Relationship between stress hyperglycemia ratio and allcause mortality in critically ill patients: Results from the MIMIC-IV database

Relationship between stress hyperglycemia ratio and progression of non target coronary lesions: a retrospective cohort study

BACKGROUND

Stress hyperglycemia ratio is a novel indicator of acute coronary synthesis (ACS), which is closely related to the severity and complications of ACS and other cardiovascular diseases. However, its relationship with the progression of non target coronary lesions remains unclear. The purpose of this paper is to explore the relationship between stress hyperglycemia ratio and the progression of non target coronary lesions.

METHODS

This study retrospectively enrolled patients diagnosed with acute coronary syndrome who underwent stent implantation and follow-up evaluations by coronary angiography at Zhongda Hospital between January 2019 and January 2024. Patients were classified into progression and non progression groups based on follow-up angiography findings. Logistic regression models, restricted cubic spline analysis, and machine learning algorithms (LightGBM, decision tree, and XGBoost) were utilized to analyse the relationship of stress hyperglycemia ratio and non target lesion progression.

RESULTS

A total of 1,234 ACS patients were included; 29.1% experienced non target lesions progression. Logistic regression analysis showed that stress hyperglycemia ratio (SHR) was a risk factor for non target disease progression (P < 0.001), and after adjusting for other variables, SHR was still independently associated with non target disease progression (OR = 2.12, 95% CI: 1.30-3.44, p = 0.003). RCS analysis revealed a near-linear relationship between SHR and nontarget lesions progression (P = 0.14). With the increase of SHR, the risk of non target lesions progression continued to increase, and the risk was significant when the SHR was greater than 0.96, but tended to be stable when the SHR was greater than 1.36 (p = 0.0047). A hybrid model combining logistic regression and XGBoost yielded the best predictive performance, with an AUC of 0.78 (95% CI: 0.72-0.85), incorporating SHR, number and stenosis severity of non target lesions (NTLs), hypertension and high-density lipoprotein cholesterol (HDL-c). Subgroup analysis showed that elevated SHR was a stronger predictor of NTL progression in non-diabetic patients (OR = 3.76, p = 0.007) compared with diabetic patients (OR = 1.69, p = 0.083).

CONCLUSION

Stress hyperglycemia ratio is closely related to the progression of non target lesions. This study provides a novel insight for optimizing the long-term management of non target lesions after PCI.

Association between stress hyperglycemia ratio and all-cause mortality in critically ill patients with sepsis: results from the MIMIC-IV database

BACKGROUND

This study aimed to explore the association between the stress hyperglycemia ratio (SHR) and short- and long-term outcomes in critically ill patients with sepsis.

METHODS

This retrospective observational cohort study was conducted using the Medical Information Mart for Intensive Care-IV (MIMIC-IV v2.2) database. Patients were categorized into 4 SHR quartiles. The main focus was on in-hospital mortality and 1-year all-cause mortality as primary endpoints, while intensive care unit and hospital stays were considered as secondary outcomes. Regression and subgroup analyses were used to assess the correlation between SHR and the primary and secondary outcomes. Restricted cubic spline analysis was utilized to explore the nonlinear relationships between SHR and in-hospital and 1-year all-cause mortality.

RESULTS

This study included two groups of patients, comprising 7456 and 6564 individuals. The in-hospital and 1-year mortality was 11.96% and 17.96% in Cohort 1 and 2, respectively. SHR was associated with an elevated risk of in-hospital mortality (OR: 2.08, 95%CI 1.66-2.61) and 1-year mortality (HR: 1.70, 95% CI 1.42-2.04). Patients in SHR quartile 4 had a higher risk of in-hospital (OR: 1.86, 95% CI 1.51-2.30) and 1-year (HR: 1.44, 95% CI 1.23-1.69) mortality than those in quartile 2. Restricted cubic spline analysis showed a "J-shaped" relationship between SHR and all-cause mortality in both cohorts. The relationship between high SHR and mortality remained consistent across almost all predefined subgroups.

CONCLUSIONS

Our study suggests that high SHR is associated with increased in-hospital and 1-year mortality in critically ill sepsis patients. Further investigations are needed to validate these results.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Effects of stress hyperglycemia ratio upon long-lasting prognosis in coronary artery disease patients with or lacking chronic renal impairment: findings from a Chinese multi-center observational study

BACKGROUND

Lately, numerous researches have portrayed stress hyperglycemia ratio (SHR) is predominantly connected with short-term adverse prognosis among individuals who have acute coronary syndrome. Nevertheless, the relation of SHR with prolonged effects and the value of SHR in predicting in coronary artery disease (CAD) patients with or lacking chronic kidney disease (CKD) remain unclear. The present study was designed to elucidate the relation of SHR with prolonged prognosis and the value of SHR in predicting the long-term all-cause and cardiovascular death of CAD patients with CKD or non-CKD.

