Predictive Value of the Acute-to-Chronic Glycemic Ratio for In-Hospital Outcomes in Patients With ST-Segment Elevation Myocardial Infarction Undergoing Percutaneous Coronary Intervention

Positive association between stress hyperglycemia ratio and ICU mortality in patients with pulmonary embolism: A retrospective study

BACKGROUND

Measurement of the Stress Hyperglycemia Ratio (SHR) aims to reduce the influence of prolonged chronic glycemic variables on stress hyperglycemia levels, which are associated with clinical outcomes. Nevertheless, the correlation between SHR and the risk of all-cause Intensive Care Unit (ICU) mortality in patients with pulmonary embolism(PE) remains unclear.

METHODS

Data for this retrospective study were o btained from the MIMIC IV2.2 database. The participants were divided into four groups based on the SHR quartiles. The primary outcome measured was 28-day ICU mortality. We employed Cox proportional hazards regression analysis and restricted cubic splines to evaluate the correlation between the SHR and clinical outcomes in patients with PE.

RESULTS

The study included 1185 patients, of which 53.3% were male. The rates of mortality observed in the ICU were 19.8%. By conducting multivariable Cox proportional hazards, it was determined that the SHR was independently associated with a heightened risk of 28-day ICU mortality (HR = 1.83 per 1-point increment, 95% CI = 1.07-3.13, p = 0.028).The analysis using restricted cubic splines showed that there was a consistent and gradually increasing risk of all-cause mortality as the SHR increased. This indicates that a higher SHR is associated with a higher risk of ICU mortality.

CONCLUSIONS

Elevated SHR was strongly linked to a higher risk of clinical outcomes in patients with PE. As an effective measure of stress hyperglycemia, SHR demonstrated superior performance in predicting risks compared to solely evaluating glycemia or HbA1c upon admission.

Machine learning-based scoring system to predict cardiogenic shock in acute coronary syndrome

Aims

Cardiogenic shock (CS) is a severe complication of acute coronary syndrome (ACS) with mortality rates approaching 50%. The ability to identify high-risk patients prior to the development of CS may allow for pre-emptive measures to prevent the development of CS. The objective was to derive and externally validate a simple, machine learning (ML)-based scoring system using variables readily available at first medical contact to predict the risk of developing CS during hospitalization in patients with ACS.

Methods and results

Observational multicentre study on ACS patients hospitalized at intensive care units. Derivation cohort included over 40 000 patients from Beth Israel Deaconess Medical Center, Boston, USA. Validation cohort included 5123 patients from the Sheba Medical Center, Ramat Gan, Israel. The final derivation cohort consisted of 3228 and the final validation cohort of 4904 ACS patients without CS at hospital admission. Development of CS was adjudicated manually based on the patients' reports. From nine ML models based on 13 variables (heart rate, respiratory rate, oxygen saturation, blood glucose level, systolic blood pressure, age, sex, shock index, heart rhythm, type of ACS, history of hypertension, congestive heart failure, and hypercholesterolaemia), logistic regression with elastic net regularization had the highest externally validated predictive performance (c-statistics: 0.844, 95% CI, 0.841-0.847).

Conclusion

STOP SHOCK score is a simple ML-based tool available at first medical contact showing high performance for prediction of developing CS during hospitalization in ACS patients. The web application is available at https://stopshock.org/#calculator.

Stress hyperglycemia ratio association with all-cause mortality in critically ill patients with coronary heart disease: an analysis of the MIMIC-IV database

Background The stress hyperglycemia ratio (SHR) indicates relative hyperglycemia levels. Research on the impact of SHR on mortality in coronary heart disease (CHD) patients in intensive care is limited. This study explores the predictive accuracy of SHR for the prognosis of CHD patients in the ICU. Methods This study included 2,059 CHD patients from the American Medical Information Mart for Intensive Care (MIMIC-IV) database. SHR was determined using the formula: SHR = (admission glucose) (mmol/L) / (1.59 * HbA1c [%] - 2.59). Subjects were stratified into quartiles based on SHR levels to examine the correlation between SHR and in-hospital mortality. The restricted cubic splines and Cox proportional hazards models were employed to assess this association, while Kaplan-Meier survival analysis was executed to ascertain the mortality rates across the SHR quartiles. Results Among the 2059 participants (1358 men), the rates of in-hospital and ICU mortality were 8.5% and 5.25%, respectively. Analysis showed SHR as a significant predictor of increased risk for both in-hospital (HR,1.16, 95% CI: 1.02-1.32, P = 0.022) and ICU mortality (HR, 1.16, 95% CI: 1.01-1.35, P = 0.040) after adjustments. A J-shaped relationship was noted between SHR and mortality risks (p for non-linearity = 0.002, respectively). Kaplan-Meier analysis confirmed substantial differences in in-hospital and ICU mortality across SHR quartiles. Conclusions SHR significantly predicts in-hospital and ICU mortality in critically ill CHD patients, indicating that higher SHR levels correlate with longer ICU stays and increased mortality. This underscores the potential of SHR as a prognostic marker for ICU CHD patients.

The association between stress hyperglycemia ratio with mortality in critically ill patients with acute heart failure

Background

It's recognized that stress hyperglycemia ratio (SHR) is considered a significant indicator of poor prognosis in many diseases. However, its role in critically ill patients with acute heart failure (acute HF) remains underexplored.

Methods

We conducted a retrospective cohort study on patients with acute HF included in the Medical Information Mart for Intensive Care IV (MIMIC-IV) version 2.2 database. A restricted cubic spline (RCS) regression analysis was used to explore the relationship between SHR and the risk of all-cause mortality in these patients. Subsequently, a Cox regression model was used to evaluate the relationship between SHR and mortality in acute HF patients.

Results

A total of 1,644 acute HF patients were included in the study and divided into two groups: the low SHR group (SHR < 1.06, N = 823) and the high SHR group (SHR ≥ 1.06, N = 821). In our study, the 30-day, 90-day, 180-day, and 365-day mortality rates for acute HF were 7.0%, 12%, 15%, and 19%, respectively, with higher mortality rates observed in the high SHR group compared to the low SHR group. SHR levels showed a linear relationship with all-cause mortality. Furthermore, SHR as a continuous variable shows a significant positive correlation with 30-day (HR = 2.31, 95% CI: 1.58-3.39), 90-day (HR = 1.81, 95% CI: 1.31-2.52), 180-day (HR = 1.57, 95% CI: 1.16-2.12), and 365-day (HR = 1.41, 95% CI: 1.07-1.85) all-cause mortality. After categorization, high SHR remains associated with increased 30-day (HR = 2.4, 95% CI: 1.59-3.61), 90-day (HR = 1.76, 95% CI: 1.31-2.36), 180-day (HR = 1.51, 95% CI: 1.16-1.95), and 365-day (HR = 1.38, 95% CI: 1.09-1.73) all-cause mortality.

Conclusion

Our findings indicate that high SHR is an independent predictor of poor short- and long-term prognosis in acute HF patients. Understanding the impact of SHR on mortality in acute HF is crucial as it can assist clinicians in identifying high-risk patients and adjusting treatment strategies accordingly.

The association between the stress hyperglycaemia ratio and mortality in cardiovascular disease: a meta-analysis and systematic review

BACKGROUND

A raised stress hyperglycaemia ratio (SHR) has been associated with all-cause mortality and may better discriminate than an absolute glucose value. The aim of this meta analysis and systematic review is to synthesise the evidence assessing the relationship between the SHR and all-cause mortality across three common cardiovascular presentations.

METHODS

We undertook a comprehensive search of Medline, Embase, Cochrane CENTRAL and Web of Science from the date of inception to 1st March 2024, and selected articles meeting the following criteria: studies of patients hospitalised for acute myocardial infarction, ischaemic stroke or acute heart failure reporting the risk (odds ratio or hazard ratio) for all-cause mortality associated with the SHR. A random effects model was used for primary analysis. Subgroup analysis by diabetes status and of mortality in the short and long term was undertaken. Risk of bias assessment was performed using the Newcastle Ottawa quality assessment scale.

