INTRODUCTION:

Coronary Artery Disease:

Coronary artery disease has emerged as an epidemic in India. CAD is one of the most important causes of mortality and morbidity in the country. It also leads to massive economic burden.¹

The condition referred to as coronary artery disease is illustrated by an inadequate supply of blood and oxygen reaching the heart muscle. The obstruction of coronary arteries causes an imbalance between the supply and demand of oxygen. The usual cause is plaques that obstruct blood flow in the lumen of the coronary vessels.

Atherosclerosis is the most common pathophysiological basis for coronary artery disease (CAD).

Most people agree that the development, course, and impact of cholesterol causing lesion are complicated processes including the interaction of immune system components, blood components, vascular wall elements, and lipoproteins. The modulation of this interaction by many factors that are involved in the process of inflammation defines the prognostic significance of persistent low-grade inflammation in atherosclerosis.

A great deal of research has been conducted on these compounds as potential biological indicators and causative agents within the pathophysiological network of plaque vulnerability and atherogenesis. There is still a strong body of research demonstrating the intimate connection between atherosclerosis and inflammation.

Since inflammation has a significant impact on the development of congestive heart failure (CHD), new research lends credence to the idea that reducing the likelihood of cardiovascular incidents can be achieved by targeting inflammatory proteins or pathways. Based on the basis of approved medical treatment for atherosclerotic disease, the potential of certain anti-inflammatory drugs to reduce residual cardiovascular risk is being studied.

It has been discovered that certain of the early stages of atherosclerosis are characterized by fatty streaks. This stage can result in the creation of fibrous plaque, which can then cause the artery lumen to shrink and cause chronic tissue ischemia.

Atherosclerotic plaque can also lead to unstable plaque problems, such as bleeding, ulceration, and ultimately intravascular thrombosis, which can result in acute coronary syndrome (ACS) and abrupt occlusion of arteries.

Repetitive reparative and inflammatory responses, induced and enhanced by several mediators, characterize the unique environment of arterial plaque and its neighboring tissue.

Early studies by Ross and colleagues identified key mechanisms in the progression of atherosclerotic plaque, including the role of lymphocytes, the recruitment of macrophages by trans endothelial cells, and the expanding and advancement of smooth muscle cells into the innermost layer of the vessel wall.

Low-density lipoprotein (LDL) accumulation within the sub endothelium has been discovered to be a critical step in the process of endothelial injury, which starts atherogenesis.

An imbalance of prostacyclin and nitric oxide-mediated vascular relaxation, as well as an increase in indigenous vascular constrictors such as endothelin-1, are characteristics of endothelial dysfunction. When endothelial cell (EC) layers are damaged or under metabolic stress, as occurs when certain circulation patterns, diabetes, HTN, dyslipidemia, and metabolic syndrome are present, endothelial dysfunction can develop.²

The primary detecting and warning mechanism of the body, inflammation serves to confine and eradicate external poisons and microbiological infections. In recent times, chronic inflammation has gained recognition as an assisting factor in the development of several chronic diseases, such as cardiovascular disease (CVD), which has a widespread impact on the general population.

One such disease that is induced by inflammation is the development of atherosclerotic plaque.

Atherosclerosis was first identified in 1958 when Russell Holman and colleagues from New Orleans, Guatemala, and Costa Rica made important observations that led to the definition of fatty streaks as one of the disease's early symptoms. Fatty streaks are thought to be the starting point for the progression from fibrous plaques to bleeding, ulceration, or thrombosis. It was observed, therefore, that not all fatty streaks result in arterial occlusive disease.

A gradually developing inflammatory and reparative response was observed in the surrounding tissues during this phase. mediators of inflammation in atherosclerosis.

(A) Many inflammatory cell types, such as T-cells, monocytes, and neutrophils, are important mediators of the inflammatory response, which is an element of atherosclerosis. Early sudation and accumulation of lipids and lipoproteins leads to the onset and persistence of inflammation, especially when lipids are oxidatively damaged.

Macrophages, dendritic cells, and smooth muscle cells absorb these lipids and lipoproteins to create lipid-laden foam cells. Growth factors, chemokines, and proinflammatory cytokines help to further develop this response in the vessel wall. Inflammation within the atherosclerotic plaque acts in concert with other extrinsic variables such as hypoxia, reactive oxygen species (ROS), and excess nitric oxide (NO).

(B) Monocytes and dendritic cells enter the vascular wall early in the process of atherogenesis.