METHODS

We assessed 45,780 adults with CAD from a Chinese multi-center registry. SHR was computed via a formula [SHR = (admission glucose) (mmol/L) / (1.59 * HbA1c [%] - 2.59)]. Based on the presence or absence of CKD and SHR levels, patients were categorized into four groups. Long-term all-cause and cardiovascular mortality were the primary endpoints. The Kaplan-Meier method, restricted cubic spline (RCS), cox regression analysis, subgroups analysis, and sensitivity analysis were employed to estimate the connection between SHR and all-cause as well as cardiovascular mortality.

RESULTS

During a median follow-up of 5.2 years ( IQR 3.0-8.0), among 45,780 CAD patients (mean age [SD]: 62.8 ± 10.6 years; 23.9% female), the number of all-cause deaths was 7144(15.6%), and cardiovascular-related deaths was 3255 (7.1%). In cohorts with CKD, patients with high SHR had higher all-cause mortality (30.2% vs. 27.6%; adjusted hazard ratio HR 1.13, 95% CI 1.04-1.22; P = 0.003) and cardiovascular mortality (18.2% vs. 15.6%; HR adjusted 1.17, 95% CI 1.06-1.30; P = 0.002) compared to the individuals in low SHR. However, this was not the case in CAD cohorts without CKD [all-cause mortality (12.9% vs. 11.9%; HR adjusted 1.04, 95%CI 0.98-1.10, P = 0.206); cardiovascular mortality (5.1% vs. 4.4%; HR adjusted 1.09, 95%CI 0.99-1.20, P = 0.084)]. KM analysis revealed that high SHR is linked with all-cause mortality [CKD (log-rank P < 0.001); no-CKD (log-rank P = 0.024)] and cardiovascular mortality [CKD (log-rank P < 0.001); no-CKD (log-rank P = 0.01)] in CAD patients with or without CKD. RCS demonstrated that the relation between SHR and all-cause mortality was U-shaped after full modification, which was shown for CKD patients (P for non-linearity = 0.003) and also for patients without CKD (P for non-linearity = 0.001). Analogous effects were discovered for cardiovascular mortality, which was the case for CKD patients (P for non-linearity < 0.001) and also for patients without CKD (P for non-linearity = 0.001).

CONCLUSIONS

Among patients with CAD, an elevated stress hyperglycemia ratio (SHR) is implicated in a heightened risk of long-term outcomes, particularly in those with CKD. This signifies that SHR might have a latent function in the cardiovascular risk categorization of the CAD population.

Association between stress hyperglycemia ratio and mortality in patients with heart failure complicated by sepsis

Individuals afflicted with heart failure complicated by sepsis often experience a surge in blood glucose levels, a phenomenon known as stress hyperglycemia. However, the correlation between this condition and overall mortality remains unclear. 869 individuals with heart failure complicated by sepsis were identified from the Medical Information Mart for Intensive Care-IV (MIMIC-IV) database and categorized into five cohorts based on their stress hyperglycemia ratio (SHR). The primary endpoints evaluated were mortality within the intensive care unit (ICU), all-cause mortality within 28 days, and all-cause mortality during hospitalization. Cox proportional hazards regression and restricted cubic spline analyses were employed to unravel the association between SHR and mortality. The ICU mortality, in-hospital mortality, and 28-day all-cause mortality were 10.01%, 13.69%, and 16.46%, respectively. Multivariable Cox proportional hazards regression analysis revealed a significant association between elevated SHR and all-cause mortality. After adjusting for confounding variables, elevated SHR was significantly associated with increased risk of ICU mortality (hazard ratio [HR] = 1.67; 95% confidence interval [CI], 1.03-2.70)), in-hospital mortality (HR = 1.53; 95% CI, 1.00-2.33)), and 28-day all-cause mortality (HR = 1.49; 95% CI, 1.02-2.17)). Restricted cubic spline analysis demonstrated a significant U-shaped relationship between SHR and the risk of all-cause mortality. This study revealed that stress hyperglycemia ratio is an independent prognostic factor in patients with heart failure complicated by sepsis. Notably, both very high and very low SHR values were associated with increased mortality risk.

The association between acute kidney injury and dysglycaemia in critically ill patients with and without diabetes mellitus: a retrospective single-center study

BACKGROUND

Critically ill patients in the intensive care unit (ICU) often experience dysglycaemia. However, studies investigating the link between acute kidney injury (AKI) and dysglycaemia, especially in those with and without diabetes mellitus (DM), are limited.

METHODS

We used the Medical Information Mart for Intensive Care IV database to investigate the association between AKI within 7 days of admission and subsequent dysglycaemia. The primary outcome was the occurrence of dysglycaemia (both hypoglycemia and hyperglycemia) after 7 days of ICU admission. Logistic regression analyzed the relationship between AKI and dysglycaemia, while a Cox proportional hazards model estimated the long-term mortality risk linked to the AKI combined with dysglycaemia.

