Stress hyperglycemia ratio and long-term clinical outcome in patients with acute coronary syndrome

Abstract Background Stress hyperglycemia is strongly associated with adverse prognosis in patients with acute coronary syndrome (ACS). Recently, the stress hyperglycemia ratio (SHR- relationship between acute/chronic glycemic values) has been proposed as a better measurement of stress hyperglycemia. Studies on SHR and long-term clinical outcome in ACS are limited. This study aimed to clarify the association between SHR and 3-year adverse clinical events in patients with ACS. Methods We analyzed data of 795 patients admitted to our center for ACS who were enrolled in the PRATO-ACS Registry (ClinicalTrials.gov ID: NCT04087200) and underwent laboratory analyses 1 month after the index event. All patients had undergone early invasive strategy and received high intensity statins during hospitalization and at discharge. Patients were stratified in baseline SHR tertiles: < 0.95, ≥ 0.95 to < 1.17 and ≥ 1.17. The primary end point was 3-year all cause death; secondary end points were major adverse clinical events (MACE) including all-cause death, myocardial infarction or congestive heart failure. The association between SHR and outcome measures was evaluated with Cox proportional analysis expressed by hazard ratio (HR) and 95% confidence intervals (CI). Results With increasing SHR, there was a significant progressive increase in mortality (4.2, 8.3, and 11.7% in the 1st, 2nd, and 3rd tertile, respectively, p= 0.006) and MACE (10.6, 14, and 20.8% in the 1st, 2nd, and 3rd tertile, respectively, p=0.004). Multivariable analysis shows that SHR was an independent predictor of 3-year all-cause death (HR 1.65, 95% CI 1.12-2.4; p= 0.012). Subgroup analysis evidenced that the relationship between SHR and mortality was statistically significant only for patients with poor glycemic control at 1 month follow up (HR 3.4, 95% CI 1.14-10.9, p= 0.02 in the 2nd tertile and HR 3.9, 95% CI 1.3-11.8, p= 0.015 in the 3rd tertile). Conclusion Baseline SHR is significantly associated with 3-year all-cause death and MACE in patients with ACS. However, its prognostic impact is much stronger in patients who do not achieve desired glycemic targets at 1 month after the index event. Therefore, insistent attention to glycemic values is mandatory in ACS patients even after discharge.