Neutrophil-to-lymphocyte ratio as a predictor of post-ablation recurrence in hypertensive patients with paroxysmal atrial fibrillation.

Background: Recurrence of atrial fibrillation (AF) after catheter ablation remains a major clinical challenge in hypertensive patients with paroxysmal AF, and reliable inflammatory predictors for recurrence are lacking. Objective: To assess the predictive value of neutrophil-to-lymphocyte ratio (NLR) for AF recurrence. Methods: Cox regression models, restricted cubic splines (RCS), receiver operating characteristic (ROC) curves, interaction and joint analyses, and mediation analysis were employed to evaluate the relationship between NLR and AF recurrence. Results: AF recurrence occurred in 17.94% of patients. The NLR was independently associated with recurrence (HR: 1.30, 95% CI: 1.12-1.50; P < 0.001). RCS analysis revealed a non-linear relationship with a threshold of 2.37, above which the recurrence risk significantly increased. ROC analysis demonstrated stable predictive performance of the NLR. No significant interaction effect between the NLR and blood pressure control status was observed. Regardless of blood pressure control, an NLR ≥ 2.37 was associated with an increased recurrence risk, with the highest risk in patients with both a high NLR and uncontrolled hypertension (HR: 3.92, 95% CI: 1.82-8.42; P < 0.001). Sensitivity analysis confirmed the robustness of the findings, and mediation analysis revealed no significant mediating effect. Conclusions: The NLR is an independent predictor of post-ablation recurrence in hypertensive patients with paroxysmal AF. The combination of NLR ≥ 2.37 and uncontrolled hypertension identifies a high-risk subgroup, underscoring the need for integrated anti-inflammatory and blood pressure control strategies. Further prospective studies are needed to validate these findings and evaluate targeted anti-inflammatory strategies.