Association of stress hyperglycemia ratio and in-hospital mortality in patients with coronary artery disease: insights from a large cohort study

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Abstract

Background

Stress hyperglycemia is strongly associated with poor clinical outcomes in patients with acute coronary syndrome (ACS). Recently, the stress hyperglycemia ratio (SHR) has been proposed to represent relative hyperglycemia. Studies regarding the relationship between SHR and mortality in coronary artery disease (CAD) are limited. This study aimed to clarify the association between SHR and in-hospital mortality in patients with CAD.

Methods

A total of 19,929 patients with CAD who were hospitalized in Beijing Hospital were enrolled in this study. Patients with an estimated glomerular filtration rate < 30 ml/min, cancer, or missing blood glucose/HbA1c data were excluded; therefore, 8,196 patients were included in the final analysis. The patients were divided into three groups based on tertiles of SHR: T1 group (SHR < 0.725, n = 2,732), T2 group (0.725 ≤ SHR < 0.832, n = 2,730), and T3 group (SHR ≥ 0.832, n = 2,734). The primary endpoint was in-hospital mortality.

Results

The overall in-hospital mortality rate was 0.91% (n = 74). After adjusting for covariates, SHR was significantly associated with in-hospital mortality in patients with CAD [odds ratio (OR) = 17.038; 95% confidence interval (CI) = 9.668–30.027; P < 0.001], and the T3 group had a higher risk of in-hospital mortality (OR = 4.901; 95% CI = 2.583–9.297; P < 0.001) compared with T1 group. In the subgroup analysis, the T3 group had an increased risk of mortality among patients with pre-diabetes mellitus (pre-DM) (OR = 9.670; 95% CI = 1.886–49.571; P = 0.007) and diabetes mellitus (DM) (OR = 5.023; 95% CI = 2.371–10.640; P < 0.001) after adjustments for covariates. The relationship between SHR and in-hospital mortality among patients with ACS and chronic coronary syndrome was consistent with the main finding. SHR and in-hospital mortality exhibited a dose-response relationship, and the risk of in-hospital mortality increased when the SHR index was above 1.20. Moreover, the area under the curve of SHR for predicting in-hospital mortality in patients with CAD was 0.741.

Conclusion

SHR is significantly associated with in-hospital mortality in patients with CAD. SHR may be an effective predictor of in-hospital mortality in patients with CAD, especially for those with pre-DM and DM.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12933-022-01645-y.

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Most cited references 29

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Equations to estimate glomerular filtration rate (GFR) are routinely used to assess kidney function. Current equations have limited precision and systematically underestimate measured GFR at higher values. To develop a new estimating equation for GFR: the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation. Cross-sectional analysis with separate pooled data sets for equation development and validation and a representative sample of the U.S. population for prevalence estimates. Research studies and clinical populations ("studies") with measured GFR and NHANES (National Health and Nutrition Examination Survey), 1999 to 2006. 8254 participants in 10 studies (equation development data set) and 3896 participants in 16 studies (validation data set). Prevalence estimates were based on 16,032 participants in NHANES. GFR, measured as the clearance of exogenous filtration markers (iothalamate in the development data set; iothalamate and other markers in the validation data set), and linear regression to estimate the logarithm of measured GFR from standardized creatinine levels, sex, race, and age. In the validation data set, the CKD-EPI equation performed better than the Modification of Diet in Renal Disease Study equation, especially at higher GFR (P < 0.001 for all subsequent comparisons), with less bias (median difference between measured and estimated GFR, 2.5 vs. 5.5 mL/min per 1.73 m(2)), improved precision (interquartile range [IQR] of the differences, 16.6 vs. 18.3 mL/min per 1.73 m(2)), and greater accuracy (percentage of estimated GFR within 30% of measured GFR, 84.1% vs. 80.6%). In NHANES, the median estimated GFR was 94.5 mL/min per 1.73 m(2) (IQR, 79.7 to 108.1) vs. 85.0 (IQR, 72.9 to 98.5) mL/min per 1.73 m(2), and the prevalence of chronic kidney disease was 11.5% (95% CI, 10.6% to 12.4%) versus 13.1% (CI, 12.1% to 14.0%). The sample contained a limited number of elderly people and racial and ethnic minorities with measured GFR. The CKD-EPI creatinine equation is more accurate than the Modification of Diet in Renal Disease Study equation and could replace it for routine clinical use. National Institute of Diabetes and Digestive and Kidney Diseases.

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Stress hyperglycaemia.

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Results of randomised controlled trials of tight glycaemic control in hospital inpatients might vary with population and disease state. Individualised therapy for different hospital inpatient populations and identification of patients at risk of hyperglycaemia might be needed. One risk factor that has received much attention is the presence of pre-existing diabetes. So-called stress hyperglycaemia is usually defined as hyperglycaemia resolving spontaneously after dissipation of acute illness. The term generally refers to patients without known diabetes, although patients with diabetes might also develop stress hyperglycaemia-a fact overlooked in many studies comparing hospital inpatients with or without diabetes. Investigators of several studies have suggested that patients with stress hyperglycaemia are at higher risk of adverse consequences than are those with pre-existing diabetes. We describe classification of stress hyperglycaemia, mechanisms of harm, and management strategies.

