Prognostic impact of stress hyperglycemia ratio in acute myocardial infarction patients with and without diabetes mellitus

Prognostic significance of stress hyperglycemia ratio in patients with type 2 diabetes mellitus and acute coronary syndromes

BACKGROUND

Prognostic significance of stress hyperglycemia ratio (SHR) has not been well studied in patients with type 2 diabetes mellitus (T2DM) and acute coronary syndromes (ACS).

METHODS

We prospectively measured admission fasting blood glucose (AFBG) and glycated hemoglobin A1c (HbA1c), and retrospectively calculated the stress hyperglycemia ratio (SHR, = AFBG/[1.59 × HbA1c (%) - 2.59]) in 791 patients with T2DM and ACS undergoing percutaneous coronary intervention (PCI). The primary endpoint was defined as major adverse cardiovascular and cerebrovascular events (MACCE), including all-cause mortality, non-fatal stroke, non-fatal myocardial infarction, and unplanned repeat coronary revascularization.

RESULTS

The mean age of the study population was 61 ± 10 years, and 72.8% were male. Over a median follow-up of 927 days, 194 patients developed at least one primary endpoint event. The follow-up incidence of MACCE increased in parallel with SHR tertiles (15.6%, 21.9%, and 36.1%, respectively; P for trend < 0.001). The Cox proportional hazards regression analysis adjusted for multiple confounding factors showed hazard ratios for MACCE of 1.525 (95% CI: 1.009-2.305; P = 0.045) for the middle tertile and 2.525 (95% CI: 1.729-3.687; P < 0.001) for the highest tertile of SHR, with the lowest tertile as the reference. The addition of SHR to the baseline reference prediction model improved model predictive performance markedly (C-statistic: increased from 0.704 to 0.721; cNRI: 0.176 [95% CI: 0.063-0.282], P = 0.002; IDI: 0.030 [95% CI: 0.009-0.063], P = 0.002).

CONCLUSION

SHR was independently and significantly associated with adverse cardiovascular outcomes in T2DM and ACS patients who underwent PCI, and had an incremental effect on the predictive ability of the baseline reference prediction model.

Glycemic Comparison Index (GCI): a retrospective analysis of its prognostic value in ICU patients with AMI and diabetes

BACKGROUND

Acute myocardial infarction (AMI) has a significant impact on global health, especially among individuals with diabetes, emphasizing the need for specialized glycemic management. This study examines the glycemic comparison index (GCI), a novel prognostic tool designed for patients with AMI and diabetes, aiming to enhance glucose management in critical care settings.

METHODS

This retrospective cohort analysis used data from the Medical Information Mart for Intensive Care IV database (version 2.2). The GCI was calculated by comparing mean blood glucose levels in the intensive care unit (ICU) to baseline glucose levels. Patients were stratified into tertiles based on their GCI scores. The primary outcome measured was one-year all-cause mortality, while secondary outcomes included hospital mortality, ICU-free days, and hypoglycemic events. Statistical analyses included time-dependent receiver operating characteristic (ROC), cox proportional hazards models, generalized linear models (GLM), and restricted cubic spline analysis.

RESULTS

The patient population comprised 622 individuals, with a mean age of 69.9 years and 64.6% male representation. The high GCI group exhibited the highest one-year mortality rate and fewer ICU-free days, while the low GCI group exhibited a higher incidence of hypoglycemia. Statistical analyses revealed that GCI was a significant predictor of one-year all-cause mortality (hazard ratio: 2.21, 95% confidence interval: 1.51-3.24). Analysis using time-dependent ROC confirmed the consistent predictive accuracy of GCI for survival at 1, 6, and 12 months (area under the curve: 0.671, 0.670, and 0.634, respectively). Furthermore, GLM analysis indicated that a higher GCI was associated with fewer ICU-free days.

CONCLUSIONS

Higher GCI values are associated with increased one-year mortality and fewer ICU-free days in patients with AMI and diabetes. In comparison, lower GCI values are correlated with a higher risk of hypoglycemia. The GCI demonstrates potential as a personalized prognostic tool, although further validation is needed.

