MON-298 - Prognostic Value of Stress Hyperglycemia Ratio in Diabetic Patients with Acute Coronary Syndromes: A Systematic Review

Background:
Stress hyperglycemia reflects acute neurohormonal and inflammatory activation during acute coronary syndromes (ACS). The stress hyperglycemia ratio (SHR), defined as the ratio of admission or fasting glucose to estimated average glucose derived from HbA1c, quantifies relative glycemic stress while accounting for baseline glycemic control. SHR may outperform absolute glucose values for risk stratification, yet its prognostic relevance in diabetic patients with ACS or coronary artery disease (CAD) has not been systematically synthesized.

Objective:
To evaluate the association between SHR and adverse clinical outcomes in patients with diabetes mellitus presenting with ACS, acute myocardial infarction (AMI), or CAD.

Methods:
A systematic review was conducted in accordance with PRISMA guidelines using PubMed, Embase, Scopus, and Google Scholar through January 2026. Eligible studies included adult patients with diabetes and ACS, AMI, or CAD reporting outcomes stratified by SHR. Outcomes included all-cause and cardiovascular mortality, major adverse cardiovascular and cerebrovascular events (MACCE), and acute kidney injury (AKI). Adjusted effect estimates and prognostic performance metrics (C-statistic, net reclassification index [NRI]) were extracted. Due to methodological heterogeneity, findings were synthesized narratively.

Results:
Seven cohort and registry studies comprising approximately 19,000 patients were included. Higher SHR was consistently associated with increased risk of adverse outcomes, including in-hospital mortality, MACCE, AKI, and long-term all-cause and cardiovascular mortality. Compared with the lowest SHR categories, patients with the highest SHR demonstrated adjusted hazard ratios of approximately 1.7–2.5 for mortality and major events, independent of demographics, comorbidities, left ventricular function, ACS severity, and HbA1c. Incorporation of SHR into established prognostic models modestly but significantly improved discrimination (ΔC-statistic +0.01–0.03) and reclassification (NRI 0.10–0.18). SHR performed comparably or superior to admission glucose alone. Mechanistic evidence suggests that elevated SHR reflects acute metabolic stress associated with systemic inflammation, endothelial dysfunction, and myocardial injury. Incremental long-term prognostic value appeared to attenuate beyond the acute phase.

Conclusion:
Among patients with diabetes presenting with ACS or CAD, elevated SHR is independently associated with adverse outcomes and provides incremental prognostic value beyond traditional glycemic markers. SHR represents a practical marker of acute metabolic stress that may enhance early risk stratification. Prospective studies are warranted to determine whether SHR-guided interventions improve clinical outcomes.

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