Stress hyperglycemia ratio and neutrophil to lymphocyte ratio are reliable predictors of new-onset atrial fibrillation in patients with acute myocardial infarction

Relationship between stress hyperglycaemic ratio (SHR) and critical illness: a systematic review

Stress-induced hyperglycemia (SIH) is a physiological response to acute or chronic stress characterized by elevated blood glucose levels. It is prevalent in both patients with and without diabetes, particularly those with acute or critical illnesses. The development of SIH is characterized by complex interactions among catecholamines, cortisol, and inflammatory mediators such as cytokines, resulting in increased hepatic glucose production and insulin resistance. While mild to moderate SIH may provide a protective mechanism during stress, prolonged or excessive hyperglycemia can exacerbate inflammation and oxidative stress, contributing to adverse outcomes in conditions such as acute myocardial infarction, heart failure, and cerebrovascular diseases. The stress-hyperglycemia ratio (SHR), defined as the ratio of admission glucose to estimated mean glucose (derived from glycated hemoglobin [HbA1c]), has emerged as a valuable tool for quantifying stress hyperglycemia. Unlike absolute glucose levels, the SHR accounts for background hyperglycemia and provides a more accurate indicator of the relative glucose elevation associated with critical illness. Extensive research has demonstrated a U-shaped or J-shaped relationship of the SHR with disease outcomes, indicating that both low and high SHRs are associated with increased mortality and morbidity. The SHR has shown significant predictive value in cardiovascular diseases (e.g., acute coronary syndrome, heart failure), cerebrovascular diseases (e.g., acute ischemic stroke, intracerebral hemorrhage), and infectious diseases (e.g., sepsis, pneumonia). It also plays a role in other conditions, such as acute pancreatitis and certain cancers. The ease of calculating the SHR from widely available admission glucose and HbA1c tests makes it a practical and valuable prognostic marker in clinical settings. This review examines the relationship between the SHR and critical illnesses, highlighting its mechanisms and predictive value across various diseases.

Joint association of the triglyceride-glucose index and stress hyperglycemia ratio with incidence and mortality risks of new-onset atrial fibrillation during sepsis: a retrospective cohort study

BACKGROUND

The triglyceride-glucose (TyG) index and stress hyperglycemia ratio (SHR) have been linked to the cardiovascular risks in critical ill patients. However, little is known about the predictive power of the TyG index, SHR and their combination on the incidence and mortality risks of new-onset atrial fibrillation (NOAF) in patients with sepsis.

METHOD

This retrospective study included patients from the Medical Information Mart for Intensive Care (MIMIC)-IV database. Primary outcomes were defined as the incidence and 360-day mortality of in-hospital NOAF among patients with sepsis. Logistic model, Cox proportional hazard model, Kaplan-Meier analysis and receiver-operating characteristic (ROC) were performed to explore the association between the indices and clinical outcomes. Machine learning approach also was constructed to evaluate and compare the indices in predicting mortality risks.

RESULTS

4276 patients meeting the inclusion criteria were enrolled and 764 individuals developed NOAF during hospitalization. The multivariable adjusted odds ratios (95%, CI) of incidence of NOAF in patients with sepsis in the highest group versus the lowest group were 1.36 (1.10-1.69), 1.35 (1.09-1.67) and 1.58 (1.23-2.02), respectively, for the TyG index, SHR and the TyG index-SHR combination. However, the predictive powers of these indices were relatively low. Among septic patients who developed in-hospital NOAF, those in the highest TyG index group and the highest SHR group exhibited an increased risk of 360-day mortality compared with those with the lowest TyG index and the lowest SHR (the TyG index: hazard ratio [HR] 1.59, 95% CI 1.00-2.62; SHR: HR 1.67, 95% CI 1.03-2.70). Patients with both the highest the TyG index and the highest SHR demonstrated the highest risk of 360-day mortality (HR 1.72, 95% CI 1.08-2.72). The ROC also confirmed the TyG index-SHR combination had more robust predictive power for 360-day mortality among septic patients with NOAF than the TyG index and SHR itself (p < 0.05). The random forest model validated that the predictive capability was significantly enhanced with the integration of the TyG index and SHR.