Stress hyperglycemia in acute pancreatitis: From mechanisms to prognostic implications

Acute pancreatitis (AP) is an inflammatory reaction of the pancreas. When the disease is severe, it is often accompanied by destruction of the pancreatic islets, resulting in dysfunction of the endocrine system of the pancreas. Stress hyperglycemia is a transient increase in glucose during a critical illness, and its possible mechanism is related to abnormal glucose metabolism and insulin resistance due to the increased release of counterregulatory hormones and cytokines, such as glucagon, cortisol, and catecholamines. Numerous studies have shown that stress hyperglycemia is strongly associated with morbidity, mortality, and increased risk of post-acute pancreatitis diabetes in AP patients. Therefore, stress hyperglycemia may be a significant independent risk factor for poor clinical outcomes and prognosis in patients with AP. This article reviews the clinical features, risk factors, and mechanisms of action of stress hyperglycemia in AP and its influence on adverse clinical outcomes and the prognosis of inpatients with AP. For AP patients with stress hyperglycemia, it is necessary to comprehensively consider their blood glucose levels, daily habits, and complications to develop an appropriate treatment plan for hyperglycemia. Limited evidence indicates that in the case of acute hyperglycemia in critically ill patients, especially during the first 3 days of hospitalization, insulin therapy should not be undertaken if the blood glucose level does not exceed 10 mmol/L. However, some important questions related to clinical practice remain to be answered. More clinical trials and studies are needed in the future to provide a sufficient basis for clinical practice.

Impact of the Stress Hyperglycemia Ratio on Heart Failure and Atherosclerotic Cardiovascular Events After Acute Myocardial Infarction

BACKGROUND

An acute hyperglycemic status is reportedly associated with poor prognosis in patients with acute cardiovascular diseases. Although the stress hyperglycemia ratio (SHR) is used to evaluate the hyperglycemic condition on admission, relationships between SHR and clinical outcomes, particularly heart failure (HF), remain uncertain in acute myocardial infarction (AMI).

METHODS AND RESULTS

This retrospective multicenter study included 2,386 patients with AMI undergoing percutaneous coronary intervention. SHR was calculated using blood glucose and HbA1c levels. Co-primary endpoints included HF-related events (death, worsening HF, and hospitalization for HF) and major adverse cardiovascular events (MACE; death, recurrent AMI, and ischemic stroke) during the index hospitalization and after discharge. The mean (±SD) SHR was 1.30±0.51; HF events and MACE occurred in 680 (28.5%) and 233 (9.8%) patients during hospitalization, respectively. SHR was independently associated with in-hospital HF events and MACE. Of 2,017 patients who survived to discharge, 195 (9.7%) and 214 (10.6%) experienced HF events and MACE, respectively, over a median follow-up of 536 days. The risk of HF events was higher in patients with a high (>1.45) SHR than in those with SHR ≤1.45; there was no significant difference in MACE rates after discharge between these 2 groups.

CONCLUSIONS

In AMI patients, SHR was predictive of in-hospital outcomes, including HF events and MACE, whereas after discharge a higher SHR was associated with higher HF risks, but not MACE.

The relationship between stress hyperglycemia ratio and the risk of delirium in patients after coronary artery bypass grafting

INTRODUCTION

The association between relative hyperglycemia and postoperative delirium (POD) following coronary artery bypass grafting (CABG) remains inadequately understood. This research aims to explore the correlation between the stress hyperglycemia ratio (SHR) and the occurrence of delirium in patients undergoing CABG.

METHODS

This study analyzed the data from 9613 patients who underwent coronary artery bypass grafting (CABG) using information from the Medical Information Mart for Intensive Care IV (MIMIC-IV) database. To assess the association between SHR and POD following CABG, restricted cubic spline (RCS) models and logistic regression analyses were applied. Patients were categorized into high SHR (SHR ≥ 1.21) and low SHR (SHR < 1.21) groups based on optimal cut-off values derived from the receiver operating characteristic (ROC) curve. To evaluate the influence of diabetes mellitus (DM) on the outcomes, further classified of four groups of patients were conducted based on the presence or absence of DM and SHR levels. Subgroup analyses were subsequently applied to assess the relationship of POD and SHR within various patient groups.

RESULTS

The average age of the enrolled patients was 67.62 ± 12.54 years, with 6284 (65.3%) males, higher SHR was associated with an increased incidence of postoperative delirium following CABG (OR 1.37, 95% CI 1.24-1.52, P < 0.001), even after adjusting for confounders (OR 1.55, 95% CI 1.32-1.79, P < 0.001). RCS analysis revealed a "J-shaped" relationship between the POD fowling CABG and SHR level. Logistic regression analysis further demonstrated that the association between SHR and POD may be higher than that of glucose or glycated hemoglobin levels alone. Among the stratified groups based on SHR and DM, the high-SHR/DM group exhibited the highest risk of developing POD. In conclusion, SHR is an independent risk factor that may have potential as a biomarker for assessing POD after CABG.

CONCLUSION

SHR serves as an independent risk factor and shows promise as a potential biomarker for predicting the risk of POD following CABG.

