The role of SHR in risk stratification for long-term prognosis in patients with coronary artery disease: findings from a large cohort study.

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 (ACS). However, the long-term prognostic significance of SHR in a broader population of coronary artery disease (CAD) remains unclear. This study aimed to explore the role of SHR in prediction of long-term prognosis of CAD. Methods: In this cohort study, we enrolled 23,591 participants diagnosed with CAD from January, 2016, to December, 2021 in Beijing Hospital. After excluding patients lacking data, with cancers, or missing follow-ups, 7,162 patients were finally enrolled into the analyses. The SHR was calculated using the following equation: SHR = admission glucose (mmol/L)/(1.59 × HbA1c [%]-2.59). The 7,162 participants were divided into three groups based on SHR tertiles: Tertile 1 (SHR ≤ 0.72, n=2391), Tertile 2 (0.73≤SHR ≤ 0.82, n=2388), and Tertile 3 group (SHR≥0.83, n=2383). The primary endpoint was all-cause mortality and cardiovascular death (CVD), while the second endpoint was major adverse cardiovascular events (MACE). The median follow-up was 28 months. Results: Our results suggest that SHR was significantly associated with increased risks of long-term all-cause death, CVD death, and MACE. The Kaplan-Meier curves revealed that the highest tertile (T3) group had the highest risk of all-cause death, CVD death, and MACE, while the lowest tertile (T1) group had the lowest risk (all log-rank P < 0.05). After adjusting risk factors, the results of cox regression analyses showed that SHR was significantly associated with all three outcomes (all P < 0.05). For all-cause death, SHR was associated with an increased risk of all-cause death in the fully adjusted model (Model 3: HR = 2.52, 95% CI: 1.57 - 4.05, P < 0.001). Compared to the lowest tertile (T1), participants in the highest tertile (T3) had a likely higher risk of all-cause death (HR = 1.40, 95% CI: 1.05 - 1.87, P = 0.021). SHR also demonstrated a positive association with CVD death (Model 3: HR = 2.87, 95% CI: 1.22 - 6.76, P = 0.016), and participants in T3 had a significantly higher risk of CVD death compared to T1 (HR = 1.94, 95% CI: 1.11 - 3.40, P = 0.021). Additionally, SHR was also independently associated with MACE (Model 3: HR = 1.70, 95% CI: 1.21 - 2.38, P = 0.002). The risk of MACE was significantly higher in T3 compared to T1 (HR = 1.21, 95% CI: 1.02 - 1.45, P = 0.031). The restricted cubic spline (RCS) analysis further confirmed a positive nonlinear association between SHR and these adverse outcomes (all-cause death, CVD death, and MACE) and exhibited a J-shaped curve. Conclusions: SHR is significantly associated with long-term all-cause death, CVD death, and MACE in CAD patients. Our findings highlight SHR can be used as a valuable tool for long-term prognosis risk stratification in CAD, potentially influencing clinical decision-making and patient management strategies.