Hyperglycemia Reveals Mortality Risk In Hospitalized Stroke Victims
Overview
The study aimed to assess various indicators of stress-induced hyperglycemia in predicting in-hospital outcomes for patients with acute intracerebral hemorrhage (ICH). Utilizing data from the Chinese Stroke Center Alliance database, which encompasses a large, nationwide cohort, the researchers examined stress-induced hyperglycemia through two metrics: glycemic gap (GG) and stress hyperglycemia ratio (SHR), specifically SHR 1 (FBG-to-estimated average blood glucose ratio) and SHR 2 (FBG-to-HbA1c ratio).
Among the 71,333 patients with acute ICH included in the analysis, multivariate analyses revealed that elevated levels of GG, SHR 1, and SHR 2 were significantly associated with higher in-hospital mortality rates, indicating their potential as prognostic markers. Specifically, the highest level of SHR 2 demonstrated the strongest association with both in-hospital death and hematoma expansion, suggesting its utility as an indicator for assessing prognosis in ICH cases.
Moreover, the areas under the ROC curve demonstrated the discriminatory power of GG, SHR 1, and SHR 2 for predicting in-hospital mortality, with all three metrics exhibiting strong performance in this regard. Additionally, SHR 2 showed promise as a predictor of hematoma expansion, further underscoring its potential clinical utility in assessing outcomes for patients with acute ICH.
In conclusion, the study highlights the significance of SHR, particularly SHR 2 (FBG-to-HbA1c ratio), as a valuable adjunctive indicator for predicting in-hospital outcomes in acute intracerebral hemorrhage cases. These findings contribute to a better understanding of stress-induced hyperglycemia’s role in ICH prognosis and may aid clinicians in risk stratification and treatment decision-making for affected patients.
Introduction
The study delves into the complex relationship between hyperglycemia and acute intracerebral hemorrhage (ICH), a form of stroke known for its high mortality rates and poor prognosis. Hyperglycemia, often observed in acute ICH cases, can arise from various factors, including poorly managed diabetes or physiological responses to acute medical conditions. However, stress-induced hyperglycemia, characterized by transiently elevated glucose levels due to neuroendocrine stress responses, is of particular interest due to its potential impact on patient outcomes.
Traditional methods of measuring stress-induced hyperglycemia, such as random plasma glucose or fasting blood glucose (FBG) levels, have limitations. These methods may not fully account for a patient’s glycemic control status at the time of disease onset, leading to a lack of precision in assessing the influence of stress-induced hyperglycemia on outcomes. Moreover, absolute glucose levels may not accurately reflect the relative increase in glucose associated with physiological stress.
To address these challenges, the study proposes the use of two biomarkers: the stress hyperglycemia ratio (SHR) and the glycemic gap (GG). These biomarkers aim to distinguish between a patient’s normal background glycemia and the acute rise in glucose levels triggered by physiological stress. By providing a more nuanced understanding of stress-induced hyperglycemia, SHR and GG offer a potentially more accurate assessment of its impact on patient outcomes in acute ICH cases.
Previous research has shown associations between SHR, GG, and unfavorable outcomes in ICH. However, the comparative effectiveness of these biomarkers in predicting outcomes remains unclear. Therefore, the study seeks to address this gap by comparing the projected values of SHR and GG concerning in-hospital outcomes in acute ICH cases.
By elucidating the relative performance of SHR and GG in outcome prediction, the study aims to provide valuable insights into the role of stress-induced hyperglycemia in acute ICH. This knowledge could inform more targeted prognostic strategies and treatment interventions tailored to the specific needs of individuals affected by acute ICH, ultimately improving patient care and outcomes in this challenging medical condition.
Method
The Chinese Stroke Center Alliance study represents a comprehensive nationwide effort to understand acute stroke and transient ischemic attack (TIA) patients’ characteristics and outcomes across China. Spanning from 2015 to 2019, this prospective cohort enrolled patients from a vast network of 1,476 hospitals, encompassing secondary and tertiary care centers. Spearheaded by the Chinese Stroke Association with guidance from the National Center of Neurological Diseases Care Management, the study was facilitated by the Clinical Research Center for Neurological Disease at Beijing Tiantan Hospital, Capital Medical University.
A meticulous approach was taken to ensure data integrity and patient confidentiality. The study, conducted in alignment with the principles of the 1964 Declaration of Helsinki, involved anonymized data collection, obviating the need for individual consent.
Baseline characteristics, vital for understanding patient demographics and clinical profiles, were meticulously captured using a web-based data collection tool. Key parameters such as age, sex, medical history (including hypertension, diabetes mellitus, dyslipidemia, and prior stroke), clinical data (e.g., blood pressure, stroke severity scores), and laboratory results (including fasting blood glucose and glycated hemoglobin levels) were rigorously recorded.