The additive effect of the stress hyperglycemia ratio on type 2 diabetes: a population-based cohort study

BACKGROUND

The stress hyperglycemia ratio (SHR) has recently gained attention as a marker for acute hyperglycemia, which has been linked to adverse clinical outcomes. However, its independent role in the development of type 2 diabetes (T2D) remains understudied. This cohort study aimed to assess the association between SHR and the incidence of T2D.

METHODS

The study included 8978 participants aged 45 or older, free of diabetes at baseline, from the China Health and Retirement Longitudinal Study (CHARLS). Incident T2D up to December 31, 2020, was the primary outcome. Participants were divided into SHR quartiles, and Cox proportional hazards regression and fine-gray competing risk models were used to assess SHR's association with T2D onset, adjusting for fasting glucose and HbA1c.

RESULTS

The mean age of participants was 59.0 ± 9.5 years, and 51.5% were women. Over a mean follow-up of 7.8 years, 1084 participants developed T2D. Cox regression analysis revealed that individuals in the highest SHR quartile had a significantly higher risk of T2D onset compared to those in the lowest quartile (HR 1.48, 95% CI 1.26-1.75, P for trend < 0.001). Stratified analyses by sex, obesity, and smoking showed consistent results. Adding SHR to fasting glucose and HbA1c models improved the AUC for T2D prediction (DeLong Test, P = 0.013).

CONCLUSION

SHR is independently associated with incident T2D, suggesting its potential use in the risk stratification and prediction for T2D, beyond glucose and HbA1c.

Prognostic value of stress hyperglycemia ratio in patients with acute myocardial infarction: A systematic review with Bayesian and frequentist meta-analysis

The present systematic review and meta-analysis aimed to investigate the prognostic value of stress hyperglycemia ratio (SHR) in patients with acute myocardial infarction (AMI). A total of 26 cohort studies, involving 87,974 patients, were analyzed. The frequentist meta-analysis showed that AMI patients with SHR in the upper quantile had a significantly higher hazard of major adverse cardiovascular and cerebrovascular events (MACCE, HR = 1.7; 95 % CI= [1.42, 2.03]; P < 0.001; I2 = 71 %; P <0.01), long-term (HR = 1.64; 95 % CI= [1.49, 1.8]; P < 0.001; I2 = 16 %; P = 0.29) and in-hospital all-cause mortality (OR = 3.87; 95 % CI= [2.98, 5.03]; P < 0.001; I2 = 54 %; P = 0.03) compared to those with lower SHR. Prespecified subgroup analyses revealed that these results were consistent irrespective of diabetes status (P = 0.32 and 0.73 for subgroup differences) and that SHR was a significant predictor of MACCE both in AMI with obstructive coronary arteries (HR = 1.57; 95 % CI= [1.34, 1.83]; P < 0.001; I2 = 66 %; P < 0.01) and MINOCA (HR = 2.57; 95 % CI= [1.86, 3.56]; P < 0.001; I2 = 0 %; P = 0.84). The Bayesian analyses with weakly prior assumptions yielded comparable results with the frequentist approach and provided strong evidence that higher SHR values were associated with significantly greater hazard of MACCE, short-term and long-term mortality. Further, prospective research is warranted to provide deeper insights into this newer index of stress hyperglycemia before its potential incorporation in clinical prediction scores.

Stress hyperglycemia ratio and its influence on mortality in elderly patients with severe community-acquired pneumonia: a retrospective study

BACKGROUND

Community-acquired pneumonia (CAP) is a significant health issue among the elderly, with severe cases (SCAP) having high mortality rates. This study assesses the predictive significance of the stress hyperglycemia ratio (SHR) in elderly SCAP patients and its impact on outcomes in both diabetic and non-diabetic patients.

METHODS AND MATERIALS

This retrospective study included 406 SCAP patients aged 65 or older from the Second People's Hospital of Lianyungang (January 2020 to December 2023). Data collected included demographics, medical history, vital signs, and lab results. SHR was calculated from initial blood glucose and estimated average glucose (HbA1c). Statistical analyses, including Cox regression and Kaplan-Meier analysis, evaluated SHR's impact on mortality. Mediation models explored the effects of neutrophil-lymphocyte ratio (NLR) and SHR.