RESULTS

A cohort of 20,008 critically ill patients were included. The AKI group demonstrated a higher prevalence of dysglycaemia, compared to the non-AKI group. AKI patients had an increased risk of dysglycaemia (adjusted odds ratio [aOR] 1.53, 95% confidence interval [CI] 1.41-1.65), hypoglycemia (aOR 1.56, 95% CI 1.41-1.73), and hyperglycemia (aOR 1.53, 95% CI 1.41-1.66). In subgroup analysis, compared to DM patients, AKI showed higher risk of dysglycaemia in non-DM patients (aOR: 1.93 vs. 1.33, Pint<0.01). Additionally, the AKI with dysglycaemia group exhibited a higher risk of long-term mortality compared to the non-AKI without dysglycaemia group. Dysglycaemia also mediated the relationship between AKI and long-term mortality.

CONCLUSION

AKI was associated with a higher risk of dysglycaemia, especially in non-DM patients, and the combination of AKI and dysglycaemia was linked to higher long-term mortality. Further research is needed to develop optimal glycemic control strategies for AKI patients.

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 and clinical outcomes in patients with sepsis-associated acute kidney injury: a secondary analysis of the MIMIC-IV database

BACKGROUND

The stress hyperglycemia ratio (SHR) is associated with poor outcomes in critically ill patients. However, the relationship between SHR and mortality in patients with sepsis-associated acute kidney injury (SA-AKI) remains unclear.

METHODS

The data of patients with SA-AKI, identified based on the KDIGO criteria, were retrospectively collected from the Beth Israel Deaconess Medical Center between 2008 and 2019. SHR was calculated as follows: (glycemia [mmol/L]) / (1.59 × HbA1c [%] - 2.59). Primary outcomes were 30-day and 1-year mortality. The cumulative incidence of all-cause mortality was assessed using Kaplan-Meier survival analysis. Multivariable-adjusted logistic and Cox models and restricted cubic spline curves were used to analyze the correlation between SHR and all-cause mortality. Post-hoc subgroup analysis was performed to compare the effects of SHR across different subgroups.

RESULTS

1161 patients with SA-AKI were identified and categorized into four SHR quartiles as follows: Q1 (0.26, 0.90), Q2 (0.91, 1.08), Q3 (1.09, 1.30), and Q4 (1.31, 5.42). The median age of patients was 69 years, with 42.7% of the patients being women and 20.2% of the patients having chronic kidney disease. The 30-day and 1-year mortality were 22.1% and 35.0% respectively. Kaplan-Meier survival analysis indicated a gradual decrease in survival probability with increasing SHR quartiles. An increased SHR exhibited a strong correlation with 30-day mortality (hazard ratio [HR], 1.50; 95% confidence interval [CI], 1.18-1.90; P < 0.001) and 1-year mortality (HR, 1.32; 95% CI, 1.06-1.65; P = 0.014). SHR has a nonlinear relationship with 1-year mortality but not with 30-day mortality (P-nonlinear = 0.048 and 0.114, respectively). The results of subgroup analysis were mostly consistent with these findings.

CONCLUSION

An increased SHR is independently associated with 30-day and 1-year mortality in patients with SA-AKI. Therefore, SHR may serve as an effective tool for risk stratification in patients with SA-AKI.

The prognostic significance of stress hyperglycemia ratio for all-cause and cardiovascular mortality in metabolic syndrome patients: prospective cohort study

OBJECTIVE

The stress hyperglycemia ratio (SHR) is a new biomarker indicating acute hyperglycemia and predicting adverse outcomes in different conditions. Yet, its impact on metabolic syndrome (MetS) has not been studied. We explored the link between SHR and long-term all-cause and cardiovascular disease (CVD) mortality in MetS patients.

METHODS

We conducted a large prospective cohort study involving 9438 participants diagnosed with MetS, drawn from the 1999-2018 NHANES. MetS diagnosis was based on NCEP-ATPIII criteria. Participants were categorized into three groups based on SHR tertiles: T1 (SHR ≤ 0.890), T2 (SHR 0.890-0.992), and T3 (SHR ≥ 0.992). Cox regression and Kaplan-Meier curve analyses assessed the correlation between SHR and mortalities. Non-linear correlations were explored using restricted cubic splines, and stratification analysis was performed.

