Elevated Stress Hyperglycemia Ratio Linked to Higher All-Cause Mortality After Cardiovascular Events

Elevated stress hyperglycemia ratio (SHR) levels significantly increased the risk of all-cause mortality after cardiovascular events in both short- and long-term follow-ups, according to one study.¹

Evidence highlights the predictive value of the stress hyperglycemia ratio (SHR) for mortality risk in patients with acute myocardial infarction, ischemic stroke, and acute heart failure. | Image credit: Ngampol - stock.adobe.com

These insights pave the way for potential interventions targeting SHR as a key tool in improving outcomes for patients with cardiovascular events.

The comprehensive meta-analysis is published in Cardiovascular Diabetology.

“Our findings suggest that an elevated SHR is associated with risk of all-cause mortality in people admitted to hospital with an acute myocardial infarction or acute ischemic stroke,” wrote the researchers of the study. “Whilst a similar trend was seen for people admitted with heart failure, this was not significant.”

Stress hyperglycemia is a common condition in critically ill patients and appears to be a marker of disease severity.² Although some clinicians, researchers, and policy makers believe this association to be causal, leading to the widespread adoption of protocols to achieve tight in-hospital glycemic control, literature has demonstrated that such attempts in both intensive care unit (ICU) and non-ICU patients do not improve health care outcomes.

In this study, the researchers aimed to assess the relationship between the SHR and all-cause mortality across 3 common cardiovascular presentations: acute myocardial infarction, ischemic stroke, and acute heart failure.¹

A comprehensive search of MEDLINE, Embase, Cochrane CENTRAL, and Web of Science was conducted from inception through March 1, 2024. Search terms focused on acute myocardial infarction, ischemic stroke, heart failure, SHR, relative hyperglycemia, and mortality. Eligible studies included longitudinal designs that reported risk ratios (RRs) or odds ratios (ORs) of all-cause mortality in relation to SHR, measured within the first 24 hours of hospital admission for the 3 conditions in adults. Studies using fasting glucose for SHR calculation, those involving hemorrhagic stroke patients, and non-English publications were excluded.

A total of 32 studies met inclusion criteria, comprising 26 studies with 31 estimates for meta-analysis and 6 additional studies for the systematic review. The meta-analysis encompassed a total population of 80,010 participants. Patients hospitalized with cardiovascular disease and an elevated SHR in the highest category showed a significantly increased risk of all-cause mortality compared with those with lower SHR levels (RR, 1.67; 95% CI, 1.46-1.91; P < .001). This association was particularly pronounced in studies focusing on myocardial infarction (RR, 1.75; 95% CI, 1.52-2.01) and ischemic stroke (RR,1.78; 95% CI, 1.26-2.50).

The elevated mortality risk was observed in both diabetic (RR, 1.49; 95% CI, 1.14-1.94; P < .001) and nondiabetic populations (RR, 1.85; 95% CI, 1.49-2.30; P < .001), with no significant difference between these subgroups (P = .21). Higher SHR values were associated with increased mortality risk in studies reporting mortality as a single outcome (RR, 1.51; 95% CI, 1.29-1.77; P < .001) and those including it as part of a composite outcome (RR, 2.02; 95% CI, 1.58-2.59; P < .001).

Furthermore, subgroup analysis by follow-up duration revealed that elevated SHR was linked to higher mortality risk at 90 days (RR, 1.84; 95% CI, 1.32-2.56; P < .001), 1 year (RR, 1.69; 95% CI, 1.32-2.16; P < .001), and beyond 1 year (RR, 1.58; 95% CI, 1.34-1.86; P < .001).

The researchers noted limitations to the study. First, the study utilized observational data, meaning causality could not be established. Second, although all studies used glucose values taken at admission or within 24 hours, the varying methods for calculating estimated average glucose for the SHR denominator could have impacted measurement accuracy. Lastly, treatment modalities were not adjusted for across all studies, which may have influenced the results.

Despite these limitations, the researchers believe the study identified that elevated SHR is associated with risk of all-cause mortality among those admitted to a hospital with an acute myocardial infarction or acute ischemic stroke.

“Future work is required to characterize further the SHR measurement, to investigate the impact of relative hypoglycemia, to evaluate any potential for the inclusion of the SHR measurement in cardiovascular risk stratification, and to investigate the SHR as a therapeutic target,” wrote the researchers.

References

1. Esdaile H, Khan S, Mayet J, et al. The association between the stress hyperglycemia ratio and mortality in cardiovascular disease: a meta-analysis and systematic review. Cardiovasc Diabetol. 2024;23(1):412. doi:10.1186/s12933-024-02454-1

2. Steinzor P. Stress hyperglycemia ratio linked with all-cause mortality in patients with psoriasis. AJMC^®. November 7, 2024. Accessed November 19, 2024. https://www.ajmc.com/view/stress-hyperglycemia-ratio-linked-with-all-cause-mortality-in-patients-with-psoriasis