(C)As atherosclerosis progresses, infiltrating monocytes give rise to T-cells and macrophages, which then infiltrate the arterial wall together with other leukocytes.

(D) Macrophages and foam cells become more prevalent as the atherosclerotic lesion deepens. These cells also contribute to the modification of the plaque microenvironment, influencing the nature of the extracellular matrix and reducing the amount of smooth muscle cells, that develops the risk of plaque rupture.³

Compared to PCI patients without diabetes mellitus (DM), individuals with DM represent a greater risk category. Patients with diabetes mellitus (DM) who undergo PCI are more probably to experience negative outcomes because DM is linked to a higher prevalence of diffuse and lengthy plaques in small-caliber arteries, quicker neointimal hyperplasia, and a higher atherosclerotic burden.⁴

GENSINI SCORE:

For the quantitative examination of cardiovascular lesions, several evaluation methods are currently available; however, the Gensini ranking system is more frequently utilized in clinical settings. A more impartial standard for grading coronary artery lesions is the Gensini score, that consider into account the quantity, location, and degree of stenosis of the lesions.

Simultaneously, this approach of ranking has been extensively employed in relevant research concerning the clinical results of CAD. Currently, Quantity of research has demonstrated that by assessing the extent of coronary artery stenosis in combination with specific biochemical markers, the Gensini grade can predict the probability of severe coronary and cerebaleventsin patients with various types of CAD.⁵

A lumen stenosis of ≥50% in any of the main coronary arteries, i.e., the left main coronary artery, left anterior descending artery, left circumflex artery, right coronary artery, or any one of its main divisions, was considered to be predictive of significant coronary artery disease (CAD). The three types include single vessel disease (SVD), double vessel disease (DVD), or triple vessel disease (TVD), which is characterized as illness in three arteries. Stenosis (≥50%) of the left main trunk, with or without concurrent lesions in other arteries, is referred to as left main disease.

Each case of coronary stenosis was given a severity score in the way that follows in order to start computing the Gensini score: Eight points are awarded for narrowing from 76 to 90%, sixteen for narrowing from 91 to 99%, sixteen for narrowing from ≤25%, twenty-six for narrowing from 26 to 50%, forty-one for narrowing from 51 to 75%, and thirty-two points to total blockage.

Next, a factor that considers the significance of the lesion's location within the coronary circulation is multiplied by each lesion score (5 for the left main coronary artery, 2.5 for the left anterior descending artery's proximal segment, 2.5 for the left circumflex artery's proximal segment, 1.5 for the left anterior descending artery's middle segment, and 1.0 for the right coronary artery.

INFLAMMATORY MARKERS:

Several research studies have been performed on the function of inflammatory indicators in cardiovascular illnesses, and a strong connection has been shown in the past between several inflammatory markers and cardiovascular disorders. One more inflammatory sign to add to the extensive list is the NLR ratio (neutrophil-to-lymphocyte). Additionally, to the conventional markers, NLR, which is a complete blood count parameter with differential, is a widely accessible, low-cost indicator for inflammation that can help in stratification of risks for patients with a range of cardiovascular conditions.

The differential white blood cell count has garnered attention recently due to the discovery that a specific cell type—neutrophils [N], lymphocytes [L], and monocytes [M]- is a better indicator of risk for heart diseases than the overall WBC count.

NLR RATIO:

Multiple research projects have provided ample evidence for the potential significance of Neutrophil count as an autonomous predictive factor for both acute and chronic cardiovascular illnesses. Additionally, it was demonstrated that increases M counts were related to an increased risk of cardiovascular illness. Recently, it is observed that the N to L count ratio (NLR) is progressively becoming recognized as a distinguish and valuable predictive indicator in cardiovascular disorders. NLR has a larger predictability than total WBC count or N count as a marker in cardiovascular disorders.

The fact that NLR is more predictive than other cell types might be based on a variety of factors, involving the fact that physiological variables like exercise and dehydration are less likely to alter it, even though they may change the complete number of different cell types.

NLR ratio integrates the harmful effects of Neutrophils, which are in charge of active nonspecific immunity, by measuring the ratio of two distinct but complimentary immune pathways.⁶

Recent research has been demonstrated that the neutrophil-to-lymphocyte ratio (NLR) is an effective marker of inflammation, elevated NLR is connected with an increased risk of cardiovascular morbidity and death. NLR and a variety of cardiovascular illnesses are tightly linked. Moreover, NLR and the complexity and severity of CAD are related.⁷

WBC:

An elevated risk of atherosclerotic vascular disease results in elevated WBC levels. It is believed that phagocytes and macrophages derived from WBCs lead to the development of arterial injury and atherosclerosis.

