The added prognostic value of stress induced hyperglycemia to the GRACE risk score for the prediction of 1-year major adverse cardiovascular events in patients with ST-elevation myocardial infarction
Authors: Stalikas N , Karagiannidis E , Papazoglou Α , Panteris E , Didagelos M , Ziakas A , Vasilikos V , Giannakoulas G , Giannopoulos G 
Published: November 2023

Abstract

Background
There is growing evidence suggesting that Stress Induced Hyperglycemia (SIH) is a risk factor of poor prognosis in acute coronary syndrome (ACS)[1–3]. However, this parameter is not included in risk prediction scores, applied in clinical practice. Ιmportantly, there is no universally accepted definition for SIH especially in the setting of ACS. Across the existing evidence base, SIH is defined either based on admission blood glucose (ABG) levels or by calculating the glycemic gap and the stress hyperglycemia ratio (SHR)[4].

Purpose
Considering the variability in SIH definitions and the need for further investigation on the long-term prognostic impact of SIH, we present herein original data concerning the prognostic role of SIH for long-term risk of major adverse cardiovascular and cerebrovascular events (MACCEs) in patients presenting with ST-elevation myocardial infarction (STEMI) on top of a traditional prediction risk score such as the GRACE 2.0 risk score.

Methods
Our data were derived from a post-hoc analysis of a prospective study (NCT04580173). Every trial procedure was conducted according to the principles set by the declaration of Helsinki. Each participant provided written informed consent before being enrolled in the study. Our analysis included 309 consecutive STEMI patients who were diagnosed with SIH if ABG was &gt; 140 mg/dl and a fasting period of at least 8 hours was confirmed. Each participant was followed-up for a median 1-year period. Baseline characteristics of the included patients are presented in Table 1. The records of all enrolled patients were retrospectively analyzed to calculate the GRACE 2.0 risk score for each patient.

Results
Cox regression analysis adjusted for age, gender, body mass index (BMI), hypertension, smoking, and SIH was performed but did not identify GRACE risk score&gt;140 as an independent predictor of MACCE (aHR=1.408, 95% CI:0.764-2.594 p=0.273, Figure 1). On the other hand, a similar model adjusted for the same covariates identified the combination of GRACE risk score&gt;140 and SIH as a significant predictor of MACCE occurrence (aHR=2.149, 95% CI:1.224-3.771, p=0.008).

Conclusions
Our results suggest that SIH combined with the GRACE 2.0 risk score was associated with improved prediction of the risk for 1-year MACCE in STEMI patients as compared to the GRACE 2.0 risk score alone. In this study, SIH was diagnosed based on the levels of admission blood glucose (after 8-hours of fasting) and not based on the SHR. Despite the heterogeneity in SIH definitions, stress hyperglycemia in the setting of STEMI might be an underrated yet robust prognostic marker not only for short term but also for long term adverse clinical events, especially when integrated in existing clinical risk scores.Survival curveBaseline characteristics