RESULTS

A total of 32 studies were included: 26 studies provided 31 estimates for the meta-analysis. The total study population in the meta analysis was 80,010. Six further studies were included in the systematic review. Participants admitted to hospital with cardiovascular disease and an SHR in the highest category had a significantly higher risk ratio of all-cause mortality in both the short and longer term compared with those with a lower SHR (RR = 1.67 [95% CI 1.46-1.91], p < 0.001). This finding was driven by studies in the myocardial infarction (RR = 1.75 [95% CI 1.52-2.01]), and ischaemic stroke cohorts (RR = 1.78 [95% CI 1.26-2.50]). The relationship was present amongst those with and without diabetes (diabetes: RR 1.49 [95% CI 1.14-1.94], p < 0.001, no diabetes: RR 1.85 [95% CI 1.49-2.30], p < 0.001) with p = 0.21 for subgroup differences, and amongst studies that reported mortality as a single outcome (RR of 1.51 ([95% CI 1.29-1.77]; p < 0.001) and those that reported mortality as part of a composite outcome (RR 2.02 [95% CI 1.58-2.59]; p < 0.001). On subgroup analysis by length of follow up, higher SHR values were associated with increased risk of mortality at 90 day, 1 year and > 1year follow up, with risk ratios of 1.84 ([95% CI 1.32-2.56], p < 0.001), 1.69 ([95% CI 1.32-2.16], p < 0.001) and 1.58 ([95% CI 1.34-1.86], p < 0.001) respectively.

CONCLUSIONS

A raised SHR is associated with an increased risk of all-cause mortality following myocardial infarction and ischaemic stroke. Further work is required to define reference values for the SHR, and to investigate the potential effects of relative hypoglycaemia. Interventional trials targeting to the SHR rather than the absolute glucose value should be undertaken.

PROSPERO DATABASE REGISTRATION

CRD 42023456421 https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023456421.

Association between stress hyperglycemia ratio and postoperative major adverse cardiovascular and cerebrovascular events in noncardiac surgeries: a large perioperative cohort study

BACKGROUND

There has been a concerning rise in the incidence of major adverse cardiovascular and cerebrovascular events (MACCE) following noncardiac surgeries (NCS), significantly impacting surgical outcomes and patient prognosis. Glucose metabolism abnormalities induced by stress response under acute medical conditions may be a risk factor for postoperative MACCE. This study aims to explore the association between stress hyperglycemia ratio (SHR) and postoperative MACCE in patients undergoing general anesthesia for NCS.

METHODS

There were 12,899 patients in this perioperative cohort study. The primary outcome was MACCE within 30 days postoperatively, defined as angina, acute myocardial infarction, cardiac arrest, arrhythmia, heart failure, stroke, or in-hospital all-cause mortality. Kaplan-Meier curves visualized the cumulative incidence of MACCE. Cox proportional hazard models were utilized to assess the association between the risk of MACCE and different SHR groups. Restricted cubic spline analyses were conducted to explore potential nonlinear relationships. Additionally, exploratory subgroup analyses and sensitivity analyses were performed.

RESULTS

A total of 592 (4.59%) participants experienced MACCE within 30 days after surgery, and 1,045 (8.10%) within 90 days. After adjusting for confounding factors, compared to the SHR T2 group, the risk of MACCE within 30 days after surgery increased by 1.34 times (95% CI 1.08-1.66) in the T3 group and by 1.35 times (95% CI 1.08-1.68) in the T1 group respectively. In the non-diabetes group, the risk of MACCE within 30 days after surgery increased by 1.60 times (95% CI 1.21-2.12) in the T3 group and by 1.61 times (95% CI 1.21-2.14) in the T1 group respectively, while no statistically significant increase in risk was observed in the diabetes group. Similar results were observed within 90 days after surgery in the non-diabetes group. Additionally, a statistically significant U-shaped nonlinear relationship was observed in the non-diabetes group (30 days: P for nonlinear = 0.010; 90 days: P for nonlinear = 0.008).

CONCLUSION

In this large perioperative cohort study, we observed that both higher and lower SHR were associated with an increased risk of MACCE within 30 and 90 days after NCS, especially in patients without diabetes. These findings suggest that SHR potentially plays a key role in stratifying cardiovascular and cerebrovascular risk after NCS.

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.

Relationship between stress hyperglycemia and worsening heart failure in patients with significant secondary mitral regurgitation

BACKGROUND AND AIMS

Secondary mitral regurgitation (sMR), a major valvular disease, is prevalent in patients with coronary artery disease (CAD), and is associated with higher incidence of heart failure (HF) and mortality when present in combination with abnormal glucose metabolism. We aimed to evaluate the relationship between stress hyperglycemia ratio (SHR) and worsening HF in CAD patients with significant (grade ≥2) sMR.

METHODS

We performed a multi-center observational study of 874 participants with significant sMR following percutaneous coronary intervention (PCI) in the Cardiorenal Improvement-II (CIN-II) cohort. Patients with glucose and glycated hemoglobin (HbA1c) data at admission were included in the analysis, and categorized according to the SHR, the ratio of mmol/L blood glucose to % HbA1c, as quartiles: Q1: <0.74; Q2: 0.74-0.91; Q3: 0.91-1.14; and Q4: ≥1.14. The primary clinical endpoint was worsening HF and the secondary endpoint was major adverse cardiac events (MACE).

RESULTS

Of the 874 participants (64.1 ± 10.8 years, 80% male), 174 showed worsening HF and 226 developed MACE during a median follow-up of 3.7 years (interquartile range: 1.8-6.2 years). Compared to participants in the lowest quartile (Q1) of SHR, the highest quartile group (Q4) was at significantly higher risks of worsening HF (adjusted hazard ratio, 2.44; 95% confidence interval, 1.51-3.94; p< 0.001), while this was not associated with increased risk of MACE (p>0.05) after adjustment for potential covariates. For worsening HF, the results obtained for the normal glucose regulation subgroup may be more meaningful than those for the diabetes mellitus (DM) and pre-DM groups (p-interaction<0.001). For MACE, the acute myocardial infarction (AMI) (Q4 vs. Q1; HR: 0.65, 95%CI: 0.26-1.59) and non-AMI (Q4 vs. Q1; HR: 2.20, 95%CI: 1.36-3.54) subgroups differed significantly on MACE (p-interaction = 0.006).

CONCLUSIONS

Increasing SHR is associated with a higher risk of worsening of HF in patients with significant sMR, especially in those with normoglycemia.

Predictive value of triglyceride glucose index combined with neutrophil-to-lymphocyte ratio for major adverse cardiac events after PCI for acute ST-segment elevation myocardial infarction

Acute ST-segment elevation myocardial infarction (STEMI) is a severe cardiovascular disease that poses a significant threat to the life and health of patients. This study aimed to investigate the predictive value of triglyceride glucose index (TyG) combined with neutrophil-to-lymphocyte ratio (NLR) for in-hospital cardiac adverse event (MACE) after PCI in STEMI patients. From October 2019 to June 2023, 398 STEMI patients underwent emergency PCI in the Second People's Hospital of Hefei. Stepwise regression backward method and multivariate logistic regression analysis were used to screen the independent risk factors of MACE in STEMI patients. To construct the prediction model of in-hospital MACE after PCI in STEMI patients: Grace score model is the old model (model A); TyG combined with NLR model (model B); Grace score combined with TyG and NLR model is the new model (model C). We assessed the clinical usefulness of the predictive model by comparing Integrated Discrimination Improvement (IDI), Net Reclassification Index (NRI), Receiver Operating Characteristic Curve (ROC), and Decision Curve Analysis (DCA). Stepwise regression and multivariate logistic regression analysis showed that TyG and NLR were independent risk factors for in-hospital MACE after PCI in STEMI patients. The constructed Model C was compared to Model A. Results showed NRI 0.5973; NRI + 0.3036, NRI - 0.2937, IDI 0.3583. These results show that the newly developed model C predicts the results better than model A, indicating that the model is more accurate. The ROC analysis results showed that the AUC of Model A for predicting MACE in STEMI was 0.749. Model B predicted MACE in STEMI with an AUC of 0.685. Model C predicted MACE in STEMI with an AUC of 0.839. For DCA, Model C has a better net return between threshold probability 0.1 and 0.78, which is better than Model A and Model B. In this study, by combining TyG, NLR, and Grace score, it was shown that TyG combined with NLR could reasonably predict the occurrence of MACE after PCI in STEMI patients and the clinical utility of the prediction model.