CONCLUSION

The TyG index and SHR were associated with the incidence of in-hospital NOAF during sepsis, although their predictive powers were limited. In septic patients with in-hospital NOAF, high levels of the TyG index and SHR were significantly associated with increased 360-day mortality risks, with their combination demonstrating superior predictive power. Joint assessments of the TyG index and SHR could help identify individuals at high risks of mortality post-discharge, enabling clinicians to prioritize follow-up care and improve patient management.

Associations Between Albumin/Neutrophil-to-Lymphocyte Ratio Score and New-Onset Atrial Fibrillation in Patients with Acute Myocardial Infarction Undergoing PCI

Background

Inflammation was associated with the increased risk of atrial fibrillation (AF). As a novel inflammatory indicator, albumin/neutrophil-to-lymphocyte ratio score (ANS) has been demonstrated to associate with coronary artery disease. However, the relationship between ANS and new onset atrial fibrillation (NOAF) in patients with acute myocardial infarction (AMI) underwent PCI was not determined.

Methods

A total of 2410 AMI patients underwent PCI were consecutively included between March 2020 and December 2023. Patients were divided into NOAF group and control group according to the occurrence of NOAF during hospitalization. The ANS was calculated and analyzed, so as to determine its predictive value in the presence of NOAF in AMI patients after PCI.

Results

In total, 88 (3.7%) individuals developed NOAF during hospitalization. We found that NOAF was associated with older age, greater LA, higher NT-proBNP, ANS and Killip ≥ 2. The ANS exhibited an accurately predictive value for the NOAF (area under the curve [AUC], 0.695; 95% CI, 0.649-0.740, P < 0.001). Moreover, when divided into three groups according to the tertile of ANS, patients in tertile 1 (lowest in ANS) showed a 2.214-fold increased risk of NOAF in comparison to those in the tertile 3 (HR, 2.214; 95% CI 1.804-5.101; P = 0.029).

Conclusion

ANS is a robust tool for the prediction of NOAF in AMI patients underwent PCI. Therefore ANS could be used for risk prediction and optimal management for NOAF in AMI patients after PCI.

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.

The role of systemic inflammatory indices in predicting atrial fibrillation and its complications: a narrative review

Atrial fibrillation (AF) is associated with increased morbidity and mortality. Inflammation and oxidative stress play critical roles in AF occurrence and its complications. Therefore, evaluating the circulating levels of inflammatory and oxidative stress biomarkers and their possible applications in AF diagnosis and management have been the focus of many efforts. The monocyte-to-high-density lipoprotein cholesterol ratio (MHR) and neutrophil-to-lymphocyte ratio (NLR) are two non-invasive, available, and established markers that serve as indicators of inflammation and oxidative stress. This review summarizes the current literature regarding alterations in the NLR, MHR, and other composite markers of systemic inflammation in AF patients. Moreover, this review discusses the clinical performance of these markers in predicting AF occurrence, recurrence, and disease outcomes. The PubMed, Scopus, and ScienceDirect online databases were searched for relevant studies using appropriate keywords, including "atrial fibrillation", "monocyte to high-density lipoprotein cholesterol ratio", and "neutrophil to lymphocyte ratio". The results of this review revealed the association of elevated levels of systemic inflammatory markers, specifically the NLR and MHR with AF and its complications. This finding indicates the potential role of subclinical inflammation in the development of AF, emphasizing its consideration in both the prevention and treatment of AF and associated complications. Despite these promising findings, the utilization of these markers in routine clinical settings faces challenges, including low specificity and sensitivity and varying cut-off values across different studies.

The interaction between neutrophils and atrial myocytes in the occurrence and development of atrial fibrillation

BACKGROUND

Atrial fibrillation (AF) is one of the most prevalent sustained cardiac arrhythmias, strongly associated with neutrophils. However, the underlying mechanism remain unclear. This study aims to explore the interaction between neutrophils and atrial myocytes in the pathogenesis of AF.

METHODS

Patch-clamp was employed to record the action potential duration (APD) and ion channels in HL-1 cells. Flow cytometry was used to assess the differentiation of neutrophils. The mRNA and protein levels of CACNA1C, CACNA2D, and CACNB2 in HL-1 cells were detected.