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Oscillating glucose is more deleterious to endothelial function and oxidative stress than mean glucose in normal and type 2 diabetic patients.

P Ihnat, Massimo Boemi, Kevin Thorpe … (2008)

To explore the possibility that oscillating glucose may outweigh A1C levels in determining the risk for cardiovascular diabetes complications. A euinsulinemic hyperglycemic clamp at 5, 10, and 15 mmol/l glucose was given in increasing steps as a single "spike" or oscillating between basal and high levels over 24 h in normal subjects and type 2 diabetic patients. Flow-mediated dilatation, a marker of endothelial function, and plasma 3-nitrotyrosine and 24-h urinary excretion rates of free 8-iso PGF2 alpha, two markers of oxidative stress, were measured over 48 h postclamp. Glucose at two different levels (10 and 15 mmol/l) resulted in a concentration-dependent fasting blood glucose-independent induction of both endothelial dysfunction and oxidative stress in both normal and type 2 diabetic patients. Oscillating glucose between 5 and 15 mmol/l every 6 h for 24 h resulted in further significant increases in endothelial dysfunction and oxidative stress compared with either continuous 10 or 15 mmol/l glucose. These data suggest that oscillating glucose can have more deleterious effects than constant high glucose on endothelial function and oxidative stress, two key players in favoring cardiovascular complications in diabetes. Concomitant vitamin C infusion can reverse this impairment.

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Author and article information

Contributors

Yatong Zhang: 750826140@qq.com

Fang Wang: bjh_wangfang@163.com

Journal

Journal ID (nlm-ta): Cardiovasc Diabetol

Journal ID (iso-abbrev): Cardiovasc Diabetol

Title: Cardiovascular Diabetology

Publisher: BioMed Central (London )

ISSN (Electronic): 1475-2840

Publication date (Electronic): 19 October 2022

Publication date PMC-release: 19 October 2022

Publication date Collection: 2022

Volume: 21

Electronic Location Identifier: 217

Affiliations

[1 ]GRID grid.415105.4, ISNI 0000 0004 9430 5605, Emergency Center, State Key Laboratory of Cardiovascular Disease of China, National Center for Cardiovascular Diseases, National Clinical Research Center of Cardiovascular Diseases, , Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, ; 100037 Beijing, China

[2 ]GRID grid.506261.6, ISNI 0000 0001 0706 7839, Hypertension Center, State Key Laboratory of Cardiovascular Disease of China, National Center for Cardiovascular Diseases of China, , Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, ; 100037 Beijing, China

[3 ]GRID grid.506261.6, ISNI 0000 0001 0706 7839, Department of Cardiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, , Chinese Academy of Medical Sciences, ; Beijing, China

[4 ]GRID grid.506261.6, ISNI 0000 0001 0706 7839, Graduate School of Peking Union Medical College, , Chinese Academy of Medical Sciences, ; Beijing, China

[5 ]GRID grid.506261.6, ISNI 0000 0001 0706 7839, Department of Pharmacy, Institute of Geriatric Medicine, , Beijing Hospital, National Center of Gerontology, Chinese Academy of Medical Sciences, Beijing Key Laboratory of Assessment of Clinical Drugs Risk and Individual Application (Beijing Hospital), ; Beijing, China

[6 ]GRID grid.506261.6, ISNI 0000 0001 0706 7839, Department of Information Center, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, , Chinese Academy of Medical Sciences, ; Beijing, China

Article

Publisher ID: 1645

DOI: 10.1186/s12933-022-01645-y

PMC ID: 9580448

PubMed ID: 36261839

SO-VID: 276a4a97-86ce-422e-980f-784c130d8cca

License:

Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

History

Date received : 21 August 2022

Date accepted : 26 September 2022

Funding

Funded by: National Key R&D Program of China

Award ID: 2020YFC2009000

Award ID: 2020YFC2008100

Custom metadata

ScienceOpen disciplines: Endocrinology & Diabetes

Keywords: coronary artery disease,diabetes,mortality,stress hyperglycemia,stress hyperglycemia ratio

Data availability:

ScienceOpen disciplines: Endocrinology & Diabetes

Keywords: coronary artery disease, diabetes, mortality, stress hyperglycemia, stress hyperglycemia ratio

Association of stress hyperglycemia ratio and in-hospital mortality in patients with coronary artery disease: insights from a large cohort study

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Abstract

Background

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Results

Conclusion

Supplementary Information

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Bioscientifica Open Endocrinology

Most cited references 29

A new equation to estimate glomerular filtration rate.

Stress hyperglycaemia.

Oscillating glucose is more deleterious to endothelial function and oxidative stress than mean glucose in normal and type 2 diabetic patients.

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