Association of acute glycemic parameters at admission with cardiovascular mortality in the oldest old with acute myocardial infarction

OBJECTIVES

Stress-related glycemic indicators, including admission blood glucose (ABG), stress-hyperglycemia ratio (SHR), and glycemic gap (GG), have been associated with worse outcomes after acute myocardial infarction (AMI). However, data regarding their prognostic value in the oldest old with AMI are unavailable. Therefore, this study aimed to investigate the association of stress-related glycemic indicators with short- and long-term cardiovascular mortality (CVM) in the oldest old (≥ 80 years) with AMI.

METHODS

In this prospective study, a total of 933 consecutive old patients with AMI admitted to FuWai hospital (Beijing, China) were enrolled. On admission, ABG, SHR, and GG were assessed and all participants were classified according to their quartiles. Kaplan-Meier, restricted cubic splines (RCS), and multivariate Cox regression analyses were performed to evaluate the association between these glycemic indicators and CVM within 30 days and long-term follow-up.

RESULTS

During an average of 1954 patient-years of follow-up, a total of 250 cardiovascular deaths were recorded. Kaplan-Meier analyses showed the lowest CVM in quartile 1 of ABG and in quartile 2 of SHR and GG. After adjusting for potential covariates, patients in quartile 4 of ABG, SHR, and GG had a respective 1.67-fold (95% CI: 1.03-2.69; P = 0.036), 1.80-fold (95% CI: 1.16-2.79; P = 0.009), and 1.78-fold (95% CI: 1.14-2.79; P = 0.011) higher risk of long-term CVM risk compared to those in the reference groups (quartile 1 of ABG and quartile 2 of SHR and GG). Furthermore, RCS suggested a J-shaped relationship of ABG and a U-shaped association of SHR and GG with long-term CVM. Additionally, we observed similar associations of these acute glycemic parameters with 30-day CVM.

CONCLUSIONS

Our data first indicated that SHR and GG consistently had a U-shaped association with both 30-day and long-term CVM among the oldest old with AMI, suggesting that they may be useful for risk stratification in this special population.

The stress hyperglycemic ratio can predict the no-reflow phenomenon following saphenous vein graft intervention in patients with acute coronary syndrome

AIMS

The no-reflow phenomenon (NRP) is a common complication of saphenous vein graft (SVG) interventions. The aim of this study was to investigate the effect of the stress hyperglycemia ratio (SHR) on the development of NRP in patients with acute coronary syndrome (ACS) undergoing percutaneous SVG intervention.

METHODS

The study included 223 patients who presented at our center with ACS, had a history of coronary artery bypass graft and underwent a saphenous graft procedure. The relationship between SHR calculated at the time of presentation from glucose and HbA1c values, and the development of NRP evaluated after the procedure with angiography was determined with univariate and multivariate binary regression analysis.

RESULT

The study population was separated into two groups as those who developed and did not develop NRP. Mean age was determined to be significantly higher in the group that did not develop NRP compared to the group with NRP (p: 0.004). Angiographically, the thrombus burden was determined to be significantly higher in the group that developed NRP (p < 0.001). Patients were separated into 3 tertiles according to the SHR level (T1, T2, T3), and the rate of NRP development was determined at a significantly higher rate in the T3 group (p < 0.001).

CONCLUSIONS

This study showed that SHR, a parameter that can be easily calculated noninvasively, is an independent predictor of NRP development in ACS patients undergoing saphenous interventions. In addition, high thrombus burden and predilatation before stenting were also found to be factors that increase the likelihood of developing NRP.

Relationship between stress hyperglycaemic ratio and incidence of in-hospital cardiac arrest in patients with acute coronary syndrome: a retrospective cohort study

BACKGROUND

The stress hyperglycaemic ratio (SHR), a new marker that reflects the true hyperglycaemic state of patients with acute coronary syndrome (ACS), is strongly associated with adverse clinical outcomes in these patients. Studies on the relationship between the SHR and in-hospital cardiac arrest (IHCA) incidence are limited. This study elucidated the relationship between the SHR and incidence of IHCA in patients with ACS.

METHODS

In total, 1,939 patients with ACS who underwent percutaneous coronary intervention (PCI) at the Affiliated Hospital of Zunyi Medical University were included. They were divided into three groups according to the SHR: group T1 (SHR ≤ 0.838, N = 646), group T2 (0.838< SHR ≤ 1.140, N = 646), and group T3 (SHR3 > 1.140, N = 647). The primary endpoint was IHCA incidence.

RESULTS

The overall IHCA incidence was 4.1% (N = 80). After adjusting for covariates, SHR was significantly associated with IHCA incidence in patients with ACS who underwent PCI (odds ratio [OR] =  2.6800; 95% confidence interval [CI] =  1.6200-4.4300; p<0.001), and compared with the T1 group, the T3 group had an increased IHCA risk (OR =  2.1800; 95% CI =  1.2100-3.9300; p =  0.0090). In subgroup analyses, after adjusting for covariates, patients with ST-segment elevation myocardial infarction (STEMI) (OR =  3.0700; 95% CI =  1.4100-6.6600; p =  0.0050) and non-STEMI (NSTEMI) (OR =  2.9900; 95% CI =  1.1000-8.1100; p =  0.0310) were at an increased IHCA risk. After adjusting for covariates, IHCA risk was higher in patients with diabetes mellitus (DM) (OR =  2.5900; 95% CI =  1.4200-4.7300; p =  0.0020) and those without DM (non-DM) (OR =  3.3000; 95% CI =  1.2700-8.5800; p =  0.0140); patients with DM in the T3 group had an increased IHCA risk compared with those in the T1 group (OR =  2.4200; 95% CI =  1.0800-5.4300; p =  0.0320). The restriction cubic spline (RCS) analyses revealed a dose-response relationship between IHCA incidence and SHR, with an increased IHCA risk when SHR was higher than 1.773. Adding SHR to the baseline risk model improved the predictive value of IHCA in patients with ACS treated with PCI (net reclassification improvement [NRI]: 0.0734 [0.0058-0.1409], p =  0.0332; integrated discrimination improvement [IDI]: 0.0218 [0.0063-0.0374], p =  0.0060).

CONCLUSIONS

In patients with ACS treated with PCI, the SHR was significantly associated with the incidence of IHCA. The SHR may be a useful predictor of the incidence of IHCA in patients with ACS. The addition of the SHR to the baseline risk model had an incremental effect on the predictive value of IHCA in patients with ACS treated with PCI.

Investigation of the effect of acute to chronic glycemic ratio on major amputation development after surgical thromboembolectomy in patients with acute lower extremity ischemia

BACKGROUND

Acute limb ischemia (ALI) is an emergency vascular pathology in which perfusion is disrupted in the lower extremity and threatens extremity viability. The admission blood glucose (ABG)/estimated average glucose (eAG) value has recently been shown as a prognostic marker in acute cardiovascular events. In this study, we aimed to investigate the predictive role of an ABG/eAG value in predicting development of early postoperative major amputation after emergency thromboembolectomy operations in patients presenting with ALI.