The WBC count is higher in smokers than in non-smokers.⁸

More number of white blood cells can lead to worse outcomes in the general population as well as in patients with stable coronary disease and acute coronary syndromes. Certain findings state that the number of white blood cells and coronary heart disease have a strong, consistent, dose-dependent, independent, physiologically reasonable, and coherent relationship.

Not only the production of proteases, eicosanoids, interleukins, and myeloperoxidase, leukocytes might be involved in oxidative and proteolytic myocardial injury.

The neutrophil-lymphocyte and eosinophil-leukocyte ratios, as well as elevated counts of almost all subtypes of white blood cells, such as neutrophils, eosinophils, monocytes, and lymphocytes, are independent predictors of adverse results following percutaneous coronary intervention and ACES.

The eosinophil-leukocyte ratio and eosinophil count were found to be novel indicators for risk classification in individuals with coronary artery disease. Given that the presence of eosinophils suggests hypersensitive inflammation, this information is essential for understanding the etiology of inflammation in order to put predictive and preventative measures into place and to consider appropriate treatment approaches.⁹

Of all the inflammatory indicators, C-reactive protein (CRP) has been investigated in great detail and is a focus of modern research.

Over the past 20 years, white blood cell (WBC) count has drawn interest, as it is readily available, inexpensive, and easy to use. Many studies have shown that a high total WBC count not only accurately predicts the development of numerous cardiovascular diseases but also serves as a major harmful factor for major cardiovascular disorders. Despite all of this research, the WBC count has not been examined or used for its potential in predicting cardiovascular risk. It has recently been proposed as one of the potential biomarkers for determining the risk of cardiovascular disease.

Recent research has focused on differential white cell count, identifying that certain cell types (lymphocytes [L], monocytes [M], and neutrophils [N]) are more reliable indicators of cardiovascular risk than the overall WBC count.⁶

AIM:

To examine the relationship within some prominent haematological blood count parameters (WBC, Neutrophil to lymphocyte ratio [NLR]) and the severity of coronary artery disease by using the Gensini scoring system.

OBJECTIVE:

To determine the severity of CAD, by using WBC count as an independent risk factor with the help of Gensini score.

To evaluate hematological parameters is less expensive and a readily available indicator for future cardiac problems.

To understand the cause of inflammation to implement prognostic and preventative strategies for CAD attacks which may occur later.

STUDY METHODOLOGY:

The methodology includes the collection of complete blood picture of the participant on the day of admission and coronary angiography reports. The Gensini score is calculated by using coronary angiography reports and the severity of CAD is estimated then it is corelated with WBC count and NLR ratio. The study was conducted in tertiary care hospital, for the period of 6 months from August 2023 – January 2024.It is a prospective observational study with a sample size of 288 subjects. A Performa is designed with the help of a health care professional. Data was collected in an abstract style in a compatible manner. The inclusion criteria include CAD Patients who underwent coronary angiogram, Patients of either gender, Patients of either gender, Hospitalized patients with CAD, the exclusion criteria include the Patients with existence of inflammatory diseases, severe renal, hepatic diseases and infections, Pregnancy and lactating women, Age less than 18, Patients with Active malignancy.

RESULTS:

Based on age: Most CAD patients fall within the age group 45-64, constituting 55% of the total.

Patients aged 18-44 make up 19%, while those above 65 account for 26% of the total.

The cumulative percentage provides insights into the distribution pattern across the specified age groups.

This distribution analysis offers a clear perspective on how CAD is distributed among different age demographics, with the highest concentration observed in the 45-64 age range.

Based on gender: The majority of CAD patients in this dataset are male, constituting 78% of the total.

Female patients make up 22% of total CAD cases.

The gender allocation shows valuable insights into the prevalence of CAD among different genders in the specified population.

This analysis sheds light on the gender dynamics within the CAD patient population, emphasizing a higher representation of males in the dataset.

Based on weight distribution: The majority of CAD patients in this dataset have a weight less than BMI 25, constituting 64% of the total.

Patients with a weight greater than BMI 25 make up 36% of total cases.

The weight distribution provides the prevalence of CAD among different weight categories in the specified population.

This analysis highlights the distribution of CAD patients based on weight, emphasizing a higher representation of individuals with a weight less than BMI 25 in the dataset.

Based on comorbidities: The majority of CAD patients in this dataset have hypertension, constituting 57% of the total.

Patients without hypertension make up 43% of the total CAD cases.

