Proposal of a New Approach to Study and Categorize Stress Hyperglycemia in Acute Myocardial Infarction

Association between stress hyperglycemia ratio and prognosis in acute ischemic stroke: a systematic review and meta-analysis

BACKGROUND

Stress hyperglycemia is a relatively transient increase in blood glucose in response to inflammation of the body and neurohormonal disorders. It is still debated whether stress hyperglycemia ratio (SHR) in the acute phase, a new indicator of stress hyperglycemia, is related to poor prognosis in acute ischemic stroke (AIS) patients. This meta-analysis provides insight into the connection between SHR and prognosis in AIS patients.

METHODS

We screened all potentially relevant studies using a comprehensive database search. The standardized mean difference (SMD) and 95% confidence interval (CI) were utilized to investigate the relationship between SHR in the acute phase and the prognosis of AIS.

RESULTS

The pooled results revealed that AIS patients with poor prognoses had significantly higher SHR values than those with good prognoses (SMD = 0.56, 95%CI: 0.37-0.75, p<0.001). Subgroup analysis indicated that study design and differences in post-stroke treatment might be the sources of heterogeneity in this meta-analysis.

CONCLUSIONS

High SHR in the acute period is related to poor prognosis after AIS. SHR may be a new predictor of poor outcomes in AIS patients.

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.

Prognostic Impact of Plasma Glucose on Patients With Cardiogenic Shock With or Without Diabetes Mellitus from the SMART RESCUE Trial

Although the presence of hyperglycemia has been shown to affect the clinical outcome of patients with cardiogenic shock, the extent of hyperglycemia and its association with prognosis have not been fully addressed in a large population. A total of 1,177 consecutive patients with cardiogenic shock were enrolled from January 2014 to December 2018 at 12 hospitals in South Korea. The primary outcome was in-hospital mortality. Patients were divided into 4 groups according to their initial plasma glucose level in patients with diabetes mellitus (DM) (n = 752) and patients without DM (n=425); group 1 (≤8 mmol/L or 144 mg/100 ml), group 2 (8 to 12 mmol/L or 144 to 216 mg/100 ml), group 3 (12 to 16 mmol/L or 216 to 288 mg/100 ml), and group 4 (≥16 mmol/L or 288 mg/100 ml). The groups with higher admission plasma glucose were associated with lower systolic blood pressure and higher lactic acid levels in patients with and without DM. In-hospital mortality increased in groups with higher admission plasma glucose level in patients without DM (group 1:24.2%, group 2: 28.6%, group 3: 38.1%, group 4: 49.0%, p <0.01), whereas in patients with DM, mortality and admission plasma glucose level showed no significant association (group 1: 45%, group 2: 35.4%, group 3: 33.3%, group 4: 43.1%, p = 0.26). Even after multivariate analysis, high plasma glucose was an independent predictor of in-hospital mortality in patients without DM. In patients with cardiogenic shock, plasma glucose obtained at admission was associated with in-hospital mortality in patients without DM.

Admission Random Blood Glucose, Fasting Blood Glucose, Stress Hyperglycemia Ratio, and Functional Outcomes in Patients With Acute Ischemic Stroke Treated With Intravenous Thrombolysis

Background

Stress hyperglycemia ratio (SHR), calculated as glucose/glycated hemoglobin, has recently been developed for assessing stress hyperglycemia and could provide prognostic information for various diseases. However, calculating SHR using random blood glucose (RBG) drawn on admission or fasting blood glucose (FBG) could lead to different results. This study intends to evaluate the association between SHR and functional outcomes in patients with acute ischemic stroke (AIS) with recombinant tissue plasminogen activator (r-tPA) intravenous thrombolysis.

Methods

Data from 230 patients with AIS following thrombolytic therapy with r-tPA in the Third Affiliated Hospital of Wenzhou Medical University from April 2016 to April 2019 were retrospectively reviewed. SHR1 was defined as [RBG (mmol/L)]/[HbA1c (%)] and SHR2 was defined as [FBG (mmol/L)]/[HbA1c (%)]. The outcomes included early neurological improvement (ENI), poor function defined as a modified Rankin Scale score (mRS) of 3–6, and all-cause death in 3 months. Multivariable logistic regression was performed to estimate the association between SHR and adverse outcomes.