METHOD

Patients who admitted to our hospital with ALI between November 01, 2016 and September 01, 2021 and underwent surgical thromboembolectomy were retrospectively included in the study. Patients who did not undergo postoperative limb amputation were recorded as Group 1, and patients who underwent major amputation in the early postoperative period (in-hospital), were recorded as Group 2.

RESULTS

The median age of the 226 patients included in Group 1 and 72 patients in Group 2 were 58 (34-86) years and 69 (33-91) years, respectively (p<0.001). In univariate analysis, in-hospital amputation was found to significantly correlate with age>70 years (odds ratio [OR]: 1.914, 95% confidence interval [CI]: 1.351-2.319, p<0.001), PAD (OR: 1.698, 95% CI: 1.270-1.992, p = 0.002 re-embolectomy (OR: 2.184, 95% CI: 1.663-3.085, p < 0.001), admission Rutherford class (OR: 0.762, 95% CI: 0.591-0.859, p = 0.032), admission time>6 h (OR: 1.770, 95% CI: 1.480-1.152, p = 0.009), ABG (OR: 1.275, 95% CI: 1.050-1.790, p < 0.001), and ABG/eAG (OR: 1.669, 95% CI: 1.315-2.239, p < 0.001).

CONCLUSION

According to our study, we can predict patient groups with a high risk of major amputation with the ABG/eAG value calculated from the blood values of the patients at the time of admission.

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.

The Relationship between Acute-to-Chronic Glycemic Ratio and SYNTAX Score in Diabetic Patients Presenting with Acute Coronary Syndrome

A new index called the acute-to-chronic (A/C) glycemic ratio has been proposed to better represent the true acute glycemic rise in people with acute disease. However, there has been no previous study investigating the relationship between A/C glycemic ratio and SYNTAX score in patients with diabetic acute coronary syndrome (ACS). The aim of this study is to evaluate the role of A/C glycemic ratio in predicting coronary artery disease severity and SYNTAX score in diabetic patients presenting with ACS. The study included 131 consecutive patients hospitalized for ACS in our hospital, previously diagnosed with diabetes and undergoing percutaneous coronary intervention. The relationship between A/C glycemic ratio and SYNTAX score calculated at the time of admission was determined in univariate and multivariate linear regression analyses. The sample size was divided into three parts (T1, T2, and T3) according to the admission blood glucose (ABG)/estimated average glucose (eAG) ratio. When ABG/eAG and SYNTAX scores were compared, there was no significant difference between the T1 and T2 groups, but a significant increase was found in the T3 group compared with the other two groups (T1: 14.26, T2: 14.77, T3: 24.41; p  < 0.001). When multivariate modeling was performed with the two or three most relevant variables (age, estimated glomerular filtration rate [eGFR], and ABG/eAG ratio), the upper tertile of the ABG/eAG variable was correlated with the severity of coronary atherosclerosis and higher SYNTAX score. This study shows that there is a significant relationship between higher ABG/eAG ratio and higher SYNTAX score in diabetic patients presenting with ACS.

Prognostic implications of stress hyperglycemia ratio in patients with myocardial infarction with nonobstructive coronary arteries

BACKGROUND

The role of stress hyperglycemia in acute myocardial infarction (AMI) has long been emphasized. Recently, the stress hyperglycemia ratio (SHR), a novel index reflecting an acute glycemia rise, has shown a good predictive value in AMI. However, its prognostic power in myocardial infarction with nonobstructive coronary arteries (MINOCA) remains unclear.

METHODS

In a prospective cohort of 1179 patients with MINOCA, relationships between SHR levels and outcomes were analyzed. SHR was defined as acute-to-chronic glycemic ratio using admission blood glucose (ABG) and glycated hemoglobin. The primary endpoint was defined as major adverse cardiovascular events (MACE), including all-cause death, nonfatal MI, stroke, revascularization, and hospitalization for unstable angina or heart failure. Survival analyses and receiver-operating characteristic (ROC) curve analyses were performed.

RESULTS

Over the median follow-up of 3.5 years, the incidence of MACE markedly increased with higher SHR tertile levels (8.1%, 14.0%, 20.5%; p < 0.001). At multivariable Cox analysis, elevated SHR was independently associated with an increased risk of MACE (HR 2.30, 95% CI: 1.21-4.38, p = 0.011). Patients with rising tertiles of SHR also had a significantly higher risk of MACE (tertile 1 as reference; tertile 2: HR 1.77, 95% CI: 1.14-2.73, p = 0.010; tertile 3: HR 2.64, 95% CI: 1.75-3.98, p < 0.001). SHR remained a robust predictor of MACE in patients with and without diabetes; whereas ABG was no longer associated with the MACE risk in diabetic patients. SHR showed an area under the curve of 0.63 for MACE prediction. By incorporating SHR to TIMI risk score, the combined model further improved the discrimination for MACE.

CONCLUSIONS

The SHR independently confers the cardiovascular risk after MINOCA, and may serve as a better predictor than glycemia at admission alone, particularly in those with diabetes.KEY MESSAGESStress hyperglycemia ratio (SHR) is independently associated with the prognosis in a distinct population with myocardial infarction with nonobstructive coronary arteries (MINOCA).SHR is a better predictor of prognosis than admission glycemia alone, especially in diabetic patients with MINOCA.SHR may serve as a prognostic marker for risk stratification as well as a potential target for tailored glucose-lowering treatment in MINOCA.

Impact of stress hyperglycemia ratio on mortality in patients with critical acute myocardial infarction: insight from american MIMIC-IV and the chinese CIN-II study

BACKGROUND

Among patients with acute coronary syndrome and percutaneous coronary intervention, stress hyperglycemia ratio (SHR) is primarily associated with short-term unfavorable outcomes. However, the relationship between SHR and long-term worsen prognosis in acute myocardial infarction (AMI) patients admitted in intensive care unit (ICU) are not fully investigated, especially in those with different ethnicity. This study aimed to clarify the association of SHR with all-cause mortality in critical AMI patients from American and Chinese cohorts.

METHODS

Overall 4,337 AMI patients with their first ICU admission from the American Medical Information Mart for Intensive Care (MIMIC)-IV database (n = 2,166) and Chinese multicenter registry cohort Cardiorenal ImprovemeNt II (CIN-II, n = 2,171) were included in this study. The patients were divided into 4 groups based on quantiles of SHR in both two cohorts.

RESULTS

The total mortality was 23.8% (maximum follow-up time: 12.1 years) in American MIMIC-IV and 29.1% (maximum follow-up time: 14.1 years) in Chinese CIN-II. In MIMIC-IV cohort, patients with SHR of quartile 4 had higher risk of 1-year (adjusted hazard radio [aHR] = 1.87; 95% CI: 1.40-2.50) and long-term (aHR = 1.63; 95% CI: 1.27-2.09) all-cause mortality than quartile 2 (as reference). Similar results were observed in CIN-II cohort (1-year mortality: aHR = 1.44; 95%CI: 1.03-2.02; long-term mortality: aHR = 1.32; 95%CI: 1.05-1.66). In both two group, restricted cubic splines indicated a J-shaped correlation between SHR and all-cause mortality. In subgroup analysis, SHR was significantly associated with higher 1-year and long-term all-cause mortality among patients without diabetes in both MIMIC-IV and CIN-II cohort.

CONCLUSION

Among critical AMI patients, elevated SHR is significantly associated with and 1-year and long-term all-cause mortality, especially in those without diabetes, and the results are consistently in both American and Chinese cohorts.

The impact of the stress hyperglycemia ratio on mortality and rehospitalization rate in patients with acute decompensated heart failure and diabetes

BACKGROUND

The relationship between stress hyperglycemia and long-term prognosis in acute decompensated heart failure (ADHF) patients is unknown. This study investigated the associations of stress hyperglycemia with mortality and rehospitalization rates among ADHF patients with diabetes.

