Key result
Diabetes without other SMuRFs is linked to up to ~40% higher 30-day mortality post-ACS.
Why the study?
Patients without standardized modifiable risk factors paradoxically experience higher mortality following ACS, prompting evaluation of the independent impact of diabetes on post-ACS mortality and how grouping it with other risk factors might obscure its effect.
Does diabetes independently increase 30-day mortality in first-time ACS patients compared to those without any standardized modifiable risk factors?
Cohort (n=70,953)
Does diabetes independently increase 30-day mortality in first-time ACS patients compared to those without any standardized modifiable risk factors?
Diabetes independently increases 30-day mortality risk after ACS, but this risk is masked by dilution bias when aggregated with other standardized modifiable risk factors.
Diabetes without other SMuRFs was associated with higher 30-day post-ACS mortality; challenges prior SMuRF-negative assumptions and requires prospective confirmation.
Background Individuals without standardized modifiable risk factors (SMuRF), which implicitly include those with diabetes, have been paradoxically reported to experience higher mortality following acute coronary syndromes (ACS). We aim to clarify the independent impact of diabetes on 30-day mortality after ACS and explore how grouping it with other SMuRF might obscure its true effect. Methods We analyzed 70,953 first-time ACS patients using inverse probability weighting to adjust for potential confounding. Mortality within 30 days post-ACS was the primary outcome.1 Results Diabetic patients without other SMuRF showed a significantly higher 30-day mortality compared with those without any SMuRF, with relative risks (RRs) of 1.29 for women (95% CI, 1.06-1.57) and 1.40 for men (95% CI, 1.16-1.69). When diabetes was combined with other SMuRF, its impact on mortality was diluted. Diabetic patients who were also smokers had RRs of 1.39 in women (95% CI, 0.92-2.09) and 0.89 in men (95% CI, 0.68-1.17), those with hypercholesterolemia had RRs of 0.91 in women (95% CI, 0.66-1.25) and 0.75 in men (95% CI, 0.53-1.06) and those with hypertension showed RRs of 1.14 in women (95% CI, 0.99-1.32) and 1.12 in men (95% CI, 0.96-1.31). Conclusions Diabetes independently increases 30-day mortality risk in ACS. Aggregating it with other SMuRF masks this risk due to dilution bias, highlighting the need for individualized risk factor assessment strategies.
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Cenko et al. (2026) conducted a cohort in Acute coronary syndromes (n=70,953). Diabetes without other SMuRF vs. No SMuRF was evaluated on Mortality within 30 days post-ACS (RR 1.29 (women), RR 1.40 (men), 95% CI 1.06-1.57 (women), 1.16-1.69 (men)). Diabetes without other standardized modifiable risk factors independently increased 30-day mortality post-ACS compared to having no such risk factors (RR 1.29 in women, 1.40 in men).
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