Results

After adjustment for possible confounders, though patients with AIS with higher SHR1 tend to have a higher risk of poor outcome and death and unlikely to develop ENI, these did not reach the statistical significance. In contrast, SHR2 was independently associated with poor functional outcome (per 0.1-point increases: odds ratios (OR) = 1.383 95% CI [1.147–1.668]). Further adjusted for body mass index (BMI), triglyceride-glucose index (TyG), and diabetes slightly strengthen the association between SHR (both 1 and 2) and adverse outcomes. In subgroup analysis, elevated SHR1 is associated with poor functional outcomes (per 0.1-point increases: OR = 1.246 95% CI [1.041–1.492]) in non-diabetic individuals and the association between SHR2 and the poor outcomes was attenuated in non-cardioembolic AIS.

Conclusion

SHR is expected to replace random or fasting glucose concentration as a novel generation of prognostic indicator and a potential therapeutic target.

Optimal glucose, HbA1c, glucose-HbA1c ratio and stress-hyperglycaemia ratio cut-off values for predicting 1-year mortality in diabetic and non-diabetic acute myocardial infarction patients

Background

Stress-induced hyperglycaemia at time of hospital admission has been linked to worse prognosis following acute myocardial infarction (AMI). In addition to glucose, other glucose-related indices, such as HbA1c, glucose-HbA1c ratio (GHR), and stress-hyperglycaemia ratio (SHR) are potential predictors of clinical outcomes following AMI. However, the optimal blood glucose, HbA1c, GHR, and SHR cut-off values for predicting adverse outcomes post-AMI are unknown. As such, we determined the optimal blood glucose, HbA1c, GHR, and SHR cut-off values for predicting 1-year all cause mortality in diabetic and non-diabetic ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation myocardial infarction (NSTEMI) patients.

Methods

We undertook a national, registry-based study of patients with AMI from January 2008 to December 2015. We determined the optimal blood glucose, HbA1c, GHR, and SHR cut-off values using the Youden’s formula for 1-year all-cause mortality. We subsequently analyzed the sensitivity, specificity, positive and negative predictive values of the cut-off values in the diabetic and non-diabetic subgroups, stratified by the type of AMI.

Results

There were 5841 STEMI and 4105 NSTEMI in the study. In STEMI patients, glucose, GHR, and SHR were independent predictors of 1-year all-cause mortality [glucose: OR 2.19 (95% CI 1.74–2.76); GHR: OR 2.28 (95% CI 1.80–2.89); SHR: OR 2.20 (95% CI 1.73–2.79)]. However, in NSTEMI patients, glucose and HbA1c were independently associated with 1-year all-cause mortality [glucose: OR 1.38 (95% CI 1.01–1.90); HbA1c: OR 2.11 (95% CI 1.15–3.88)]. In diabetic STEMI patients, SHR performed the best in terms of area-under-the-curve (AUC) analysis (glucose: AUC 63.3%, 95% CI 59.5–67.2; GHR 68.8% 95% CI 64.8–72.8; SHR: AUC 69.3%, 95% CI 65.4–73.2). However, in non-diabetic STEMI patients, glucose, GHR, and SHR performed equally well (glucose: AUC 72.0%, 95% CI 67.7–76.3; GHR 71.9% 95% CI 67.7–76.2; SHR: AUC 71.7%, 95% CI 67.4–76.0). In NSTEMI patients, glucose performed better than HbA1c for both diabetic and non-diabetic patients in AUC analysis (For diabetic, glucose: AUC 52.8%, 95% CI 48.1–57.6; HbA1c: AUC 42.5%, 95% CI 37.6–47. For non-diabetic, glucose: AUC 62.0%, 95% CI 54.1–70.0; HbA1c: AUC 51.1%, 95% CI 43.3–58.9). The optimal cut-off values for glucose, GHR, and SHR in STEMI patients were 15.0 mmol/L, 2.11, and 1.68 for diabetic and 10.6 mmol/L, 1.72, and 1.51 for non-diabetic patients respectively. For NSTEMI patients, the optimal glucose values were 10.7 mmol/L for diabetic and 8.1 mmol/L for non-diabetic patients.