METHODS

We consecutively enrolled 1904 ADHF patients. Among them, 780 were with diabetes. Stress hyperglycemia was estimated using the stress hyperglycemia ratio (SHR), which was calculated by the following formula: SHR = admission blood glucose/[(28.7 × HbA1c%) - 46.7]. All diabetic ADHF subjects were divided into quintiles according to the SHR. The primary endpoint was all-cause death at the 3-year follow-up. The secondary endpoints were cardiovascular (CV) death and heart failure (HF) rehospitalization at the 3-year follow-up. A Cox proportional hazards model and restricted cubic spline analysis were used to elucidate the relationship between the SHR and the endpoints in diabetic ADHF patients. Further analyses were performed to examine the relationships between SHR and the outcomes in heart failure with preserved ejection fraction (HFpEF) and heart failure with reduced ejection fraction (HFrEF).

RESULTS

A total of 169 all-cause deaths were recorded during a median follow-up of 3.24 years. Restricted cubic spline analysis suggested a U-shaped association between the SHR and the mortality and rehospitalization rates. Kaplan-Meier survival analysis showed the lowest mortality in the 2nd quintile (P = 0.0028). Patients categorized in the highest range (5th quintile) of SHR, compared to those in the 2nd quintile, exhibited the greatest susceptibility to all-cause death (with a hazard ratio [HR] of 2.76 and a 95% confidence interval [CI] of 1.63-4.68), CV death (HR 2.81 [95% CI 1.66-4.75]) and the highest rate of HF rehospitalization (HR 1.54 [95% CI 1.03-2.32]). Similarly, patients in the lowest range (1st quintile) of SHR also exhibited significantly increased risks of all-cause death (HR 2.33, 95% CI 1.35-4.02) and CV death (HR 2.32, 95% CI 1.35-4.00). Further analyses indicated that the U-shape association between the SHR and mortality remained significant in both HFpEF and HFrEF patients.

CONCLUSION

Both elevated and reduced SHRs indicate an unfavorable long-term prognosis in patients with ADHF and diabetes.

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.

Impact of the Stress Hyperglycemia Ratio on In-Hospital and Long-Term Poor Prognosis in Patients with Acute Myocarditis

Background

Few studies have focused on the impact of stress hyperglycemia on adverse outcomes in patients with acute myocarditis. We conducted the present study to assess the association between the stress hyperglycemia ratio (SHR) and poor prognosis in patients with acute myocarditis.

Methods

From 2006 to 2020, 185 patients with acute myocarditis were enrolled. The SHR was defined as glucose at admission divided by estimated average glucose ([(1.59 × HbA1c %) - 2.59], glycated hemoglobin [HbA1c]). Participants were divided into two groups according to their SHR values. The primary endpoint was defined as in-hospital major adverse cardiovascular events (MACE), including death, heart transplantation, the need for mechanical circulatory support (MCS), and transfer to the intensive care unit (ICU). The secondary endpoint was defined as long-term MACE.

Results

Subjects in the higher SHR group had more serious conditions, including lower systolic blood pressure, higher heart rate, higher white blood cell count, higher levels of alanine transaminase, troponin I, and C-reactive protein, and worse cardiac function. Multivariate logistic analysis showed that SHR > 1.12 (hazard ratio (HR): 3.946, 95% confidence interval (CI): 1.098-14.182; p = 0.035) was independently associated with in-hospital MACE in patients with acute myocarditis. Kaplan-Meier survival analysis and multivariate Cox analysis suggested that an SHR > 1.39 (HR: 1.931, 95% CI: 0.323-2.682; p = 0.895) was not significantly associated with long-term prognosis.

Conclusions

SHR was independently associated with in-hospital adverse outcomes in patients with acute myocarditis but not with long-term prognosis.

Positive association between stress hyperglycemia ratio and pulmonary infection in patients with ST-segment elevation myocardial infarction undergoing percutaneous coronary intervention

BACKGROUND

Previous studies have shown that the stress hyperglycemia ratio (SHR), a parameter of relative stress-induced hyperglycemia, is an excellent predictive factor for all-cause mortality and major adverse cardiovascular events (MACEs) among patients with ST-segment elevation myocardial infarction (STEMI). However, its association with pulmonary infection in patients with STEMI during hospitalization remains unclear.

METHODS

Patients with STEMI undergoing percutaneous coronary intervention (PCI) were consecutively enrolled from 2010 to 2020. The primary endpoint was the occurrence of pulmonary infection during hospitalization, and the secondary endpoint was in-hospital MACEs, composed of all-cause mortality, stroke, target vessel revascularization, or recurrent myocardial infarction.

RESULTS

A total of 2,841 patients were finally included, with 323 (11.4%) developing pulmonary infection and 165 (5.8%) developing in-hospital MACEs. The patients were divided into three groups according to SHR tertiles. A higher SHR was associated with a higher rate of pulmonary infection during hospitalization (8.1%, 9.9%, and 18.0%, P < 0.001) and in-hospital MACEs (3.7%, 5.1%, and 8.6%, P < 0.001). Multivariate logistic regression analysis demonstrated that SHR was significantly associated with the risk of pulmonary infection during hospitalization (odds ratio [OR] = 1.46, 95% confidence interval [CI] 1.06-2.02, P = 0.021) and in-hospital MACEs (OR = 1.67, 95% CI 1.17-2.39, P = 0.005) after adjusting for potential confounding factors. The cubic spline models demonstrated no significant non-linear relationship between SHR and pulmonary infection (P = 0.210) and MACEs (P = 0.743). In receiver operating characteristic curve, the best cutoff value of SHR for pulmonary infection was 1.073.

CONCLUSIONS

The SHR is independently associated with the risk of pulmonary infection during hospitalization and in-hospital MACEs for patients with STEMI undergoing PCI.

Fasting stress hyperglycemia ratio and in-hospital mortality after acute myocardial infarction in patients with different glucose metabolism status: Results from China acute myocardial infarction registry

AIMS

To evaluate the predictive value of fasting stress hyperglycemia ratio (SHR) for in-hospital mortality in patients with acute myocardial infarction (AMI) under different glucose metabolism status.

METHODS

We evaluated 5,308 AMI patients from the prospective, nationwide, multicenter China Acute Myocardial Infarction (CAMI) registry, of which 2,081 had diabetes. Fasting SHR was calculated by the formula [(first fasting plasma glucose (mmol/l))/(1.59 × HbA1c (%)-2.59)]. Patients were divided into high and low fasting SHR groups according to the optimal fasting SHR thresholds to predict in-hospital mortality for patients with and without diabetes, respectively. The primary endpoint was in-hospital mortality.

RESULTS

The optimal cutoff values of SHR were 1.06 and 1.26 for patients with and without diabetes. Patients with high fasting SHR presented higher in-hospital mortality than those with low fasting SHR in both cohorts with diabetes (7.9% vs 2.2%; OR adjusted 3.159, 95% CI 1.932-5.165; OR IPTW 3.311, 95%CI 2.326-4.713) and without diabetes (10.1% vs 2.5%; OR adjusted 3.189, 95%CI 2.161-4.705; OR IPTW 3.224, 95%CI 2.465-4.217). The prognostic powers of fasting SHR for in-hospital mortality were similar in patients with different glucose metabolism status. Moreover, adding fasting SHR to the original model led to a significant improvement in C-statistic, net reclassification, and integrated discrimination regardless of diabetes status.

CONCLUSIONS

This study firstly demonstrated a strong positive association between fasting SHR and in-hospital mortality in AMI patients with and without diabetes. Fasting SHR should be considered as a useful marker for risk stratification in AMI patients regardless of glucose metabolism status.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01874691.

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.

