# Predictive value of exercise-induced hyperglycemia ratio in patients with acute ST-segment elevation myocardial infarction: insights from a multicenter observational study | Cardiovascular diabetes

### The basic characteristics

A total of 5417 patients with acute STEMI were included in the final analysis. The median age of the study population was 65 (54–72) years and 1641 (30.9%) patients were female.

Patients were divided into three groups according to SHR tertiles (Fig. 1). Table 1 shows the basic characteristics of the study population according to SHR tertiles. Older age, female gender, hypertension, diabetes, and history of stroke were most common in the highest tertile (SHR3 group). Lower blood pressure, higher heart rate, higher Killip classes and higher TIMI risk score were also more likely in the SHR3 group than in the other groups. ABG values were higher, while HbA1c levels were lower, in the SHR3 group than in the other two groups.

### Clinical outcomes by SHR tertiles and diabetes status

During the 30 days of follow-up, a total of 1547 MACE (28.6%) occurred, while 789 all-cause deaths (14.6%) occurred. As shown in Table 2, compared to the SHR1-2 group, the SHR3 group had an increased incidence of MACE and all-cause mortality in analyzes covering the total study population, those with DM, and those without DM (p

The study population was classified into six subgroups for further analysis: SHR1 with and without DM, SHR2 with and without DM and SHR3 with and without DM. Figure 2 shows the incidence of MACE in the different groups. The incidence of MACE was highest (42.6%) in the SHR3 + DM group. Interestingly, the incidence of MACE in the SHR3 + non-DM group was even higher than that in the SHR2 + DM group (36.2% versus 33.4%). The Kaplan-Meier curves shown in Fig. 3 (A) indicate that patients with acute STEMI and DM had a higher risk of MACE than their counterparts in the non-DM group (p = 0.004). As shown in Fig. 3 (B), the SHR3 group had the highest risk of MACE (p

Univariate Cox regression models suggested that the SHR3 group had a 1.694-fold increased risk of MACE (HR: 1.694, 95% CI 1.532-1.873) and a 1.936-fold increased risk of death from all causes ( HR: 1.936, 95% CI 1.647–2.276) compared to the SHR1-2 group (all p

After adjusting for risk factors including age, SBP, HR, Killip’s classification, DS, hypertension, angina, weight, anterior ST-segment elevation or LBBB and time to treatment > 4 h, SHR3 was always associated with an increased risk of MACE and all-cause mortality (all p

### Predictive value of SHR in DM and non-DM groups

Figure 4A shows the unadjusted Cox regression models. In the analysis of the total study population, each 1-SD change in GBS was associated with a 5.6% increase in MACE risk, while each 1-SD increase in SHR was associated to a 41.0% increased risk of MACE overall. population (all p

In multivariate Cox regression models adjusted for age, SBP, HR, Killip classification, SD, hypertension, angina, weight, anterior ST-segment elevation, or LBBB, time to treatment > 4 h, C statistic values for MACE were 0.765 (0.750–0.781), 0.755 (0.724–0.785) and 0.770 (0.752–0.788) for total population, DM group and non-DM group, respectively (Table 3). Additionally, the C statistic improved significantly when SHR3 was added to the original model; the ΔC statistics (95% CI) were 0.008 (0.000–0.013) for the total population, 0.010 (0.003–0.017) for the DM group and 0.007 (0.002–0.013) for the non-DM group, respectively (all p

In the subgroup analysis, there were no interactions between the DM subgroups (odds ratio [OR] for SHR: 1.620; 95% CI: 1.254–2.093) and non-DM subgroup (OR for SHR, 1.538; 95% CI, 1.334–1.773) with the impact of SHR on MACE (p for interaction = 0.354) (Supplementary File 1 Table S2).

### Predictive power of the TIMI risk score considering SHR3 as 1 point

In the ROC analysis, the AUC of the baseline TIMI risk score for all-cause death in the total study population was 0.760 (Table 5). When SHR3 was used to replace history of DM, hypertension, or angina in the original TIMI risk score at a value of 1 point, Delong’s test suggested that AUC improved significantly in the total population and in the DM subgroup (∆AUC 0.009 and 0.010, respectively, all p 0.05).