RESULTS

Out of 9438 MetS patients, 1929 deaths occurred during an average follow-up of 107 ± 64 months, including 541 CVD deaths. All-cause and CVD mortality rates were significantly higher with elevated SHR values (T3) than lower tertiles (23.4% vs. 19.5% and 18.3%, P < 0.001; 6.8% vs. 5.3% and 5.1%, P = 0.007, respectively). A U-shaped relationship was observed between SHR and all-cause and CVD mortality (all P for non-linear < 0.001). Kaplan-Meier analysis indicated higher SHR values associated with increased risk of all-cause and CVD mortality (all log-rank P < 0.001). After adjusting for confounders, multivariate Cox regression showed SHR remained associated with a 1.256-fold and 1.023-fold risk of all-cause and CVD mortality.

CONCLUSIONS

SHR independently correlates with all-cause and CVD mortality in MetS patients, displaying a U-shaped relationship with clinical endpoints.

Association of Stress Hyperglycemia Ratio and in-Hospital Mortality in Patients with Sepsis: A Two Center Retrospective Cohort Study

Introduction

In critically ill patients, the stress hyperglycemia ratio (SHR) was significantly associated with mortality. However, the relationship between SHR and mortality in septic patients is still unclear.In this study, patients with sepsis from two Chinese academic centers were identified and divided into quartiles based on SHR levels.

Methods

Multivariable regression analysis will be used to determine associations between SHR and clinical outcomes in sepsis patients.The Kaplan-Meier curve was used to predict mortality in various groups of septic patients.

Results

A total of 1835 septic patients were included in the study.The in-hospital, 30-day, and 60-day mortality rates for all septic patients were 22.8%, 18.7%, and 21.7%, respectively. Increased SHR was significantly associated with hospital mortality in multivariate regression analysis.These results were further confirmed in the adjusted analysis, where the hospital mortality and the 60-day mortality of the highest SHR quartile were significantly increased compared to the lowest SHR quartile. However, the highest SHR quartile was not associated with 30-day mortality.In addition, the risk of in-hospital mortality, 30-day mortality and 60-day mortality showed a consistent upward trend with increasing SHR quartile. The survival curve showed that the worst prognosis was in the fourth SHR quartile.

Discussion

In conclusion, SHR was significantly associated with hospital mortality in patients with sepsis. This finding indicates that the SHR may be useful in identifying septic patients at higher risk of hospital mortality.

What is the optimal range of fasting stress hyperglycemia ratio for all-cause mortality in American adults: An observational study

To date, no studies have been conducted to assess the impact of fasting stress hyperglycemia ratio (SHR) on all-cause mortality. Therefore, the objective of our study is to investigate the association between SHR and all-cause mortality in a population of American adults. The study population was derived from NHANES data spanning from 2005 to 2018. The exposure variable SHR was derived from fasting blood glucose (FBG) and glycosylated hemoglobin (HbA1c%), and the specific calculation formula was as follows: (FBG (mmol/L))/(1.59 × HbA1c (%) - 2.59). The outcome variable was all-cause mortality. A total of 18,457 participants were enrolled in this prospective cohort study. Following a median follow-up period of 90 months, all-cause mortality was observed in 10.32% of the subjects. Cox proportional hazards regression model indicates that there is no significant difference between SHR and all-cause mortality in the fully adjusted model, whether analyzed as a continuous or categorical variable (P for trend > 0.05). Through the 2-piecewise Cox proportional hazards regression model, we have determined that the inflection point of SHR in relation to all-cause mortality is 0.88. It has also been observed that when the value of SHR is on the left side of the inflection point (SHR ≤ 0.88), there is a significant 77% (HR: 0.23; 95% CI: 0.10-0.50) reduction in all-cause mortality for each additional unit increase in SHR. Conversely, when the value of SHR exceeds 0.88, there is a substantial 2.40-fold (HR: 2.40; 95% CI: 1.61-3.58) increase in the risk of all-cause mortality (P for log likelihood ratio test < .001). The subgroup analysis results demonstrate that sex has the potential to modify the association between SHR and all-cause mortality within the population exhibiting SHR ≤ 0.88. The relationship between SHR and all-cause mortality follows a U-shaped pattern, where in the lowest risk of death for the average American adult is observed at an SHR value of 0.88. Furthermore, in men with SHR ≤ 0.88, there is a significant inverse relationship between the increase in SHR and the risk of all-cause mortality.

Association between stress hyperglycemia ratio index and all-cause mortality in critically ill patients with atrial fibrillation: a retrospective study using the MIMIC-IV database

BACKGROUND

The stress hyperglycemia ratio (SHR) was developed to mitigate the influence of long-term chronic glycemic factors on stress hyperglycemia levels, which are associated with adverse clinical events, particularly cardiovascular events. However, studies examining the SHR index and its prognostic significance in patients with atrial fibrillation (AF) are lacking. This study aims to evaluate the relationship between the SHR index and all-cause mortality in critically ill patients with AF upon Intensive Care Unit admission.