RESULTS

The 28-day mortality rate was 21.67%. Deceased patients had higher age, Charlson Comorbidity Index, procalcitonin, NLR, glucose, and SHR levels compared to survivors (P < 0.05). Both SHR and NLR significantly increased mortality risk, particularly in non-diabetic patients. Combining NLR and SHR improved ROC AUC to 0.898, with 89.80% sensitivity and 81.10% specificity. Kaplan-Meier analysis showed higher cumulative survival for SHR < 1.14, regardless of diabetes status (P < 0.05). NLR mediated 13.02% of the SHR-survival relationship, while SHR mediated 14.06% of the NLR-survival relationship.

CONCLUSION

Elevated SHR is a significant mortality risk factor in elderly SCAP patients, independent of diabetes status. Stringent glucose control and careful monitoring of SHR may improve outcomes in elderly patients with acute respiratory conditions.

Association between stress hyperglycemia ratio and in-hospital outcomes: findings from the improving Care for Cardiovascular Disease in China-Acute Coronary Syndrome (CCC-ACS) Project

BACKGROUND

Stress hyperglycemia ratio (SHR) could provide accurate information on the acute status of hyperglycemia. The relationship between SHR and acute coronary syndrome (ACS) prognosis remains unclear. This study was conducted to identity the association between SHR and in-hospital outcomes in patients with ACS.

METHODS

A total of 12,010 patients were eventually enrolled in the study. The relationship between SHR and in-hospital major adverse cardiovascular events (MACEs) was then modeled by restricted cubic spline (RCS) curves, and all patients were divided into three groups according to the results. The multivariate logistic regression analysis was used to determine the associations between the SHR and in-hospital outcomes, described as odds ratios (ORs) and 95% confidence intervals (CIs). Subgroup analyses were also performed on different diseases.

RESULTS

The median age of this cohort was 63 (54, 71) years old, and 8942 (74.5%) were male. Group 1 was defined as SHR < 0.6 (n = 426), Group 2 was defined as SHR between 0.6 and 1 (n = 5821), and Group 3 was defined as SHR > 1 (n = 5763). Compared with Group 2, Group 1 (OR = 1.891, 95% CI: 1.028-3.479, P < 0.001) and Group 3 (OR = 1.868, 95% CI: 1.434-2.434, P < 0.001) had higher risks of suffering from in-hospital MACEs. SHR was associated with higher risks of in-hospital MACEs in the subgroups of DM [OR = 2.282, 95% CI: 1.477-3.524).

CONCLUSIONS

Both low and high SHR levels were independently associated with in-hospital MACEs. Young males with DM, hypertension, and decreased renal function had much higher risks of suffering from SHR-correlated MACEs.

Association between the stress-hyperglycemia ratio and all-cause mortality in community-dwelling populations: An analysis of the National Health and Nutrition Examination Survey (NHANES) 1999-2014

BACKGROUND

Reportedly, the stress-hyperglycemia ratio (SHR) is closely associated with poor prognosis in patients with severe acute disease. However, the community-dwelling may also be in a state of stress due to environmental exposure. Our study aimed to explore the association between SHR and all-cause mortality in the community-dwelling population.

METHODS

A total of 18 480 participants were included out of 82 091 from the NHANES 1999-2014 survey. The Kaplan-Meier survival analyses were used to assess the disparities in survival rates based on SHR, and the log-rank test was employed to investigate the distinctions between groups. The multivariate Cox regression analysis and restricted cubic spline (RCS) analysis were performed to assess the association of SHR with all-cause mortality. A subgroup analysis was also conducted.

RESULTS

A total of 3188 deaths occurred during a median follow-up period of 11.0 (7.7; 15.4) years. The highest risk for all-cause mortality was observed when SHR≤ 0.843 or SHR ≥0.986 (log-rank p < .001). After adjusting for the confounding factors, compared with subjects in the second SHR quartile (Q2), participants in the highest (Q4, adjusted hazard ratio [HR] 1.49, 95% confidence interval [CI] 1.28-1.73) and lowest quartiles (Q1, adjusted HR 1.37, 95% CI 1.16-1.60) have a higher probability of all-cause death. The RCS observed a dose-response U-shaped association between SHR and all-cause mortality. The U-shaped association between SHR and all-cause mortality was similar across subgroup analysis.

CONCLUSIONS

The SHR was significantly associated with all-cause mortality in the community-dwelling population, and the relationship was U-shaped.

The relative and combined ability of stress hyperglycemia ratio and N-terminal pro-B-type natriuretic peptide to predict all-cause mortality in diabetic patients with multivessel coronary artery disease

BACKGROUND

Stress hyperglycemia ratio (SHR) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) are independently associated with increased mortality risk in diabetic patients with coronary artery disease (CAD). However, the role of these biomarkers in patients with diabetes and multivessel disease (MVD) remains unknown. The present study aimed to assess the relative and combined abilities of these biomarkers to predict all-cause mortality in patients with diabetes and MVD.