Conclusions

SHR was the most consistent independent predictor of 1-year all-cause mortality in both diabetic and non-diabetic STEMI, whereas glucose was the best predictor in NSTEMI patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12933-021-01395-3.

The risk score for in-hospital mortality in patients with ST-segment elevation myocardial infarction

Aim    To develop a scale (score system) for predicting the individual risk of in-hospital death in patients with ST segment elevation acute myocardial infarction (STEMI) with an account of results of percutaneous coronary intervention (PCI).Material and methods    The analysis used data of 1 649 sequential patients with STEMI included into the hospital registry of PCI from 2006 through 2017. To test the model predictability, the original sample was divided into two groups: a training group consisting of 1150 (70 %) patients and a test group consisting of 499 (30 %) patients. The training sample was used for computing an individual score. To this purpose, β-coefficients of each variable obtained at the last stage of the multivariate logistic regression model were subjected to linear transformation. The scale was verified using the test sample.Results    Seven independent predictors of in-hospital death were determined: age ≥65 years, acute heart failure (Killip class III-IV), total myocardial ischemia time ≥180 min, anterior localization of myocardial infarction, failure of PCI, SYNTAX scale score ≥16, glycemia on admission ≥7.78 mmol/l for patients without a history of diabetes mellitus and ≥14.35 mmol/l for patients with a history of diabetes mellitus. The contribution of each value to the risk of in-hospital death was ranked from 0 to 7. A threshold total score of 10 was determined; a score ≥10 corresponded to a high probability of in-hospital death (18.2 %). In the training sample, the sensitivity was 81 %, the specificity was 80.6 %, and the area under the curve (AUC) was 0.902. In the test sample, the sensitivity was 96.2 %, the specificity was 83.3 %, and the AUC was 0.924.Conclusion    The developed scale has a good predictive accuracy in identifying patients with acute STEMI who have a high risk of fatal outcome at the hospital stage.

Basic types of the first-day glycemia in acute myocardial infarction: Prognostic, diagnostic, threshold and target glycemia

We described the importance of stress hyperglycemia (SH) in critical illnesses and their evaluation in the emergency department (ED) and coronary care unit (CCU). Hyperglycemia is found in over half of the patients with suspected acute myocardial infarction (AMI). SH can be used for several purposes in AMI. Receiver operating characteristic curves are needed to find optimal cut-offs to divide blood glucose levels associated with good from bad prognosis in AMI. There is a need for a consensus for pragmatic classification of first day glycemia in order to be useful in a busy ED and CCU.

Effects of Stress Hyperglycemia on Short-Term Prognosis of Patients Without Diabetes Mellitus in Coronary Care Unit

Background: Diabetes mellitus (DM) has a high morbidity and mortality worldwide, and it is a risk factor for cardiovascular diseases. Non-diabetic stress hyperglycemia is common in severely ill patients, and it could affect prognosis. This study aimed to analyze the influence of different blood glucose levels on prognosis from the perspective of stress hyperglycemia by comparing them with normal blood glucose levels and those of patients with DM.

Methods: A retrospective study of 1,401 patients in coronary care unit (CCU) from the critical care database called Medical Information Mart for Intensive Care IV was performed. Patients were assigned to the following groups 1–4 based on their history of DM, random blood glucose, and HbA1c levels: normal blood glucose group, moderate stress hyperglycemia group, severe stress hyperglycemia group and DM group. The main outcome of this study was 30- and 90-day mortality rates. The associations between groups and outcomes were analyzed using Kaplan–Meier survival analysis, Cox proportional hazard regression model and competing risk regression model.