METHODS

The patients' data were extracted from the Medical Information Mart for Intensive Care IV (MIMIC-IV) database. All patients were categorized into four groups based on the SHR index. The outcomes include both primary and secondary endpoints, with the primary endpoints being 30-day and 365-day all-cause mortality, and the secondary endpoints being 90-day and 180-day all-cause mortality. The SHR index was analyzed using quartiles, and the Kaplan-Meier curve was employed to compare the outcomes across groups. Cox proportional-hazards regression and restricted cubic splines (RCS) were used to assess the relationship between the SHR index and the outcomes.

RESULTS

Out of a total of 1,685 participants, the average age was 63.12 years (range: 40.17 to 101.49), with 1,004 (59.58%) being male. Higher levels of the SHR index were associated with an increased risk of all-cause mortality at 30 days, 90 days, 180 days, and 365 days, as indicated by the Kaplan-Meier curves (log-rank P < 0.01). Additionally, Cox proportional-hazards regression analysis revealed that the risk of mortality at these time points was significantly higher in the highest quartile of the SHR index. Restricted cubic splines (RCS) analysis demonstrated U-shaped relationships between the SHR index and all-cause mortality, with inflection points at 0.73 for 30-day mortality and 0.76 for 365-day mortality. Compared to patients with SHR levels below these inflection points, those with higher levels had a 69.9% increased risk for 30-day all-cause mortality (hazard ratio [HR] 1.699; 95% confidence interval [CI] 1.336 to 2.159) and a 61.6% increased risk for 365-day all-cause mortality (HR 1.616; 95% CI 1.345 to 1.942).

CONCLUSION

In critically ill patients with AF, higher levels of the SHR index are significantly associated with an increased risk of all-cause mortality at 30 days, 90 days, 180 days, and 365 days. The SHR index may serve as a valid indicator for assessing the severity and guiding the treatment of AF patients in the ICU.

Stress hyperglycemia is associated with poor prognosis in critically ill patients with cardiogenic shock

Background

Stress hyperglycemia is now more common in intensive care unit (ICU) patients and is strongly associated with poor prognosis. Whether this association exists in critically ill patients with cardiogenic shock (CS) is unknown. This study investigated the prognostic relationship of stress hyperglycemia on critically ill patients with CS.

Methods

We included 393 critically ill patients with CS from the MIMIC IV database in this study and categorized the patients into four groups based on quartiles of Stress hyperglycemia ratio (SHR). We assessed the correlation between SHR and mortality using restricted cubic spline analysis and Cox proportional hazards models. The primary outcomes observed were ICU mortality and hospitalization mortality.

Results

The mean age of the entire study population was 68 years, of which 30% were male (118 cases). There was no significant difference between the four groups in terms of age, gender, BMI, and vital signs (P>0.05). There was an increasing trend in the levels of lactate (lac), white blood cell count (WBC), glutamic oxaloacetic transaminase (AST), glucose and Hemoglobin A1C (HbA1c) from group Q1 to group Q2, with the greatest change in patients in group Q4 (P<0.05) and the patients in group Q4 had the highest use of mechanical ventilation, the longest duration of mechanical ventilation, ICU stay and hospital stay. After adjusting for confounders, SHR was found to be strongly associated with patient ICU mortality, showing a U-shaped relationship.

Conclusion

In critically ill patients with CS, stress hyperglycemia assessed by SHR was significantly associated with patient ICU mortality.

Association of Relative Dysglycemia With Hospital Mortality in Critically Ill Patients: A Retrospective Study

OBJECTIVES

Relative dysglycemia has been proposed as a clinical entity among critically ill patients in the ICU, but is not well studied. This study aimed to clarify associations of relative hyperglycemia and hypoglycemia during the first 24 hours after ICU admission with in-hospital mortality and the respective thresholds.

DESIGN

A single-center retrospective study.

SETTING

An urban tertiary hospital ICU.

PATIENTS

Adult critically ill patients admitted urgently between January 2016 and March 2022.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Maximum and minimum glycemic ratio (GR) was defined as maximum and minimum blood glucose values during the first 24 hours after ICU admission divided by hemoglobin A1c-derived average glucose, respectively. Of 1700 patients included, in-hospital mortality was 16.9%. Nonsurvivors had a higher maximum GR, with no significant difference in minimum GR. Maximum GR during the first 24 hours after ICU admission showed a J-shaped association with in-hospital mortality, and a mortality trough at a maximum GR of approximately 1.12; threshold for increased adjusted odds ratio for mortality was 1.25. Minimum GR during the first 24 hours after ICU admission showed a U-shaped relationship with in-hospital mortality and a mortality trough at a minimum GR of approximately 0.81 with a lower threshold for increased adjusted odds ratio for mortality at 0.69.

CONCLUSIONS

Mortality significantly increased when GR during the first 24 hours after ICU admission deviated from between 0.69 and 1.25. Further evaluation will necessarily validate the superiority of personalized glycemic management over conventional management.