METHODS

This study included 1148 diabetic patients with MVD who underwent coronary angiography at Tianjin Chest Hospital between January 2016 and December 2016. The patients were divided into four groups according to their SHR (SHR-L and SHR-H) and NT-proBNP (NT-proBNP-L and NT-proBNP-H) levels. The primary outcome was all-cause mortality. Multivariate Cox regression analyses were performed to evaluate the association of SHR and NT-proBNP levels with all-cause mortality.

RESULTS

During a mean 4.2 year follow-up, 138 patients died. Multivariate analysis showed that SHR and NT-proBNP were strong independent predictors of all-cause mortality in diabetic patients with MVD (SHR: HR hazard ratio [2.171; 95%CI 1.566-3.008; P < 0.001; NT-proBNP: HR: 1.005; 95%CI 1.001-1.009; P = 0.009). Compared to patients in the first (SHR-L and NT-proBNP-L) group, patients in the fourth (SHR-H and NT-proBNP-H) group had the highest mortality risk (HR: 12.244; 95%CI 5.828-25.721; P < 0.001). The areas under the curve were 0.615(SHR) and 0.699(NT-proBNP) for all-cause mortality. Adding either marker to the original models significantly improved the C-statistic and integrated discrimination improvement values (all P < 0.05). Moreover, combining SHR and NT-proBNP levels into the original model provided maximal prognostic information.

CONCLUSIONS

SHR and NT-proBNP independently and jointly predicted all-cause mortality in diabetic patients with MVD, suggesting that strategies to improve risk stratification in these patients should incorporate SHR and NT-porBNP into risk algorithms.

Association of stress hyperglycemia ratio with in-hospital new-onset atrial fibrillation and long-term outcomes in patients with acute myocardial infarction

AIMS

To investigate the predictive value and prognostic impact of stress hyperglycemia ratio (SHR) for new-onset atrial fibrillation (NOAF) complicating acute myocardial infarction (AMI).

MATERIALS AND METHODS

This retrospective study included 2145 AMI patients without AF history between February 2014 and March 2018. SHR was calculated using fasting blood glucose (mmol/L)/[1.59*HbA1c (%)-2.59]. The association between SHR and post-MI NOAF was assessed with multivariable logistic regression analyses. The primary outcome was a composite of cardiac death, heart failure hospitalisation, recurrent MI, and ischaemic stroke (MACE). Cox regression-adjusted hazard ratios with 95% confidence intervals (CI) were estimated for MACE.

RESULTS

A total of 245 (11.4%) patients developed NOAF. In the multivariable logistic regression analyses, SHR (each 10% increase) was significantly associated with increased risks of NOAF in the whole population (OR: 1.05, 95% CI: 1.01-1.10), particularly in non-diabetic individuals (OR:1.08, 95% CI: 1.01-1.17). During a median follow-up of 2.7 years, 370 (18.5%) MACEs were recorded. The optimal cut-off value of SHR for MACE prediction was 1.119. Patients with both high SHR (≥1.119) and NOAF possessed the highest risk of MACE compared to those with neither high SHR nor NOAF after multivariable adjustment (HR: 2.18, 95% CI: 1.39-3.42), especially for diabetics (HR: 2.63, 95% CI: 1.41-4.91). Similar findings were observed using competing-risk models.

CONCLUSIONS

SHR is an independent predictor of post-MI NOAF in non-diabetic individuals. Diabetic patients with both high SHR and NOAF had the highest risk of MACE, suggesting that therapies targeting SHR may be considered in these patients.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03533543.

Impact of stress hyperglycemia ratio, derived from glycated albumin or hemoglobin A1c, on mortality among ST-segment elevation myocardial infarction patients

BACKGROUND

Stress hyperglycemia ratio (SHR), associated with adverse outcomes in patients with ST-segment elevation myocardial infarction (STEMI), has several definitions. This study aims to assess the prognostic value of SHR, derived from hemoglobin A1c (HbA1c) or glycated albumin (GA), to mortality.

METHODS

The study comprised 1,643 STEMI patients who underwent percutaneous coronary intervention (PCI) in two centers. SHR1 was calculated using fasting blood glucose (FBG)/GA, while SHR2 was calculated using the formula FBG/(1.59*HbA1c-2.59). The primary endpoints were in-hospital death and all-cause mortality, with a median follow-up duration of 1.56 years.