RESULTS

High-frequency electrical stimulation resulted in a shortening of the APD in HL-1 cells. Flow cytometry demonstrated that neutrophils were polarized into N1 phenotype when cultured with stimulated HL-1 cells medium. Compared to control neutrophils conditioned medium (CM), cocultured with TNF-α knockout neutrophils CM prolonged APD and the L-type Ca (2+) channel (LTCC) of HL-1 cells. Additionally, the expression of CACNA2D, CACNB2 and CACNA1C in HL-1 cells were upregulated. Compared with CACNA1C siRNA-transfected HL-1 cells treated with TNF-α siRNA-transfected neutrophils CM, the APD and LTCC of CACNA1C siRNA-transfected HL-1 cells were shortened in control N1 neutrophil CM. The APD and LTCC of control HL-1 cells were also shortened in control N1 neutrophil CM, but prolonged in TNF-α siRNA-transfected neutrophils CM.

CONCLUSION

These findings suggest that neutrophils were polarized into N1 phenotype in AF, TNF-α released from N1 neutrophils contributes to the pathogenesis of AF, via decreasing the APD and LTCC in atrial myocytes through down-regulation of CACNA1C expression.

Association between stress hyperglycemia ratio and all-cause mortality in critically ill patients with atrial fibrillation: insights from a MIMIC-IV study

Background

The stress hyperglycemia ratio (SHR) has emerged as a potential prognostic indicator for various critical illnesses. However, its role in determining outcomes in patients with atrial fibrillation (AF) within the intensive care unit (ICU) remains unclear. This study aimed to elucidate the association between SHR and all-cause mortality in this clinical setting.

Methods

We conducted a retrospective cohort study utilizing data from a large, retrospective database. Critically ill patients with documented AF were stratified based on quartiles of SHR. The primary outcome was 365-day all-cause mortality, with secondary outcomes including 90-day and 28-day mortality. COX proportional hazards models adjusted for confounders and Kaplan-Meier curve analyses were used to explore the relationship between SHR and mortality.

Results

2,679 patients with critical AF were enrolled in the final study. Among the patients studied, those in the highest SHR quartiles exhibited an increased risk of 365-day all-cause mortality (HR:1.32, 95%CI=1.06-1.65). Notably, in subgroup analyses, the prognostic value of SHR was particularly pronounced in patients with hypertension. Sensitivity analyses confirmed the persistence of these findings after excluding cohorts with malignant tumors, and heart failure.

Conclusions

Our research discerns a positive association between SHR and all-cause mortality in critically ill patients with AF, highlighting the significance of acute glycemic dysregulation on patient outcomes. Longer follow-up is still needed in the future to study the association between SHR and all-cause mortality in critically ill patients with AF.

Association between inflammation markers and all-cause mortality in critical ill patients with atrial fibrillation: Analysis of the Multi-Parameter Intelligent Monitoring in Intensive Care (MIMIC-IV) database

Background

Inflammation is related to cardiovascular disease. Among the many inflammatory markers, neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and systemic immune-inflammatory index (SII) were considered as novel predictors for atherosclerosis outcomes. We aimed to investigate the impact of these inflammatory markers on the prognosis of patients with atrial fibrillation (AF).

Methods

We obtained data on AF patients from the Medical Information Mart for Intensive Care (MIMIC)-IV database. These patients were classified into two groups based on their survival status within 30 days. Then, they were divided into three groups based on the tertile of baseline NLR, PLR, and SII, respectively. We comprehensively explored the relationship between those inflammatory indicators and all-cause mortality in patients with AF by Kaplan-Meier analysis, multivariate Cox regression analysis, receiver operating characteristic (ROC) analyses, restricted cubic spline regression (RCS), and subgroup analysis.

Results

A total of 4562 patients with AF were included. Statistically significant differences were found between survivor and non-survivor groups for NLR, PLR and SII. Patients in the high tertile of the NLR had a higher mortality rate than those in the low and intermediate tertiles, as did patients in the PLR and the SII. NLR, PLR and SII were independently associated with increased risk of all-cause mortality. RCS showed that the 30-day and 365-day risk of death were linearly associated with increases in NLR, PLR, and SII, respectively.