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

BACKGROUND

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

METHODS AND MATERIALS

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

RESULTS

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

CONCLUSION

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

Association between stress hyperglycemia ratio and functional outcomes in patients with acute ischemic stroke

OBJECTIVE

This study aimed to evaluate the association between stress hyperglycemia ratio (SHR) and poor functional outcomes at 90 days in patients with acute ischemic stroke (AIS).

METHODS

This study retrospectively collected 1988 AIS patients admitted to two hospitals in the Shenzhen area between January 2022 and March 2023. A total of 1255 patients with Fasting Blood-glucose (FBG) and hemoglobin A1c (HbA1C) values at admission were included in this analysis. SHR, measured by FBG/HbA1C, was evaluated as both a tri-categorical variable (Tertile 1: ≤ 0.83; Tertile 2: 0.84 -0.95; Tertile 3: ≥ 0.96). The outcome was poor functional outcomes (modified Rankin Scale [mRS] score 2-6) at 90 days. We performed univariate analysis, multiple equation regression analysis, stratified analysis, and interactive analysis.

RESULTS

Compared with patients in the lowest tertile of SHR, the highest tertile group had significantly lower odds of achieving poor functional outcomes (adjusted odds ratio, OR = 2.84, 95% CI: 2.02-3.99, P < 0.0001) at 90 days after adjusting for potential covariates. Similar results were observed after further adjustment for white blood cell count, neutrophil count, lymphocyte count, fasting blood glucose, stroke type, intravenous thrombolytic therapy, baseline Glasgow score, and baseline NIHSS score.

CONCLUSION

SHR, as measured by the FBG/HbA1C, was associated with an increased odds of achieving poor functional outcomes in patients with AIS at 90 days.

Relationship between stress hyperglycemia ratio and prognosis in patients with aneurysmal subarachnoid hemorrhage: a two-center retrospective study

Previous research have demonstrated that the stress hyperglycemia ratio (SHR) accurately reflects acute hyperglycemic states and correlates with adverse outcomes. This study aims to explore the relationship between SHR and the prognosis of patients with aneurysmal subarachnoid hemorrhage (aSAH). Patients with aSAH were categorized into four groups based on SHR tertiles. Functional outcomes were evaluated at 12 months using the modified Rankin Scale (mRS), with scores ranging from 0 to 2 indicating a good outcome and 3-6 indicating a poor outcome. The associations between SHR and functional outcomes were analyzed using logistic regression models and restricted cubic spline analysis. A total of 127 patients exhibited poor functional outcomes. Following comprehensive adjustments, those in the highest SHR tertile had a significantly increased risk of poor prognosis compared to those in the lowest tertile (odds ratio [OR], 4.12; 95% confidence interval [CI]: 1.87-9.06). Moreover, each unit increase in SHR was associated with a 7.51-fold increase in the risk of poor prognosis (OR, 7.51; 95% CI: 3.19-17.70). Further analysis using restricted cubic spline confirmed a linear correlation between SHR and poor prognosis (P for nonlinearity = 0.609). Similar patterns were observed across all studied subgroups. Elevated SHR significantly correlates with poor functional prognosis at one year in patients with aSAH, independent of their diabetes status.

Nutritional Prescription in ICU Patients: Does it Matter?

Background

The nutritional status of the patients before critical illness and nutrition support given during the critical illness play an important role in the recovery. We aimed to evaluate the nutritional prescription and its effect on ICU mortality.

Materials and methods

This was a prospective observational study conducted after institutional ethical committee approval (IEC 94/2018, CTRI/2018/06/014625) in a case-mixed (medical and surgical) ICU. Patients admitted to the ICU were enrolled within 24 hours of admission. The amount of calories and proteins prescribed and received by the patients was collected for 7 days. The primary outcome was ICU mortality.

Results

A total of 100 patients were included. The mean age was 48.63 (16.25) years, and 62% were males. The acute physiology and chronic health evaluation (APACHE II), sequential organ failure assessment (SOFA), and modified Nutric (mNUTRIC) scores were comparable between the two groups. The ICU mortality was 30%. The calorie and protein deficits were comparable between survivors and non-survivors. Among the secondary outcomes, a significant time effect (p = 0.013) and interaction effect (p = 0.004) were noted for maximum glucose levels. The glucose variability calculated by coefficient of variation (CV) was significantly higher in non-survivors than survivors (p = 0.031).

Conclusion

The calorie and protein deficits did not affect ICU mortality. The maximum glucose variability and CV were significant parameters associated with ICU mortality.

How to cite this article

Havaldar AA, Selvam S. Nutritional Prescription in ICU Patients: Does it Matter? Indian J Crit Care Med 2024;28(7):657-661.

