Performance comparison of stress hyperglycemia ratio for predicting fatal outcomes in patients with thrombolyzed acute ischemic stroke

The authors have no conflicts of interest directly relevant to the content of this article.

Stroke is a prevalent neurological condition and a primary global cause of death, resulting in

approximately 6 million annual fatalities [1].Stroke is the leading cause of death in Thailand, accounting for over 250,000 new cases and 50,000 annual fatalities [2].  Recombinant tissue plasminogen activator (rt-PA) is recommended as a safe and effective treatment [3]. Elevated blood sugar in 40-50%of acute stroke patients may exacerbate ischemic injury through heightened oxidative stress, endothelial dysfunction, and impaired fibrinolysis, resulting in larger infarctions, worse clinical outcomes, and increased mortality rates.[4-5]. Stress hyperglycemia (SH) refers to transient hyperglycemia in the context of illness accompanied by diabetes mellitus (DM) or non-DM. Recently, Roberts et al. [6] introduced the

stress hyperglycemia ratio (SHR) to evaluate SH. Hemoglobin A1c (HbA1c), a stable indicator, was used to assess glycemic management in DM patients over three months. SHR is calculated by dividing the admission glucose concentration by the estimated average glucose concentration derived from HbA1c [7]. Different studies employed the glucose/HbA1c ratio to define SHR, aiming for its practical use in clinical settings [8-10].

Poor outcomes and symptomatic intracerebral hemorrhage (sICH) in acute ischemic stroke (AIS) patients treated with rt-PA were associated with hyperglycemia. According to the American Diabetes Association, patients were classified as DM, newly diagnosed DM, or experiencing transient hyperglycemia during hospitalization. The definition of SH remains unclear, but an abrupt increase in plasma glucose levels above the average blood glucose level serves as a reliable indicator [6,11]. Two types of biological markers for SH, SHR and glycemic gap (GG), have been developed to represent SH [11]. Recently, the SHR, a ratio of plasma glucose level to HbA1c, has emerged as a prognostic biomarker for poor outcomes in AIS patients receiving rt-PA treatment.

Although different SHR equations effectively predicted unfavorable outcomes or critical illness in AIS patients [12], the optimal threshold of SHR for assessing SH and predicting fatal outcomes (in-hospital mortality [IHM], malignant

cerebral edema [MCE], and sICH) has not been definitively confirmed.  Limited data currently exists regarding the

comparative predictive value of various types of SHR, GG, absolute plasma glucose, and HbA1c in predicting fatal outcomes in AIS patients treated with rt-PA. Hence, this study aims to explore the predictive performance, optimal thresholds, and association between these variables in predicting fatal outcomes.

Lab Protocol Article Template Stress hyperglycemia ratio.pdf