Conclusion

NLR, PLR, and SII have the potential to be used as indicators for stratifying the risk of mortality in critically ill patients with AF.

Association between the Albumin-to-Globulin Ratio and Atrial Fibrillation in Patients with Hypertrophic Cardiomyopathy

Background

Atrial fibrillation (AF), which occurs four to six times more frequently in hypertrophic cardiomyopathy (HCM) patients than in the general population, is the most common persistent arrhythmia and has a substantial therapeutic consequence. In HCM patients, there are currently no discovered signs that could be utilized to identify AF.

Methods

From 2018 to 2022, 493 individuals with a continuous diagnosis of HCM were examined at Beijing Anzhen Hospital. AF was proven using routine electrocardiography (ECG), 24-hour Holter ECGs, or bedside ECGs. Echocardiography and blood tests were performed for all patients. Analysis and comparison of the traits were performed in HCM patients with AF (n = 77) and without AF (n = 416).

Results

Age (p < 0.001), prevalence of ventricular tachycardia (VT, p < 0.001), prevalence of pulmonary artery hypertension (p = 0.027), and albumin-to-globulin ratio (AGR, p = 0.046) were all significantly higher in patients with AF, compared to patients without AF. In multivariate logistic analysis, age (odds ratio [OR], 1.063; 95% confidence interval [CI], 1.032-1.095; p < 0.001), history of VT (OR, 2.702; 95% CI, 1.007-7.255; p = 0.048), AGR (OR, 3.477; 95% CI, 1.417-8.536; p = 0.007), left atrial diameter (OR, 1.132; 95% CI, 1.073-1.194; p < 0.001), left ventricular end-diastolic diameter (OR, 0.861; 95% CI, 0.762-0.974; p = 0.017), left ventricular end-systolic diameter (OR, 1.239; 95% CI, 1.083-1.417; p = 0.002), and peak A wave velocity (OR, 0.983; 95% CI, 0.972-0.994; p = 0.002) were independently associated with AF in HCM patients. In the receiver operating characteristic curve analysis, the area under the curve for the established model was 0.819 (95% CI, 0.755-0.883, p = 0.033), with a sensitivity and specificity of 0.763 and 0.816, respectively, for AF occurrence in HCM patients.

Conclusions

In individuals with HCM, a history of VT and a higher AGR are independently linked to AF. Further investigation is necessary to determine whether increased AGR represents a risk factor for embolic stroke or cardiovascular death.

A Predictive Model of New-Onset Atrial Fibrillation After Percutaneous Coronary Intervention in Acute Myocardial Infarction Based on the Lymphocyte to C-Reactive Protein Ratio

Purpose

Lymphocyte to C-reactive protein ratio (LCR) is a recognized systemic inflammatory marker and novel prognostic indicator for several cancers. This study investigated the relationship between preoperative LCR and new-onset atrial fibrillation (NOAF) in patients with acute myocardial infarction (AMI) after percutaneous coronary intervention (PCI).

Patients and Methods

Patients with AMI (n=662) with no history of atrial fibrillation (AF) were enrolled and classified into NOAF and non-NOAF groups based on the occurrence of postoperative NOAF during hospitalization. Logistic regression models were used to analyze NOAF risk factors and to assess the association between preoperative LCR and NOAF incidence. We constructed a new nomogram from the selected NOAF risk factors, and tested its predictive performance, degree of calibration, and clinical utility using receiver operating characteristic and calibration curves, decision curve analysis, and clinical impact curves.

Results

Overall, 84 (12.7%) patients developed NOAF during hospitalization. The LCR was significantly lower in the NOAF group. Preoperative LCR accurately predicted NOAF after AMI and was correlated with increased NOAF risk. Age, body mass index, diabetes, serum albumin levels, uric acid levels, left atrium (LA) diameter, left ventricular ejection fraction, left circumflex artery stenosis > 50%, and Killip class II status were independent predictors of NOAF after AMI. In addition, a new nomogram combined with LCR was constructed to stratify the risk of NOAF in patients with AMI. The performance of the new nomogram was satisfactory, as shown by the receiver operating characteristic curve, calibration curve, decision curve analysis and clinical impact curve.