'Stress hyperglycemia ratio and in-hospital prognosis in non-surgical patients with heart failure and type 2 diabetes

OBJECTIVE

To evaluate the impact of stress hyperglycemia on the in-hospital prognosis in non-surgical patients with heart failure and type 2 diabetes.

RESEARCH DESIGN AND METHODS

We identified non-surgical hospitalized patients with heart failure and type 2 diabetes from a large electronic medical record-based database of diabetes in China (WECODe) from 2011 to 2019. We estimated stress hyperglycemia using the stress hyperglycemia ratio (SHR) and its equation, say admission blood glucose/[(28.7 × HbA1c)- 46.7]. The primary outcomes included the composite cardiac events (combination of death during hospitalization, requiring cardiopulmonary resuscitation, cardiogenic shock, and the new episode of acute heart failure during hospitalization), major acute kidney injury (AKI stage 2 or 3), and major systemic infection.

RESULTS

Of 2875 eligible Chinese adults, SHR showed U-shaped associations with composite cardiac events, major AKI, and major systemic infection. People with SHR in the third tertile (vs those with SHR in the second tertile) presented higher risks of composite cardiac events ([odds ratio, 95% confidence interval] 1.89, 1.26 to 2.87) and major AKI (1.86, 1.01 to 3.54). In patients with impaired kidney function at baseline, both SHR in the first and third tertiles anticipated higher risks of major AKI and major systemic infection.

CONCLUSIONS

Both high and low SHR indicates poor prognosis during hospitalization in non-surgical patients with heart failure and type 2 diabetes.

Stress hyperglycemia ratio and long-term mortality after acute myocardial infarction in patients with and without diabetes: A prospective, nationwide, and multicentre registry

AIMS

To assess the predictive value of stress hyperglycemia ratio (SHR) for long-term mortality after acute myocardial infarction (AMI) in patients with and without diabetes.

MATERIALS AND METHODS

We evaluated 6892 patients with AMI from the prospective, nationwide, multicentre China Acute Myocardial Infarction registry, of which 2820 had diabetes, and the remaining 4072 were nondiabetic patients. Patients were divided into high SHR and low SHR groups according to the optimal cutoff values of SHR to predict long-term mortality for diabetic and nondiabetic patients, respectively. The primary endpoint was all-cause mortality at 2 years.

RESULTS

The optimal cutoff values of SHR for predicting 2-year mortality were 1.20 and 1.08 for the diabetic and nondiabetic population, respectively. Overall, patients with high SHR were significantly associated with higher all-cause mortality compared with those with low SHR, in both diabetic patients (18.5% vs. 9.7%; hazard ratio [HR] 2.01, 95% confidence interval 1.63-2.49) and nondiabetic patients (12.0% vs. 6.4%; HR 1.95, 95%CI 1.57-2.41). After the potential confounders were adjusted, high SHR was significantly associated with higher risks of long-term mortality in both diabetic (adjusted HR 1.73, 95%CI 1.39-2.15) and nondiabetic (adjusted HR 1.63, 95%CI 1.30-2.03) patients. Moreover, adding SHR to the original model led to a slight albeit significant improvement in C-statistic, net reclassification, and integrated discrimination regardless of diabetic status.

CONCLUSIONS

This study demonstrated a strong positive association between SHR and long-term mortality in patients with AMI with and without diabetes, suggesting that SHR should be considered a useful marker for risk stratification in these patients.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01874691.

Quantification of stress-induced hyperglycaemia associated with key diagnostic categories using the stress hyperglycaemia ratio

AIM

Stress-induced hyperglycaemia (SIH) is the acute increase from preadmission glycaemia and is associated with poor outcomes. Early recognition of SIH and subsequent blood glucose (BG) management improves outcomes, but the degree of SIH provoked by distinct diagnostic categories remains unknown. Quantification of SIH is now possible using the stress hyperglycaemia ratio (SHR), which measures the proportional change from preadmission glycaemia, based on haemoglobin A_1c (HbA_1c ).

METHODS

We identified eligible patients for eight medical (n = 892) and eight surgical (n = 347) categories. Maximum BG from the first 24 h of admission for medical, or postoperatively for surgical patients was used to calculate SHR.

RESULTS

Analysis of variance indicated differing SHR and BG within both the medical (p < 0.0001 for both) and surgical cohort (p < 0.0001 for both). Diagnostic categories were associated with signature levels of SHR that varied between groups. Medically, SHR was greatest for ST-elevation myocardial infarction (1.22 ± 0.33) and sepsis (1.37 ± 0.43). Surgically, SHR was greatest for colectomy (1.62 ± 0.48) and cardiac surgeries (coronary artery graft 1.56 ± 0.43, aortic valve replacement 1.71 ± 0.33, and mitral valve replacement 1.75 ± 0.34). SHR values remained independent of HbA_1c , with no difference for those with HbA_1c above or below 6.5% (p > 0.11 for each). BG however was highly dependent on HbA_1c , invariably elevated in those with HbA_1c  ≥ 6.5% (p < 0.001 for each), and unreliably reflected SIH.

CONCLUSION

The acute stress response associated with various medical and surgical categories is associated with signature levels of SIH. Those with higher expected SHR are more likely to benefit from early SIH management, especially major surgery, which induced SIH typically 40% greater than medical cohorts. SHR equally recognised the acute change in BG from baseline across the full HbA_1c spectrum while BG did not and poorly reflected SIH.

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

BACKGROUND AND AIMS

Stress hyperglycemia ratio (SHR) is associated with increased in-hospital morbidity and mortality in patients with acute myocardial infarction (AMI). We aimed to investigate the impact of stress "hyperglycemia" on long-term mortality after AMI in patients with and without diabetes mellitus (DM).

METHODS AND RESULTS

We included 2089 patients with AMI between February 2014 and March 2018. SHR was measured with the fasting glucose divided by the estimated average glucose derived from glycosylated hemoglobin (HbA1c). The primary endpoint was all-cause death. Of 2 089 patients (mean age: 65.7 ± 12.4, 76.7% were men) analyzed, 796 (38.1%) had DM. Over a median follow-up of 2.7 years, 141 (6.7%) and 150 (7.2%) all-cause deaths occurred in the diabetic and nondiabetic cohorts, respectively. Compared with participants with low SHR (<1.24 in DM; <1.14 in non-DM), the hazard ratios and 95% confidence intervals for those with high SHR (≥1.24 in DM; ≥1.14 in non-DM) for all-cause mortality were 2.23 (1.54-3.23) and 1.79 (1.15-2.78); for cardiovascular mortality were 2.42 (1.63-3.59) and 2.10 (1.32-3.35) in DM and non-DM subjects, respectively. The mortality prediction was improved in the diabetic individuals with the incorporation of SHR into the Global Registry of Acute Coronary Events (GRACE) score, showing an increase in a continuous net reclassification index of 0.184 (95%CI: 0.003-0.365) and an absolute integrated discrimination improvement of 0.014 (95%CI: 0.002-0.025).

CONCLUSION

The improvement in the prediction of long-term mortality beyond the GRACE score indicates the potential of SHR as a biomarker for post-MI risk stratification among patients with DM.

REGISTRATION NUMBER FOR CLINICAL TRIALS

NCT03533543.

Predictive value of the stress hyperglycemia ratio in patients with acute ST-segment elevation myocardial infarction: insights from a multi-center observational study

Background

Stress hyperglycemia is a strong predictor of adverse outcomes in patients with acute myocardial infarction (AMI). Recently, the stress hyperglycemia ratio (SHR) has been designed as an index to identify acute hyperglycemia with true risk; however, data regarding the impact of SHR on the prognosis of ST-segment elevation myocardial infarction (STEMI) remains limited. This study aimed to evaluate the predictive value of the SHR in patients with acute STEMI and to assess whether it can improve the predictive efficiency of the Thrombolysis in Myocardial Infarction (TIMI) risk score.