Results: A total of 1,401 patients in CCU were enrolled in this study. The Kaplan–Meier survival curve showed that group 1 had a higher survival probability than groups 3 and 4 in terms of 30- and 90-day mortalities. After controlling the potential confounders in Cox regression, groups 3 and 4 had a statistically significant higher risk of both mortalities than group 1, while no difference in mortality risk was found between groups 2 and 1. The hazard ratios [95% confidence interval (CI)] of 30- and 90-day mortality rates for group 3 were 2.77(1.39,5.54) and 2.59(1.31,5.12), respectively, while those for group 4 were 1.92(1.08,3.40) and 1.94(1.11,3.37), respectively.

Conclusions: Severe stress hyperglycemia (≥200 mg/dL) in patients without DM in CCU may increase the risk of short-term death, which is greater than the prognostic effect in patients with diabetes. Patients with normal blood glucose levels and moderate stress hyperglycemia (140 mg/dL ≤ RBG <200 mg/dL) had no effect on short-term outcomes in patients with CCU.

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.

Blood Glucose Levels and Mortality in Patients With Sepsis: Dose-Response Analysis of Observational Studies

BACKGROUND

We undertook a systematic review and meta-analysis to investigate the relationship between blood glucose levels and mortality in patients with sepsis.

METHODS

Medline and EMBASE were searched from inception to April 8, 2018. Cohort studies or case-control studies reported the association between blood glucose and mortality in patients with sepsis were selected. Study characteristics, baseline characteristics, definition of hyperglycemia, and outcomes of interest were extracted. We performed a dose-response meta-analysis to assess the effect of blood glucose level on mortality. We also conducted meta-analysis for patients with or without diabetes separately.

RESULTS

Ten cohort studies involving 26 429 patients were included, of which 5 were prospective studies and 5 retrospective studies. Dose-response analysis showed that the effect of blood glucose on mortality may differ in patients with versus without diabetes. There was a U-shaped relationship for patients with diabetes and a J-shaped relationship for patients without diabetes, with blood glucose at 145 to 155 mg/dL corresponding to lowest mortality both in patients with and without diabetes.

CONCLUSIONS

Current evidence suggested U-shaped relationship between blood glucose and mortality in all patients irrespective of their diabetes status. Diabetic patients with blood glucose below 145 mg/dL may have poorer prognosis compared to patients without established diabetes.

High admission glucose levels predict worse short-term clinical outcome in non-diabetic patients with acute myocardial infraction: a retrospective observational study

BACKGROUND

Patients with acute myocardial infarction (AMI) often accompanied by admission hyperglycemia, which usually predicts a poor clinical outcomes for non-diabetes mellitus. Appropriate cut-point to identify high risk individuals in these patients remains controversial.

METHODS

One thousand six hundred ninety-eight non-diabetes AMI patients in this retrospective study were divided into 3 groups according to admission glucose levels (euglycemia group≤140 mg/dL, moderate hyperglycemia group 141-179 mg/dL, severe hyperglycemia group≥180 mg/dL). The primary endpoint of this study was all-cause in-hospital mortality rate. In-hospital motality related risk factors was analyzed by multivariate binary logistic regression analyses.

RESULTS

All myocardial necrosis markers and Log NT-proBNP in severe hyperglycemia group were significantly higher than those in the other 2 groups. Logistic regression showed that independent predictors of the in-hospital mortality rate in non-diabetic patients with AMI were age (OR = 1.057, 95% CI 1.024-1.091, P < 0.001), logarithm of the N-terminal pro-brain natriuretic peptide (OR = 7.697, 95% CI 3.810-15.550, P < 0.001), insufficient myocardial reperfusion (OR = 7.654, 95% CI 2.109-27.779, P < 0.001), percutaneous coronary intervention (OR = 0.221, 95% CI 0.108-0.452, P < 0.001) and admission glucose (as categorical variable). Patients with moderate hyperglycemia (OR = 1.186, 95% CI 0.585-2.408, P = .636) and severe hyperglycemia (OR = 4.595, 95% CI 1.942-10.873, P = 0.001) had a higher all-cause in-hospital mortality rate compared with those with euglycemia after AMI in non-diabetic patients.