J-shaped relationship between stress hyperglycemia ratio and 90-day and 180-day mortality in patients with a first diagnosis of acute myocardial infarction: analysis of the MIMIC-IV database

AIMS

The Stress Hyperglycemia Ratio (SHR) potently predicts adverse outcomes in patients with cardiovascular and cerebrovascular diseases. However, the relationship between SHR and short-term mortality risk in patients with a first diagnosis of acute myocardial infarction (AMI) remains contentious. This study sought to understand better the relationship between SHR and short-term mortality risk in patients with a first diagnosis of AMI.

METHODS

We conducted a cohort study using data from 1961 patients with a first diagnosis of AMI from the MIMIC-IV (version 2.2) database. Patients were divided into three groups based on SHR tertiles. The Cox proportional hazards model and a two-segmented Cox proportional hazards model were used to elucidate the nonlinear relationship between SHR in patients with a first diagnosis of AMI and mortality.

RESULTS

Of the surveyed population, 175 patients (8.92%) died within 90 days, and 210 patients (10.71%) died within 180 days. After multivariate adjustments, elevated SHR levels were significantly and non-linearly associated with a higher risk of 90-day and 180-day mortality in patients with a first diagnosis of AMI, showing a J-shaped correlation with an inflection point at 0.9. Compared to participants with SHR levels below the inflection point, those with higher SHR levels had a fivefold increased risk of 90-day mortality (hazard ratio [HR] 5.74; 95% confidence interval [CI] 3.19, 10.33) and a fourfold increased risk of 180-day mortality (HR 4.56; 95% CI 2.62, 7.95). In the subgroup analysis, patients with pre-diabetes mellitus (pre-DM) and higher SHR levels had increased 90-day (HR 6.90; 95% CI  1.98, 24.02) and 180-day mortality risks (HR 5.30; 95% CI  1.96, 14.27).

CONCLUSION

In patients with a first diagnosis of AMI, there is a J-shaped correlation between SHR and 90-day and 180-day mortality, with an adverse prognostic inflection point of SHR at 0.9.

Association between the stress hyperglycemia ratio and 28-day all-cause mortality in critically ill patients with sepsis: a retrospective cohort study and predictive model establishment based on machine learning

BACKGROUND

Sepsis is a severe form of systemic inflammatory response syndrome that is caused by infection. Sepsis is characterized by a marked state of stress, which manifests as nonspecific physiological and metabolic changes in response to the disease. Previous studies have indicated that the stress hyperglycemia ratio (SHR) can serve as a reliable predictor of adverse outcomes in various cardiovascular and cerebrovascular diseases. However, there is limited research on the relationship between the SHR and adverse outcomes in patients with infectious diseases, particularly in critically ill patients with sepsis. Therefore, this study aimed to explore the association between the SHR and adverse outcomes in critically ill patients with sepsis.

METHODS

Clinical data from 2312 critically ill patients with sepsis were extracted from the MIMIC-IV (2.2) database. Based on the quartiles of the SHR, the study population was divided into four groups. The primary outcome was 28-day all-cause mortality, and the secondary outcome was in-hospital mortality. The relationship between the SHR and adverse outcomes was explored using restricted cubic splines, Cox proportional hazard regression, and Kaplan‒Meier curves. The predictive ability of the SHR was assessed using the Boruta algorithm, and a prediction model was established using machine learning algorithms.

RESULTS

Data from 2312 patients who were diagnosed with sepsis were analyzed. Restricted cubic splines demonstrated a "U-shaped" association between the SHR and survival rate, indicating that an increase in the SHR is related to an increased risk of adverse events. A higher SHR was significantly associated with an increased risk of 28-day mortality and in-hospital mortality in patients with sepsis (HR > 1, P < 0.05) compared to a lower SHR. Boruta feature selection showed that SHR had a higher Z score, and the model built using the rsf algorithm showed the best performance (AUC = 0.8322).

CONCLUSION

The SHR exhibited a U-shaped relationship with 28-day all-cause mortality and in-hospital mortality in critically ill patients with sepsis. A high SHR is significantly correlated with an increased risk of adverse events, thus indicating that is a potential predictor of adverse outcomes in patients with sepsis.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The prognostic value of the stress hyperglycemia ratio for all-cause and cardiovascular mortality in patients with diabetes or prediabetes: insights from NHANES 2005-2018

BACKGROUND

The Stress hyperglycemia ratio (SHR) is a novel marker reflecting the true acute hyperglycemia status and is associated with clinical adverse events. The relationship between SHR and mortality in patients with diabetes or prediabetes is still unclear. This study aimed to investigate the predictive value of the SHR for all-cause and cardiovascular mortality in patients with diabetes or prediabetes.