Methods

This study included 7476 consecutive patients diagnosed with acute STEMI across 274 emergency centers. After excluding 2052 patients due to incomplete data, 5417 patients were included in the final analysis. Patients were divided into three groups according to SHR tertiles (SHR1, SHR2, and SHR3) and were further categorized based on diabetes status. All patients were followed up for major cardiovascular adverse events (MACEs) and all-cause mortality.

Results

After 30 days of follow-up, 1547 MACEs (28.6%) and 789 all-cause deaths (14.6%) occurred. The incidence of MACEs was highest among patients in the SHR3 group with diabetes mellitus (DM) (42.6%). Kaplan–Meier curves demonstrated that patients with SHR3 and DM also had the highest risk for MACEs when compared with other groups (p < 0.001). Moreover, C-statistics improved significantly when SHR3 was added into the original model: the ΔC-statistics (95% confidence interval) were 0.008 (0.000–0.013) in the total population, 0.010 (0.003–0.017) in the DM group, and 0.007 (0.002–0.013) in the non-DM group (all p < 0.05). In the receiver operating characteristic analysis, the area under the curve (AUC) for the original TIMI risk score for all-cause death was 0.760. When an SHR3 value of 1 point was used to replace the history of DM, hypertension, or angina in the original TIMI risk score, the Delong test revealed significant improvements in the AUC value (∆AUC of 0.009, p < 0.05), especially in the DM group (∆AUC of 0.010, p < 0.05).

Conclusion

The current results suggest that SHR is independently related to the risks of MACEs and mortality in patients with STEMI. Furthermore, SHR may aid in improving the predictive efficiency of the TIMI risk score in patients with STEMI, especially those with DM.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12933-022-01479-8.

Higher Stress Hyperglycemia Ratio Is Associated With a Higher Risk of Stroke-Associated Pneumonia

Objective

Stroke-associated pneumonia (SAP) is a frequent complication in stroke patients. This present study aimed to investigate the association between stress hyperglycemia and SAP.

Methods

Patients were screened between February 2013 and August 2020 from the First Affiliated Hospital of Wenzhou Medical University. We divided the blood glucose of the patients at admission by the glycated hemoglobin to calculate the stress hyperglycemia ratio (SHR). Binary logistic regression analysis was used to identify the association between SAP and SHR, with the confounders being controlled. Further, subgroup analyses were separately performed for stroke patients with and without diabetes.

Results

A total of 2,039 patients were finally recruited, of which 533 (26.14%) were diagnosed with SAP. SHR were divided into four quartiles in the logistic regression analysis, the highest SHR quartile (SHR ≥ 1.15) indicated a higher risk of SAP (OR = 1.57; 95% CI = 1.13–2.19, p = 0.01) in total patients. In patients without diabetes, the third quantile (SHR = 0.96–1.14) and the highest quantile (SHR ≥ 1.15) were both related to a higher risk of SAP (both p < 0.05). However, we did not find such an association in diabetic patients.

Conclusion

SHR was significantly associated with the risk of SAP in patients without diabetes. Adequate attention should be paid to the patients with high SHR levels at admission, especially those without diabetes.

WHAT IS STRESS HYPERGLYCEMIA? A SUGGESTION FOR AN IMPROVEMENT OF ITS DEFINITION

CONTEXT

Stress hyperglycemia has been studied in numerous critical illnesses for several decades. Despite the extensive accumulation of knowledge about this topic, the definition of stress hyperglycemia is not updated since 2007.

SUBJECTS AND METHODS

We performed a narrative review about stress hyperglycemia in acute myocardial infarction (AMI), aiming to improve its current definition and to give evidence supporting this.

RESULTS

The definition of stress hyperglycemia in 2021 we recommend is: "SH is a high ABGly in an AMI patient irrespective of DM status. It can be calculated as e.g., "stress hyperglycemia ratio" or "admission glucose delta"/"glycemic gap". This definition may serve to start a consensus document of the experts in the field. The evidence accumulates supporting the possibility to recognize stress hyperglycemia also in AMI patients with diabetes mellitus (DM) by calculating glycemia during the previous 2-3 months using glycated hemoglobin. Moreover, it is now obvious that 2007 definition of stress hyperglycemia did not take into account the necessity to separate cut-offs for the subgroups with vs. without DM.

CONCLUSIONS

We demonstrated the insufficiency of the current 2007 definition of stress hyperglycemia, provided evidence-based recommendation for the improvement and suggested the need for a consensus of the experts on this topic. In order to optimize the treatment of stress hyperglycemia in numerous critical illnesses, we ought to have its universal definition (as we already have the universal definition of AMI).

Stress Induced Hyperglycemia in the Context of Acute Coronary Syndrome: Definitions, Interventions, and Underlying Mechanisms

Elevation of glucose level in response to acute coronary syndrome (ACS) has been recognized as stress induced hyperglycemia (SIH). Plenty of clinical studies have documented that SIH occurs very common in patients hospitalized with ACS, even in those without previously known diabetes mellitus. The association between elevated blood glucose levels with adverse outcome in the ACS setting is well-established. Yet, the precise definition of SIH in the context of ACS remains controversial, bringing confusions about clinical management strategy. Several randomized trials aimed to evaluate the effect of insulin-based therapy on outcomes of ACS patients failed to demonstrate a consistent benefit of intensive glucose control. Mechanisms underlying detrimental effects of SIH on patients with ACS are undetermined, oxidative stress might play an important role in the upstream pathways leading to subsequent harmful effects on cardiovascular system. This review aims to discuss various definitions of SIH and their values in predicting adverse outcome in the context of ACS, as well as the effect of intensive glucose control on clinical outcome. Finally, a glimpse of the underlying mechanisms is briefly discussed.

Predictive value of stress hyperglycemia ratio for the occurrence of acute kidney injury in acute myocardial infarction patients with diabetes

Background

Acute hyperglycemia has been recognized as a robust predictor for occurrence of acute kidney injury (AKI) in nondiabetic patients with acute myocardial infarction (AMI), however, its discriminatory ability for AKI is unclear in diabetic patients after an AMI. Here, we investigated whether stress hyperglycemia ratio (SHR), a novel index with the combined evaluation of acute and chronic glycemic levels, may have a better predictive value of AKI as compared with admission glycemia alone in diabetic patients following AMI.

Methods

SHR was calculated with admission blood glucose (ABG) divided by the glycated hemoglobin-derived estimated average glucose. A total of 1215 diabetic patients with AMI were enrolled and divided according to SHR tertiles. Baseline characteristics and outcomes were compared. The primary endpoint was AKI and secondary endpoints included all-cause death and cardiogenic shock during hospitalization. The logistic regression analysis was performed to identify potential risk factors. Accuracy was defined with area under the curve (AUC) by a receiver-operating characteristic (ROC) curve analysis.

Results

In AMI patients with diabetes, the incidence of AKI (4.4%, 7.8%, 13.0%; p < 0.001), all-cause death (2.7%, 3.6%, 6.4%; p = 0.027) and cardiogenic shock (4.9%, 7.6%, 11.6%; p = 0.002) all increased with the rising tertile levels of SHR. After multivariate adjustment, elevated SHR was significantly associated with an increased risk of AKI (odds ratio 3.18, 95% confidence interval: 1.99–5.09, p < 0.001) while ABG was no longer a risk factor of AKI. The SHR was also strongly related to the AKI risk in subgroups of patients. At ROC analysis, SHR accurately predicted AKI in overall (AUC 0.64) and a risk model consisted of SHR, left ventricular ejection fraction, N-terminal B-type natriuretic peptide, and estimated glomerular filtration rate (eGFR) yielded a superior predictive value (AUC 0.83) for AKI.

Conclusion

The novel index SHR is a better predictor of AKI and in-hospital mortality and morbidity than admission glycemia in AMI patients with diabetes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12872-021-01962-2.

