Faculty of Medicine, Department of Metabolism, Digestion and Reproduction, Imperial Centre for Translational and Experimental Medicine, Imperial College London, London, UK.
Faculty of Medicine, National Heart and Lung Institute, Imperial College London, London, UK.
Cardiovasc Diabetol. 2024 Nov 16;23(1):412. doi: 10.1186/s12933-024-02454-1.
A raised stress hyperglycaemia ratio (SHR) has been associated with all-cause mortality and may better discriminate than an absolute glucose value. The aim of this meta analysis and systematic review is to synthesise the evidence assessing the relationship between the SHR and all-cause mortality across three common cardiovascular presentations.
We undertook a comprehensive search of Medline, Embase, Cochrane CENTRAL and Web of Science from the date of inception to 1st March 2024, and selected articles meeting the following criteria: studies of patients hospitalised for acute myocardial infarction, ischaemic stroke or acute heart failure reporting the risk (odds ratio or hazard ratio) for all-cause mortality associated with the SHR. A random effects model was used for primary analysis. Subgroup analysis by diabetes status and of mortality in the short and long term was undertaken. Risk of bias assessment was performed using the Newcastle Ottawa quality assessment scale.
A total of 32 studies were included: 26 studies provided 31 estimates for the meta-analysis. The total study population in the meta analysis was 80,010. Six further studies were included in the systematic review. Participants admitted to hospital with cardiovascular disease and an SHR in the highest category had a significantly higher risk ratio of all-cause mortality in both the short and longer term compared with those with a lower SHR (RR = 1.67 [95% CI 1.46-1.91], p < 0.001). This finding was driven by studies in the myocardial infarction (RR = 1.75 [95% CI 1.52-2.01]), and ischaemic stroke cohorts (RR = 1.78 [95% CI 1.26-2.50]). The relationship was present amongst those with and without diabetes (diabetes: RR 1.49 [95% CI 1.14-1.94], p < 0.001, no diabetes: RR 1.85 [95% CI 1.49-2.30], p < 0.001) with p = 0.21 for subgroup differences, and amongst studies that reported mortality as a single outcome (RR of 1.51 ([95% CI 1.29-1.77]; p < 0.001) and those that reported mortality as part of a composite outcome (RR 2.02 [95% CI 1.58-2.59]; p < 0.001). On subgroup analysis by length of follow up, higher SHR values were associated with increased risk of mortality at 90 day, 1 year and > 1year follow up, with risk ratios of 1.84 ([95% CI 1.32-2.56], p < 0.001), 1.69 ([95% CI 1.32-2.16], p < 0.001) and 1.58 ([95% CI 1.34-1.86], p < 0.001) respectively.
A raised SHR is associated with an increased risk of all-cause mortality following myocardial infarction and ischaemic stroke. Further work is required to define reference values for the SHR, and to investigate the potential effects of relative hypoglycaemia. Interventional trials targeting to the SHR rather than the absolute glucose value should be undertaken.
CRD 42023456421 https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023456421.
升高的应激性高血糖比值（SHR）与全因死亡率相关，并且可能比绝对血糖值更具判别能力。本荟萃分析和系统评价的目的是综合评估三种常见心血管表现中 SHR 与全因死亡率之间的关系的证据。
我们从成立日期到 2024 年 3 月 1 日，全面搜索了 Medline、Embase、Cochrane CENTRAL 和 Web of Science，并选择了符合以下标准的文章：报告急性心肌梗死、缺血性卒中和急性心力衰竭住院患者的 SHR 与全因死亡率相关的风险（优势比或风险比）的研究。主要分析采用随机效应模型。根据糖尿病状态和短期及长期死亡率进行了亚组分析。使用纽卡斯尔-渥太华质量评估量表进行了偏倚风险评估。
共纳入 32 项研究：26 项研究提供了 31 项荟萃分析结果。荟萃分析的总研究人群为 80010 人。另外还有 6 项研究纳入了系统评价。与 SHR 较低的患者相比，心血管疾病住院且 SHR 处于最高类别的患者在短期和长期内全因死亡率的风险比显著更高（RR=1.67[95%CI 1.46-1.91]，p<0.001）。这一发现主要来自心肌梗死（RR=1.75[95%CI 1.52-2.01]）和缺血性卒中队列（RR=1.78[95%CI 1.26-2.50]）的研究。在有和没有糖尿病的患者中都存在这种关系（糖尿病：RR 1.49[95%CI 1.14-1.94]，p<0.001，无糖尿病：RR 1.85[95%CI 1.49-2.30]，p<0.001），p=0.21 为亚组差异，并且在报告单一结局的研究（RR 为 1.51[95%CI 1.29-1.77]；p<0.001）和报告复合结局的研究（RR 为 2.02[95%CI 1.58-2.59]；p<0.001）中均存在这种关系。根据随访时间的亚组分析，更高的 SHR 值与 90 天、1 年和>1 年随访时的死亡率增加相关，风险比分别为 1.84[95%CI 1.32-2.56]，p<0.001、1.69[95%CI 1.32-2.16]，p<0.001 和 1.58[95%CI 1.34-1.86]，p<0.001。
SHR 升高与心肌梗死和缺血性卒中后全因死亡率的增加相关。需要进一步研究来确定 SHR 的参考值，并研究相对低血糖的潜在影响。应开展针对 SHR 而不是绝对血糖值的干预性试验。
PROSPERO 数据库注册：CRD42023456421 https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023456421.
