The role of SHR in risk stratification for long-term prognosis in patients with coronary artery disease

Abstract Background Recently, the Stress Hyperglycemia Ratio (SHR) — which integrates acute increases in blood glucose with long-term glycemic control levels — has shown independent predictive value for adverse events in patients with acute coronary syndrome(1, 2). However, the prognostic significance of SHR in a broader population of coronary artery disease (CAD) remains unclear, and there is a gap in evidence on its role in stratifying long-term prognosis. This study aims to evaluate the predictive efficacy of SHR for long-term prognosis in CAD patients through a large-scale cohort analysis. Purpose This study aimed to explore the role of SHR in prediction of long-term prognosis of CAD. Methods In this cohort study, 23,591 participants diagnosed with CAD were included, from January, 2016, to December, 2021. All participants were followed up for at least one year, with the maximum follow-up period extending to four years. Patients lacking glucose or HbA1c measurements (n=14,103), diagnosed with cancers (n=1,625), and those missing follow-ups were excluded from this study. Finally, 7,162 patients were enrolled into the analyses. The SHR was calculated using the following equation: SHR = admission glucose (mmol/L)/(1.59 × HbA1c %-2.59). The 7,126 participants were divided into three groups based on SHR tertiles: Tertile1 group (SHR ≤ 0.72, n = 2391), Tertile2 group (0.72 0.82, n = 2383). The primary endpoint is all-cause mortality, while the second endpoint is cardiovascular death. This study utilized Restricted Cubic Splines (RCS) to evaluate the impact of SHR on the risk of all-cause and cardiovascular death in patients with CAD, and used Kaplan-Meier curves to assess the role of SHR in prognostic risk stratification among these patients. Results The RCS curve in Figure 1A illustrates that the relationship between SHR and all-cause mortality is an L-shaped curve, indicating that the hazard ratio (HR) for all-cause mortality elevates as the SHR increases, highlighting a significant rise in risk with higher values. Similar to the relationship of SHR and all-cause mortality, Figure 1B also shows a positive correlation between SHR and cardiovascular death. In addition, the Kaplan-Meier curves in Figure 2 illustrates the cumulative hazard for all-cause mortality and cardiovascular disease mortality during 48 months, with significant differences observed among different SHR groups (T1, T2, T3). CAD patients in the SHR-T3 group had the highest risk for all-cause and cardiovascular mortality, followed by the T2 group, with the T1 group having the lowest risk (p 0.001) Conclusions SHR is significantly associated with worse long-term prognosis in CAD patients, with the T3 group exhibiting the highest risk for both all-cause and cardiovascular mortality. Our findings highlight SHR can be used as a valuable marker for long-term prognosis risk stratification in CAD, and may potentially influence clinical decision-making and management strategies.RCS Curves of SHR on Risk of Mortality Cumulative Hazard of Mortality by SHR