Conclusion

Preoperative LCR was an independent predictor of NOAF in patients with AMI after PCI. The novel nomogram combined with LCR could rapidly and individually identify and treat patients at a high risk of NOAF.

Elevated Neutrophil-to-Lymphocyte Ratio Is Associated with Severe Asthma Exacerbation in Children

Asthma is the most common chronic respiratory disease in children. The neutrophil-to-lymphocyte ratio (NLR) is a marker of a chronic inflammatory state; however, data on the association of NLR with acute asthma exacerbations in children is lacking. In this cross-sectional study, between 2016 and 2021, children aged 2-18 years who were referred to the emergency department (ED) due to asthma exacerbation, were included. NLR, calculated from complete blood count upon arrival, was assessed as a continuous variable and was classified into four groups according to quartiles. The association between severity parameters and NLR quartiles was examined. A total of 831 ED visits for asthma exacerbation were included in the study. The median NLR was 1.6, 3.8, 6.7, and 12.9 in quartiles 1-4, respectively (p < 0.001). Demographic parameters, background diseases, and chronic medications were similar between the quartiles. Higher heart rate, body temperature, systolic blood pressure, and respiratory rate were observed in the higher NLR quartiles, as well as lower oxygen saturation. Higher urgency scale and higher rates of intravenous magnesium sulfate were observed in the higher NLR quartiles, with higher admission rates and prolonged hospitalizations. In summary, NLR upon admission is associated with the severity of asthma exacerbation and higher chances of hospitalization among children in the ED.

Elevated stress hyperglycemia and the presence of intracranial artery stenosis increase the risk of recurrent stroke

BACKGROUND

Stress hyperglycemia has served as a reliable biomarker to predict poor outcomes after ischemic stroke. However, recent studies have reported some contrary conclusions. Different stroke subtypes may respond inconsistently to stress hyperglycemia. The progression of intracranial atherosclerotic stenosis (ICAS) is tightly related to hyperglycemia. Thus, this study aims to determine the relationship between stress hyperglycemia and recurrent stroke in ischemic stroke patients with or without intracranial atherosclerotic stenosis.

METHODS

This is a multicenter retrospective observational cohort study. Patients with acute minor ischemic stroke and eligible computed tomography and magnetic resonance imaging data were enrolled. The severity of stress hyperglycemia is measured by the stress hyperglycemia ratio (SHR). SHR was calculated based on fasting plasma glucose (FPG) and hemoglobin A1c (HbA1c) levels. The primary outcome was stroke recurrence during hospitalization. The interaction of SHR levels with the presence of ICAS on the primary outcome was investigated using univariable and multivariable Cox proportional hazards models. Restricted cubic splines were applied to determine the nonlinear relationship between SHR and primary outcome. A two-piecewise linear regression model was used to identify the threshold of SHR.

RESULTS

A total of 610 participants were included in the study. The average age of the patients was 61.4 ± 12.9 years old, and approximately 70% of participants were males. A total of 189 (30.98%) patients had ICAS. The patients were categorized into 3 groups based on the tertiles of SHR. Compared with the group with a lower SHR, a higher SHR was significantly associated with the risk of stroke recurrence in the ICAS group (hazard ratio [HR], 8.52, 95% confidence interval [CI], 3.16-22.96, P<0.001). When SHR was treated as a continuous variable, each 0.1-unit increase in SHR in the ICAS group was associated with a 1.63-fold increase in the risk of recurrence (HR, 1.63, 95% CI, 1.39-1.9, P<0.001) with a threshold of 0.75. FPG but not HbA1c was associated with stroke recurrence in ICAS patients (HR, 1.17, 95% CI, 1.08-1.26, P<0.001). Sensitive analyses showed consistent results after adjusting for previous diabetes mellitus, oral hypoglycemic agents and insulin injection.

CONCLUSIONS

SHR represents a better biomarker to predict the risk of stroke recurrence in patients with ICAS than FPG and HbA1c regardless of previous diabetes mellitus.

TRIAL REGISTRATION

https://www.chictr.org.cn/showproj.aspx?proj=125817; Identifier, [ChiCTR2100046958].