The stress hyperglycaemia ratio is associated with left ventricular remodelling after first acute ST-segment elevation myocardial infarction

BACKGROUND

Left ventricular negative remodelling after ST-segment elevation myocardial infarction (STEMI) is considered as the major cause for the poor prognosis. But the predisposing factors and potential mechanisms of left ventricular negative remodelling after STEMI remain not fully understood. The present research mainly assessed the association between the stress hyperglycaemia ratio (SHR) and left ventricular negative remodelling.

METHODS

We recruited 127 first-time, anterior, and acute STEMI patients in the present study. All enrolled patients were divided into 2 subgroups equally according to the median value of SHR level (1.191). Echocardiography was conducted within 24 h after admission and 6 months post-STEMI to measure left ventricular ejection fraction (LVEF), left ventricular end-diastolic diameter (LVEDD), and left ventricular end-systolic diameter (LVESD). Changes in echocardiography parameters (δLVEF, δLVEDD, δLVESD) were calculated as LVEF, LVEDD, and LVESD at 6 months after infarction minus baseline LVEF, LVEDD and LVESD, respectively.

RESULTS

In the present study, the mean SHR was 1.22 ± 0.25 and there was significant difference in SHR between the 2 subgroups (1.05 (0.95, 1.11) vs 1.39 (1.28, 1.50), p < 0.0001). The global LVEF at 6 months post-STEMI was significantly higher in the low SHR group than the high SHR group (59.37 ± 7.33 vs 54.03 ± 9.64, p  = 0.001). Additionally, the global LVEDD (49.84 ± 5.10 vs 51.81 ± 5.60, p  = 0.040) and LVESD (33.27 ± 5.03 vs 35.38 ± 6.05, p  = 0.035) at 6 months after STEMI were lower in the low SHR group. Most importantly, after adjusting through multivariable linear regression analysis, SHR remained associated with δLVEF (beta = -9.825, 95% CI -15.168 to -4.481, p  < 0.0001), δLVEDD (beta = 4.879, 95% CI 1.725 to 8.069, p  = 0.003), and δLVESD (beta = 5.079, 95% CI 1.421 to 8.738, p  = 0.007).

CONCLUSIONS

In the present research, we demonstrated for the first time that SHR is significantly correlated with left ventricular negative remodelling after STEMI.

Single prognostic cut-off value for admission glycemia in acute myocardial infarction has been used although high-risk stems from hyperglycemia as well as from hypoglycemia (a narrative review)

All original articles and meta-analysis use the single cut-off value to distinguish high-risk hyperglycemic from other acute myocardial infarction (AMI) patients. The mortality rate is 3.9 times higher in non-diabetic AMI patients with admission glycemia ≥6.1mmol compared to normoglycemic non-diabetic AMI patients. On the other hand, admission hypoglycemia in AMI is an important predictor of mortality. Because both admission hypo- and hyperglycemia correspond to higher in-hospital mortality, this graph is recognized as "J or U shaped curve". The review suggests two cut-off values for admission glycemia for risk assessment in AMI instead of single one because hypoglycemia as well as hyperglycemia represents a high-risk factor.

Association of stress hyperglycemia ratio with intracoronary thrombus burden in diabetic patients with ST-segment elevation myocardial infarction

Background

Large intracoronary thrombus burden is not rare during primary percutaneous coronary intervention (PCI) in patients with acute ST-segment elevation myocardial infarction (STEMI). Stress hyperglycemia is independently associated with poor prognosis. However, the underlying relationship between stress hyperglycemia and thrombus burden remains unknown. This study aims to investigate the association of stress hyperglycemia, evaluated by the combination of acute and chronic glycemic levels, with intracoronary thrombus burden in diabetic patients with STEMI.

Methods

We enrolled 227 consecutive diabetic patients with STEMI undergoing primary PCI within 12 hours after symptom onset. Stress hyperglycemia was estimated using the stress hyperglycemia ratio (SHR), which was calculated as admission glycemia divided by estimated average glucose derived from glycosylated hemoglobin. Based on reclassified angiographic thrombolysis in myocardial infarction (TIMI) thrombus grades, patients were divided into small thrombus burden (STB) group (TIMI thrombus grades <4) and large thrombus burden (LTB) group (TIMI thrombus grades 4 or 5).

Results

Of the entire study population, 77 (33.9%) patients were categorized as LTB group, whereas 150 (66.1%) patients presented with STB. The mean age was 64.1 years, and 80.6% of the patients were male. The SHR levels were significantly higher in patients with LTB than in those with STB [1.31; interquartile range (IQR): 1.13–1.48 versus 1.11; IQR: 0.96–1.32; P<0.001]. The predictive performance of SHR for LTB was moderate (area under the curve: 0.669; 95% confidence interval: 0.604–0.730; P<0.001), with the best cut-off value 1.19 (sensitivity 71.4%, specificity 64.7%). The incidence of LTB with SHR ≥1.19 was significantly higher compared with SHR <1.19 (50.9% versus 18.5%; P<0.001). Based on the multivariable logistic regression analysis, the high SHR (≥1.19) was found to be an independent predictor of LTB following adjustment for baseline clinical confounders.

Conclusions

A high SHR value was independently associated with large thrombus burden and has a better predictive value than glycemia at admission in diabetic patients with STEMI undergoing primary PCI. Stress hyperglycemia may play an important role on the intracoronary thrombus formation.

Augmented glycaemic gap is a marker for an increased risk of post-infarct left ventricular systolic dysfunction

BACKGROUND

Left ventricular systolic dysfunction (LVSD) occurs frequently after acute ST-segment elevation myocardial infarction (STEMI). The predisposing factors and underlying mechanism of post-infarct LVSD are not fully understood. The present study mainly investigated the correlation between glycaemic gap, a novel index of stress-induced hyperglycaemia (SIH), and post-infarct LVSD.

METHODS

A total of 274 first STEMI patients were enrolled in this cross-sectional study. Transthoracic echocardiography was performed within 48 h after admission and at 6 months after discharge to obtain left ventricular ejection fraction (LVEF). The change in LVEF was calculated as LVEF at 6 months after discharge minus baseline LVEF. Additionally, post-infarct LVSD was defined as LVEF ≤ 50%. Most importantly, glycaemic gap was calculated as admission blood glucose (ABG) minus the estimated average glucose over the previous 3 months.

RESULTS

In patients without diabetes mellitus (DM), multivariate linear regression analysis revealed that both glycaemic gap (Beta = - 1.214, 95% CI - 1.886 to - 0.541, p < 0.001) and ABG (Beta = - 1.124, 95% CI - 1.795 to - 0.453, p = 0.001) were associated with change in LVEF. In DM patients, only glycaemic gap was still associated with change in LVEF, although this association was not observed in univariate linear regression analysis. Regarding the association between SIH and post-infarct LVSD, multivariate logistic regression analysis revealed that both glycaemic gap (OR = 1.490, 95% CI 1.043 to 2.129, p = 0.028) and ABG (OR = 1.600, 95% CI 1.148 to 2.229, p = 0.005) were associated with an increased risk of having post-infarct LVSD in non-DM patients. However, after multivariate adjustment in DM patients, only glycaemic gap (OR = 1.399, 95% CI 1.021 to 1.919, p = 0.037) remained associated with an increased risk of having post-infarct LVSD. Furthermore, the predictive value of glycaemic gap for post-infarct LVSD was not inferior to ABG in non-DM patients (p = 0.499), and only glycaemic gap, instead of ABG, could significantly predict post-infarct LVSD in DM patients (AUC = 0.688, 95% CI 0.591 to 0.774, p = 0.002).

CONCLUSIONS

Glycaemic gap was strongly associated with a change in LVEF and an increased risk of having post-infarct LVSD in patients following STEMI. In STEMI patients with DM, glycaemic gap could provide more valuable information than ABG in identifying patients at high risk of developing post-infarct LVSD.