RESULTS

Higher SHR1 and SHR2 values are associated with increased risks of in-hospital death and all-cause mortality. Each standard deviation increase in SHR1 corresponded to a 39% and 22% escalation in in-hospital death and all-cause mortality, respectively. The respective increases for SHR2 were 51% and 26%. Further examinations validated these relationships as linear. Additionally, the areas under the curve (AUC) for in-hospital death were not significantly different between SHR1 and SHR2 (p > 0.05). Incorporating SHR1 or SHR2 into the base model significantly improved the discrimination and risk reclassification for in-hospital and all-cause mortality. A subgroup analysis revealed that the effects of SHR1 and SHR2 were more pronounced in patients with hypercholesteremia.

CONCLUSION

SHR1 and SHR2 have emerged as robust and independent prognostic markers for STEMI patients undergoing PCI. The SHR calculation based on either HbA1c or GA can provide additional predictive value for mortality beyond traditional risk factors, helping to identify high-risk STEMI patients.

Predictive value of the stress hyperglycemia ratio in dialysis patients with acute coronary syndrome: insights from a multi-center observational study

BACKGROUND

Various studies have indicated that stress hyperglycemia ratio (SHR) can reflect true acute hyperglycemic status and is associated with poor outcomes in patients with acute coronary syndrome (ACS). However, data on dialysis patients with ACS are limited. The Global Registry of Acute Coronary Events (GRACE) risk score is a well-validated risk prediction tool for ACS patients, yet it underestimates the risk of major events in patients receiving dialysis. This study aimed to evaluate the association between SHR and adverse cardiovascular events in dialysis patients with ACS and explore the potential incremental prognostic value of incorporating SHR into the GRACE risk score.

METHODS

This study enrolled 714 dialysis patients with ACS from January 2015 to June 2021 at 30 tertiary medical centers in China. Patients were stratified into three groups based on the tertiles of SHR. The primary outcome was major adverse cardiovascular events (MACE), and the secondary outcomes were all-cause mortality and cardiovascular mortality.

RESULTS

After a median follow-up of 20.9 months, 345 (48.3%) MACE and 280 (39.2%) all-cause mortality occurred, comprising 205 cases of cardiovascular death. When the highest SHR tertile was compared to the second SHR tertile, a significantly increased risk of MACE (adjusted hazard ratio, 1.92; 95% CI, 1.48-2.49), all-cause mortality (adjusted hazard ratio, 2.19; 95% CI, 1.64-2.93), and cardiovascular mortality (adjusted hazard ratio, 2.70; 95% CI, 1.90-3.83) was identified in the multivariable Cox regression model. A similar association was observed in both diabetic and nondiabetic patients. Further restricted cubic spline analysis identified a J-shaped association between the SHR and primary and secondary outcomes, with hazard ratios for MACE and mortality significantly increasing when SHR was > 1.08. Furthermore, adding SHR to the GRACE score led to a significant improvement in its predictive accuracy for MACE and mortality, as measured by the C-statistic, net reclassification improvement, and integrated discrimination improvement, especially for those with diabetes.

CONCLUSIONS

In dialysis patients with ACS, SHR was independently associated with increased risks of MACE and mortality. Furthermore, SHR may aid in improving the predictive efficiency of the GRACE score, especially for those with diabetes. These results indicated that SHR might be a valuable tool for risk stratification and management of dialysis patients with ACS.

Acute hyperglycemia, a rabble-rouser or innocent bystander? A prospective analysis of clinical implications of acute hyperglycemia in STE-ACS patients

BACKGROUND

Acute hyperglycemia is considered an independent prognosticator of both in-hospital and long-term outcomes in patients with acute coronary syndrome (ACS). This study aimed To analyze the incidence of acute hyperglycemia and its impact on the adverse in-hospital outcome in patients with STE-ACS undergoing primary percutaneous coronary intervention (PCI).

METHODS

In this study, we enrolled patients presenting with STE-ACS and undergoing primary PCI at a tertiary care cardiac center. Acute hyperglycemia was defined as random plasma glucose (RBS) > 200 mg/dl at the time of presentation to the emergency room.

RESULTS

Of the 4470 patients, 78.8% were males, and the mean age was 55.52 ± 11 years. In total, 39.4% (1759) were found to have acute hyperglycemia, and of these, 59% (1037) were already diagnosed with diabetes. Patients with acute hyperglycemia were observed to have a higher incidence of heart failure (8.2% vs. 5.5%; p < 0.001), contrast-induced nephropathy (10.9% vs. 7.4%; p < 0.001), and in-hospital mortality (5.7% vs. 2.5%; p < 0.001). On multivariable analysis, acute hyperglycemia was found to be an independent predictor of mortality with an adjusted odds ratio of 1.81 [1.28-2.55]. Multi-vessel disease (1.73 [1.17-2.56]), pre-procedure left ventricular end-diastolic pressure (LVEDP) (1.02 [1.0-1.03]), and Killip class III/IV (4.55 [3.09-6.71]) were found to be the additional independent predictors of in-hospital mortality.