CONCLUSIONS

The all-cause in-hospital mortality risk increases remarkably as admission glucose levels elevated in non-diabetic patients with AMI, especially in patients with admission glucose levels ≥180 mg/dL. Severe admission hyperglycemia could be regarded as prospective high-risk marker for non-diabetic AMI patients.

Correlation of triglycerides with myocardial infarction and analysis of risk factors for myocardial infarction in patients with elevated triglyceride

Background

This study aims to investigate the associations of different (low/medium/high) levels of fasting triglyceride (TG) levels with cardiovascular endpoints.

Methods

This cohort study comprised of in-service and retired employees of the Kailuan Coal Mine Group, who participated in the health examination conducted in 11 hospitals in the Kailuan region from June 2006 to October 2007 (n=100,271). The study population was divided into five groups according to different TG levels. Logistic regression analysis was used to analyze the risk factors for myocardial infarction (MI) in patients with elevated TG, and Cox proportional hazards regression analysis was used to analyze the effects of different TG levels on endpoint events.

Results

After a median follow-up of 7 years, 961 patients developed MI and 3,142 subjects died. The multivariate logistic regression analysis revealed that elevated TG, an age of ≥65 years old, body mass index (BMI) >25 kg/m², fasting blood glucose (FBG) ≥6.1 mmol/L and high density lipoprotein cholesterol (HDL-C) <1.5 mmol/L were all risk factors for MI (P<0.05). Furthermore, Cox proportional hazards regression model revealed that after controlling for gender, age and other factors, with the increase in TG level, the relative risk of MI also increased. Compared to the TG1 group, the risk of MI increased to 1.32 folds in the TG4 group (95% CI: 1.05-1.66, P=0.018) and 1.61 folds in the TG5 group (95% CI: 1.21-1.93, P=0.004). Furthermore, the risk of MI combined with all-cause death and all-cause death also increased, but the differences were not all statistically significant.

Conclusions

In the study population of the Kailuan region, elevated fasting TG increases the risk of MI, particularly in populations with an age of ≥65 years old, BMI >25 kg/m², FBG ≥6.1 mmol/L and HDL-C <1.5 mmol/L.

Relative hyperglycemia is associated with complications following an acute myocardial infarction: a post-hoc analysis of HI-5 data

Background

Hyperglycemia is associated with increased morbidity and mortality in patients with an acute myocardial infarction (AMI). We evaluated whether complications after AMI are associated with absolute or relative glycemia.

Methods

A total of 192 patients with AMI were randomized to intensive or conventional insulin therapy. Absolute glycemia was defined as mean blood glucose level (BGL) during the first 24 h following randomization. Relative glycemia was defined by the stress hyperglycaemia ratio (SHR), calculated as mean BGL divided by average glucose concentration over the prior 3 months estimated from glycosylated haemoglobin. The primary endpoint was a “complicated AMI”, defined as an AMI complicated by death, congestive cardiac failure, arrhythmia, cardiac arrest, reinfarction, cardiogenic shock, inotrope use or emergency revascularization.

Results

There was not a significant association between mean BGL and complicated AMI (odds ratio (OR) 1.05 per mmol/L glucose increment, 95% confidence intervals (CI) 0.93–1.19). In contrast, SHR was positively associated with a complicated myocardial infarction (OR 1.22 per 0.1 SHR increment, 95% CI 1.06–1.42), and individual complications of death (OR 1.55, 95% CI 1.14–2.11), congestive cardiac failure (OR 1.27, 95% CI 1.05–1.54), arrhythmia (OR 1.31, 95% CI 1.12–1.54) and cardiogenic shock (OR 1.42, 95% CI 1.03–1.97). The relationship between SHR and a complicated AMI was independent of diabetic status, intensive insulin therapy, sex and hypoglycemia.

Conclusions

Relative, but not absolute, glycemia during insulin treatment is independently associated with complications after an AMI. Future studies should investigate whether basing therapeutic glycaemic targets on relative glycemia improves patient outcomes.