarcinoma, it has been demonstrated that eleva-
tion of neutrophils, platelets, NLR or PLR were associated
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with some adverse clinico-pathologic events (31,32).
Although the association between NLR and cardiovascular
disease has been demonstrated in numerous studies, the
association between PLR and cardiovascular diseases
remained unclear except a few clinical studies (30,33). To
date, there is no study investigating the relationship between
PLR and dipper versus non-dipper status. Our study, for the
first time demonstrated that PLR was not only higher in the
non-dipper group than the dipper group it also emerged as an
For personal use only.
independent predictor of non-dipper status. In a recent study,
Demir (34) showed for the first time that patients with non-
dipper hypertension had higher NLR compared with dipper
patients. However, the number of sample size was smaller in
his study and he did not report whether NLR was an
independent predictor of non-dipper status (34).
Study limitations
Our study had some limitations. One of them was the small
sample size. We were also not able to evaluate the prognostic
value of the NLR and PLR in patients with hypertension. Our
study had a cross-sectional design, and it would be better if
we had followed the patients and explore the relation between
adverse cardiac events and NLR and/or PLR in these patients.
Conclusions
We demonstrated that patients with non-dipper hypertension
had significantly higher NLR and PLR compared to dipper
hypertension. Moreover, PLR more than 107 but not NLR was
independent predictors of non-dipper status.
Declaration of interest
The authors report no conflicts of interest. The authors alone
are responsible for the content and writing of this article.
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