CONCLUSIONS

Acute hyperglycemia, regardless of diabetic status, is an independent predictor of in-hospital mortality among patients with STE-ACS undergoing primary PCI. Acute hyperglycemia, along with other significant predictors such as multi-vessel involvement, LVEDP, and Killip class III/IV, can be considered for the risk stratification of these patients.

The impact of fasting stress hyperglycemia ratio, fasting plasma glucose and hemoglobin A1c on in-hospital mortality in patients with and without diabetes: findings from the China acute myocardial infarction registry

BACKGROUND

Stress hyperglycemia was positively associated with poor prognosis in individuals with acute myocardial infarction (AMI). However, admission glucose and stress hyperglycemia ratio (SHR) may not be the best indicator of stress hyperglycemia. We performed this study to evaluate the comparative prognostic value of different measures of hyperglycemia (fasting SHR, fasting plasma glucose [FPG], and hemoglobin A1c [HbA1c]) for in-hospital mortality in AMI patients with or without diabetes.

METHODS

In this prospective, nationwide, multicenter China Acute Myocardial Infarction (CAMI) registry, 5,308 AMI patients including 2081 with diabetes and 3227 without diabetes were evaluated. Fasting SHR was calculated using the formula [(first FPG (mmol/l))/(1.59×HbA1c (%)-2.59)]. According to the quartiles of fasting SHR, FPG and HbA1c, diabetic and non-diabetic patients were divided into four groups, respectively. The primary endpoint was in-hospital mortality.

RESULTS

Overall, 225 (4.2%) patients died during hospitalization. Individuals in quartile 4 had a significantly higher rate of in-hospital mortality compared with those in quartile 1 in diabetic cohort (9.7% vs. 2.0%; adjusted odds ratio [OR] 4.070, 95% CI 2.014-8.228) and nondiabetic cohort (8.8% vs. 2.2%; adjusted OR 2.976, 95% CI 1.695-5.224). Fasting SHR was also correlated with higher in-hospital mortality when treated as a continuous variable in diabetic and nondiabetic patients. Similar results were observed for FPG either as a continuous variable or a categorical variable. In addition, fasting SHR and FPG, rather than HbA1c, had a moderate predictive value for in-hospital mortality in patients with diabetes (areas under the curve [AUC] for fasting SHR: 0.702; FPG: 0.689) and without diabetes (AUC for fasting SHR: 0.690; FPG: 0.693). The AUC for fasting SHR was not significantly different from that of FPG in diabetic and nondiabetic patients. Moreover, adding fasting SHR or FPG to the original model led to a significant improvement in C-statistic regardless of diabetic status.

CONCLUSIONS

This study indicated that, in individuals with AMI, fasting SHR as well as FPG was strongly associated with in-hospital mortality regardless of glucose metabolism status. Fasting SHR and FPG might be considered as a useful marker for risk stratification in this population.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01874691.

Association of hyperglycemia ratio and ventricular arrhythmia in critically ill patients admitted to the intensive care unit

INTRODUCTION

The relationship between relative hyperglycemia and ventricular arrhythmia (VA) in critically ill patients admitted to intensive care units (ICU) remains unclear. This study aims to investigate the association between stress hyperglycemia ratio (SHR) and VA in this population.

METHODS

This retrospective and observational study analyzed data from 4324 critically ill patients admitted to the ICU, obtained from the Medical Information Mart for Intensive Care IV (MIMIC-IV) database. The SHR was calculated as the highest blood glucose level during the first 24 h of ICU admission divided by the admission blood glucose level. Based on the optimal cut-off values under the receiver operating characteristic curve, patients were stratified into high SHR (≥ 1.31) and low SHR (< 1.31) group. To investigate the impact of diabetes mellitus (DM) on the outcome, patients were stratified as low SHR/DM; low SHR/non-DM; high SHR/DM, and high SHR/non-DM. Restricted cubic spline (RCS) and logistic regression analysis were performed to analyze the relationship between SHR and VA.

