Hemoglobin-to-Red Cell Distribution Width Ratio Predicts Three-Year Major Adverse Cardiovascular Events After Percutaneous Coronary Intervention: A Vietnamese Multicenter Cohort Study

Abstract Introduction Percutaneous coronary intervention (PCI) is a widely adopted strategy for managing coronary artery disease (CAD), leading to improved survival rates, particularly in developing countries. However, the increased survival of these patients imposes a substantial burden on long-term management, especially at the primary healthcare level. Recently, the hemoglobin-to-red cell distribution width ratio (HRR) has emerged as a potentially valuable prognostic biomarker for post-PCI patients. Despite its accessibility and cost-effectiveness, HRR has not been extensively investigated in resource-limited settings. Aim This study aimed to evaluate the prognostic value of the HRR in predicting 3-year major adverse cardiovascular events (MACE) among patients undergoing PCI who were managed at the primary healthcare level. Methods We conducted a multicenter prospective cohort study in Vietnam. A total of 626 post-PCI patients were ultimately included in the final analysis. The study commenced in October 2019 and concluded in October 2025. The association between HRR and 3-year MACE was evaluated using Cox proportional hazards regression models. Results The MACE incidence decreased progressively across the ascending HRR quartiles (p < 0.001). According to the unadjusted Cox model, each unit increase in HRR was associated with a lower risk of MACE (HR = 0.756; 95% CI, 0.703–0.814; p < 0.001). This association persisted after adjustment for age, sex, comorbidities (Model I: HR = 0.810; 95%CI: 0.750–0.878; p < 0.001). HRR outperformed its individual components, hemoglobin and red cell distribution width. Subgroup analyses confirmed the consistency of the association across clinically relevant strata. Calibration and decision-curve analyses further suggested acceptable risk estimation and potential clinical utility of HRR for 3-year MACE risk stratification. In the discriminative analysis for predicting 3-year MACE, the HRR had the highest area under the curve outperforming other inflammation-based indices. Conclusion A lower HRR was independently associated with a greater 3-year MACE risk in post-PCI patients. HRR outperforms commonly used leukocyte- and platelet-derived indices, highlighting its potential utility as a simple, cost-effective prognostic marker in resource-constrained healthcare settings.