Objective To evaluate the relationship between hemoglobin-to-red blood cell distribution width ratio (HRR) and all-cause mortality in patients with myocardial infarction (MI).

Methods Based on data of the National Health and Nutrition Examination Survey (NHANES) from 1999 to 2018, MI patients were screened and divided into Q1 to Q4 groups according to the quartile of HRR. Schoenfeld residual method was used to test the proportional hazards assumption. A three-level weighted Cox proportional hazards model was constructed, including unadjusted, demographic-adjusted variables and adjusted full covariates. The association between HRR and all-cause mortality was analyzed and subgroup analyses were performed. Restricted cubic spline (RCS) regression was used to verify the nonlinear relationship between the two, and Kaplan-Meier (K-M) curves were used to compare the survival differences of different HRR groups.

Results A total of 2,188 patients with MI were enrolled. Cox regression analysis showed that high HRR level was still significantly correlated with low all-cause mortality risk after adjusting for all covariates. Compared with group Q1, the adjusted hazard ratios (HR) of groups Q2, Q3 and Q4 were 0.69 [95%CI (0.53, 0.88)], 0.56 [95%CI (0.44, 0.70)] and 0.37 [95%CI (0.28, 0.50)], respectively. RCS analysis showed no nonlinear correlation between HRR and all-cause mortality (nonlinear P=0.834). K-M analysis showed that the survival rate of patients with higher HRR levels was higher (P < 0.001). Subgroup analysis showed that drinking status changed the association between HRR and mortality (interaction P=0.025).

Conclusion In adult patients with MI, high HRR levels are significantly associated with low all-cause mortality, and the association varies with drinking status.

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