RESULTS

A total of 4,324 critically ill patients were included in this retrospective and observational study. The incidence of VA was higher in the high SHR group. Multiple-adjusted RCS revealed a "J-shaped" correlation between SHR and VA morbidity. The logistic regression model demonstrated that high SHR was associated with VA. The high SHR/non-DM group had a higher risk of VA than other groups stratified based on SHR and DM. Subgroup analysis showed that high SHR was associated with an increased risk of VA in patients with coronary artery disease.

CONCLUSION

High SHR is an independent risk factor and has potential as a biomarker of higher VT/VF risk in ICU-admitted patients.

Prognostic implication of stress hyperglycemia in patients with acute coronary syndrome undergoing percutaneous coronary intervention

BACKGROUND

It is now understood that stress hyperglycemia is associated with adverse outcomes in hospitalized patients. Herein, we aimed to investigate the association between stress hyperglycemia and mortality risk in acute coronary syndrome (ACS) patients who underwent percutaneous coronary intervention (PCI).

METHODS

This cohort study comprised 5190 ACS patients who underwent PCI from the Cardiovascular Center Beijing Friendship Hospital Database Bank (CBDBANK) from January 2013 to January 2021. Stress hyperglycemia was defined by the glucose/glycated albumin (GA) ratio, calculated as admission fasting plasma glucose divided by GA. The patients were divided into four groups according to glucose/GA ratio quartiles (Q1-Q4). Cox proportional hazards regression and restricted cubic spline were used to evaluate the association between glucose/GA ratio and all-cause and cardiovascular mortality.

RESULTS

During a median follow-up of 4.0 years, the number of all-cause deaths was 313 (6.0%) and cardiovascular-associated deaths was 177 (3.4%). After adjustment for potential confounders, the risk of all-cause mortality increased in the lowest (HR, 1.43; 95% CI, 1.01-2.03) and highest (HR, 1.51; 95% CI, 1.03-2.21) glucose/GA ratio quartiles compared to Q2. The restricted cubic splines showed that the association between glucose/GA ratio and all-cause mortality was U-shaped after full adjustment (P _nonlinear = 0.008). Similar results were observed for cardiovascular mortality. In subgroup analyses according to diabetes status, the U-shaped relationship was only significant in patients with diabetes mellitus.

CONCLUSION

In ACS patients undergoing PCI, low and high glucose/GA ratio values were associated with an increased all-cause and cardiovascular mortality, especially in those with diabetes mellitus.

Association of stress hyperglycemia ratio and poor long-term prognosis in patients with myocardial infarction with non-obstructive coronary arteries

BACKGROUND

Stress hyperglycemia ratio (SHR) is a novel biomarker of true acute hyperglycemia condition and is associated with a worse prognosis in patients with myocardial infarction (MI). However, the effects of SHR in the setting of MI with non-obstructive coronary arteries (MINOCA) have not been investigated. This study aimed to explore the association between SHR and long-term clinical outcomes among MINOCA patients.

METHODS

A total of 410 MINOCA patients were included in the final analysis of this study. The patients were divided into three groups based on the SHR tertiles: [SHR1 group (SHR ≤ 0.73), (n = 143); SHR2 group (SHR 0.73-0.84), n = 131; and SHR3 group (SHR ≥ 0.84), n = 136]. Follow-up for major adverse cardiovascular events (MACE) was conducted on all patients. Cox regression and Kaplan-Meier curve analysis were used to evaluate the relationship between SHR and MACE. The receiver operating curve (ROC) analysis was applied to obtain the optimal cut-off value of SHR for predicting clinical MACE.

RESULTS

A total of 92 patients developed MACE during the mean 34 months of follow-up. A significant increase in MACE was observed in the SHR3 group compared to the SHR1 and SHR2 groups (35.3% vs. 15.4% and 16.8%, respectively; P < 0.001). The Kaplan-Meier curves demonstrate that SHR3 patients had the highest MACE risk compared to SHR1 and SHR2 patients (log-rank P < 0.001). In addition, when both SHR tertiles and diabetes status were considered, those with SHR3 and diabetes had the highest hazard of MACE (log-rank P < 0.001). Multivariate Cox regression analysis showed that the SHR3 is associated with a 2.465-fold increase in the risk of MACE (adjusted HR, 2.465; 95% CI 1.461-4.159, P = 0.001). The ROC curve analysis showed that the optimal SHR cut-off value for predicting clinical MACE among MINOCA was 0.86.

CONCLUSION

Our data indicates, for the first time, that SHR is independently associated with poor long-term prognosis in patients suffering from MINOCA. The optimal SHR cut-off value for predicting clinical MACE among MINOCA patients was 0.86. These findings suggest that SHR may play a potential role in the cardiovascular risk stratification of the MINOCA population.