This binary variable distribution provides insights into the occurrence of hypertension among participants with coronary artery disease.

This analysis highlights the distribution of patients based on their hypertension status, offering information about the coexistence of hypertension in the CAD patient population.

Among CAD patients in this dataset, 33% have diabetes.

Patients without diabetes make up the majority, constituting 67% of the total CAD cases.

This binary variable distribution provides insights into the occurrence of diabetes among the subjects.

This analysis sheds light on the distribution of patients based on their diabetes status, offering information about the coexistence of diabetes in the CAD patient population.

Based on social habits: Among CAD patients, 47% are non-smokers, while 53% are smokers.

In terms of alcohol consumption, 55% of CAD patients are non-alcoholic, while 45% are alcoholic.

This data concludes the distribution of smoking and alcohol consumption habits among CAD patients, highlighting the prevalence of these lifestyle factors within the specified population.

Based on WBC count: The majority of CAD patients in this dataset have a WBC count greater than 9000, constituting 66% of the total.

Patients with WBC counts in the range of 7000-8999 make up 25% of the total CAD cases.

Those with WBC counts in the range of 5301-6999 represent 9% of the total.

This graph shows the distribution of CAD patients based on their WBC, allowing to know the prevalence of different WBC count ranges within the specified population.

Based on NLR ratio: The majority of CAD patients in this dataset have an NLR greater than 3, constituting 49% of the total.

Patients with NLR in the range of 1-2.3 make up 28% of the total CAD cases.

Those with NLR in the range of 2.3-3 represent 23% of the total.

This data represents the distribution of CAD patients based on their Neutrophil-to-Lymphocyte Ratios, allowing for an understanding of the prevalence of different NLR ranges within the specified population.

Based on genisini score: The majority of CAD patients in this dataset have a Gensini Score less than 32, constituting 36% of the total. Patients with Gensini Scores greater than 32 make up 64% of total cases. The Gensini Score is generally used to evaluate the severity and extent of coronary artery disease. In this dataset, the distribution provides insights into the occurrence of different Gensini Score ranges within the specified population.

Based on number of vessels affected: Most CAD patients in this dataset have Single Vessel Disease (SVD), constituting 57% of the total.

Double Vessel Disease (DVD) is observed in 31% of the total CAD cases.

Triple Vessel Disease (TVD) is identified in 12% of the total cases.

This interpretation shows the distribution of patients depending on the number of vessels affected, offering information about the severity and extent of coronary artery disease within the specified population.

Based on surgical procedure: Major CAD patients in this dataset underwent Percutaneous Transluminal Coronary Angioplasty (PTCA), constituting 87% of the total.

Coronary Artery Bypass Grafting (CABG) was carried out in 13% of the total CAD cases.

This information shows the distribution of patients based upon the treatment modality received, indicating the prevalence of different therapeutic interventions within the specified population.

Table 1: A table demonstrating correlation between WBC, NLR ratio and Gensini score.

Based on WBC count	No. of patients
>9000	190
7000-8999	72
5301-6999	26
Based on NLR ratio	No. of patients
>3	141
1-2.3	80
2.3-3	67
Based on Gensini score	No. of patients
<32	103
>32	185

Figure 1: A graph demonstrating correlation between WBC, NLR ratio and Gensini score.

DISCUSSION:

In this study, we revealed that WBC count and NLR ratio were higher (66% and 49%, respectively, out of 100%) in CAD patients diagnosed by angiography procedures, so these markers have an essential function in predicting and preventing cardiovascular disease. Moreover, many studies and research have concluded an association among WBC count and severity of CAD. In our study, we revealed the WBC and NLR ratio has more prevalence as an inflammatory marker in the detection of CAD.

Here, a higher level of NLR (>2.3) from baseline has been seen in 64% of CAD patients. As it is well known, an activated WBC count is likely a good marker of inflammatory activity of atherosclerosis, which exacerbates arterial injury and tissue ischemia. In our study, this was the case for over 66% of patients with an activated WBC count of >9000 from baseline. Numerous factors, including smoking, drinking alcohol, and having concomitant conditions like type 2 diabetes and hypertension, might change it.

Higher the social habits greater the WBC and NLR values which are contributing to arterial injury and leading to atherosclerosis.

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Received on 09.06.2025 Revised on 22.10.2025

Accepted on 31.12.2025 Published on 05.06.2026

Available online from June 06, 2026

Research J. Pharmacy and Technology. 2026;19(6):2760-2766.

DOI: 10.52711/0974-360X.2026.00394

This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. Creative Commons License.