METHODS

This study included 11,160 patients diagnosed with diabetes or prediabetes from the National Health and Nutrition Examination Survey (2005-2018). The study endpoints were all-cause and cardiovascular mortality, and morality data were extracted from the National Death Index (NDI) up to December 31, 2019. Patients were divided into SHR quartiles. Cox proportion hazards regression was applied to determine the prognostic value of SHR. Model 1 was not adjusted for any covariates. Model 2 was adjusted for age, sex, and race. Model 3 was adjusted for age, sex, race, BMI, smoking status, alcohol use, hypertension, CHD, CKD, anemia, and TG.

RESULTS

During a mean follow-up of 84.9 months, a total of 1538 all-cause deaths and 410 cardiovascular deaths were recorded. Kaplan-Meier survival analysis showed the lowest all-cause mortality incidence was in quartile 3 (P < 0.001). Multivariate Cox regression analyses indicated that, compared to the 1st quartile, the 4th quartile was associated with higher all-cause mortality (model 1: HR = 0.89, 95% CI 0.74-10.7, P = 0.226; model 2: HR = 1.24, 95% CI 1.03-1.49, P = 0.026; model 3: HR = 1.30, 95% CI 1.08-1.57, P = 0.006). The 3rd quartile was associated with lower cardiovascular mortality than quartile 1 (model 1: HR = 0.47, 95% CI 0.32-0.69, P < 0.001; model 2: HR = 0.66, 95% CI 0.45-0.96, P = 0.032; model 3: HR = 0.68, 95% CI 0.46-0.99, P = 0.049). There was a U-shaped association between SHR and all-cause mortality and an L-shaped association between SHR and cardiovascular mortality, with inflection points of SHR for poor prognosis of 0.87 and 0.93, respectively.

CONCLUSION

SHR is related to all-cause and cardiovascular mortality in patients with diabetes or prediabetes. SHR may have predictive value in those patients.

Fibrinogen-to-Albumin Ratio and Glucose Metabolic States in Patients With Coronary Heart Disease

This study investigated the relationship between fibrinogen-to-albumin ratio (FAR) and glucose metabolic state in patients with coronary heart disease (CHD). A total of 52,062 patients were enrolled in this study. Patients were classified according to FAR tertiles (T1: FAR < 0.0073; T2: 0.0073 ≤ FAR ≤ 0.0886; T3: FAR ≥ 0.0887). Patients were also classified into the normal glucose regulation (NGR) and elevated blood glucose (EBG) groups. The relationship between FAR and EBG was analyzed using logistic regression, and the association was evaluated according to sex and age. Among the participants, 32,471 (62.4%) had EBG, which was positively associated with FAR (odds ratio [OR], 1.19; 95% confidence interval [CI] 1.15-1.23). The OR of the FAR for EBG in males was higher than that in females (1.25; 95% CI 1.18-1.33 vs 1.15; 95% CI 1.10-1.20). Moreover, the OR of FAR for EBG was greater in patients aged 60 or younger (OR: 1.25; 95% CI 1.18-1.33) than in the elderly patients (over 60 years of age) (OR: 1.15; 95% CI 1.10-1.20). The results indicated a significant relationship between FAR and EBG and this association was higher in males and middle-aged patients.

Prognostic significance of the stress hyperglycemia ratio in critically ill patients

BACKGROUND

The stress hyperglycemia ratio (SHR) has demonstrated a noteworthy association with unfavorable cardiovascular clinical outcomes and heightened in-hospital mortality. Nonetheless, this relationship in critically ill patients remains uncertain. This study aims to elucidate the correlation between SHR and patient prognosis within the critical care setting.

METHODS

A total of 8978 patients admitted in intensive care unit (ICU) were included in this study. We categorized SHR into uniform groups and assessed its relationship with mortality using logistic or Cox regression analysis. Additionally, we employed the restricted cubic spline (RCS) analysis method to further evaluate the correlation between SHR as a continuous variable and mortality. The outcomes of interest in this study were in-hospital and 1-year all-cause mortality.

RESULTS

In this investigation, a total of 825 (9.2%) patients experienced in-hospital mortality, while 3,130 (34.9%) individuals died within the 1-year follow-up period. After adjusting for confounding variables, we identified a U-shaped correlation between SHR and both in-hospital and 1-year mortality. Specifically, within the SHR range of 0.75-0.99, the incidence of adverse events was minimized. For each 0.25 increase in the SHR level within this range, the risk of in-hospital mortality rose by 1.34-fold (odds ratio [OR]: 1.34, 95% CI: 1.25-1.44), while a 0.25 decrease in SHR within 0.75-0.99 range increased risk by 1.38-fold (OR: 1.38, 95% CI: 1.10-1.75).

CONCLUSION

There was a U-shaped association between SHR and short- and long-term mortality in critical ill patients, and the inflection point of SHR for poor prognosis was identified at an SHR value of 0.96.