The study’s primary outcomes centered on in-hospital mortality and hematoma expansion (HE), with rigorous radiographic criteria defining the latter. Additionally, stress-induced hyperglycemia (SIH) was assessed using innovative metrics such as glycemic gap (GG) and stress hyperglycemia ratio (SHR), leveraging fasting blood glucose and HbA1c measurements.
Statistical analyses, utilizing SAS software, were employed to discern associations and predictors of outcomes. Logistic regression models, systematically adjusted for confounding factors, provided insights into the odds ratios and confidence intervals associated with outcomes. Receiver operating characteristic (ROC) curves were utilized to gauge the predictive value of SIH metrics.
The study’s findings, grounded in robust methodology and extensive data analysis, hold promise for informing clinical practice and guiding future research endeavors in stroke management. By elucidating the nuances of acute stroke and its determinants, this study contributes valuable insights to the broader landscape of stroke care and prevention in China and beyond.
Result
The study analyzed data from 71,333 patients with acute intracerebral hemorrhage (ICH) from a comprehensive database. Among them, 2.1% experienced in-hospital death, and 8.3% had hematoma expansion (HE). The average age was 63.0 ± 12.8 years, with 62.4% being male.
Comparing survivors to nonsurvivors and those with HE to without HE revealed several significant associations. Nonsurvivors tended to be older, male, with higher blood pressure, more severe neurological deficits on admission, and a history of comorbidities such as diabetes, dyslipidemia, and stroke. They were more likely to smoke, consume alcohol, and use certain medications. Similar patterns were observed between patients with and without HE.
The study examined stress-induced hyperglycemia indicators (GG, SHR 1, and SHR 2) and their association with in-hospital outcomes. Higher levels of these indicators were significantly associated with increased risk of in-hospital death, with the strongest association observed for SHR 2. Similar associations were found for HE, particularly with the highest quartile of SHR 2.
When assessing the predictive value of these indicators, they demonstrated good discriminatory ability for in-hospital mortality, with area under the curve (AUC) values ranging from 0.8806 to 0.8808. SHR 2 also showed moderate predictive ability for HE, with an AUC of 0.7133.
These findings highlight the potential utility of stress-induced hyperglycemia indicators as prognostic markers for adverse outcomes in acute ICH patients. Further research may elucidate their clinical applicability and refine risk prediction models in this population.
Conclusion
In this study, researchers delved into the intricate relationship between stress-induced hyperglycemia (SIH) and in-hospital outcomes among patients experiencing acute intracerebral hemorrhage (ICH). They aimed to discern how different indicators of SIH might influence the prognosis of these patients, specifically focusing on the risk of in-hospital death and hematoma enlargement (HE). By comparing various SIH indicators, they sought to identify the most reliable predictors of adverse outcomes in this patient population.
The findings illuminated a compelling association between elevated levels of glycemic gap (GG), stress hyperglycemia ratio 1 (SHR 1), and stress hyperglycemia ratio 2 (SHR 2) with in-hospital death among acute ICH patients. Moreover, SHR 2 exhibited a unique correlation with HE, indicating its potential as a prognostic marker for this complication. These results underscored the importance of vigilant monitoring for patients presenting with GG ≥ 0.8 mmol/l, SHR 1 ≥ 1.14, or SHR 2 ≥ 1.26, as they may face heightened risks of mortality or adverse events during hospitalization.
A significant aspect of the study was the emphasis on using HbA1c-based adjusted indicators of SIH, such as GG and SHR, to provide a more nuanced assessment of the in-hospital prognosis for acute ICH patients. Of particular interest was the utility of SHR, calculated by dividing fasting blood glucose levels by HbA1c, which emerged as a comprehensive indicator associated with both in-hospital death and HE. This approach addressed the limitations of relying solely on absolute glucose levels, offering a more accurate evaluation by considering baseline glycemic status.
Previous research has often overlooked the importance of adjusting for baseline glycemic status when assessing SIH and its impact on patient outcomes. By incorporating relative measurements of SIH, adjusted for HbA1c, this study shed light on the predictive value of indicators like SHR, providing valuable insights into the prognosis of acute ICH patients.
The study’s comprehensive analysis compared the efficacy of different SIH indicators, including GG, SHR 1, and SHR 2, in predicting adverse outcomes among acute ICH patients. While all three indicators were associated with in-hospital mortality, SHR 2 emerged as a particularly promising predictor for HE as well. This nuanced understanding of SIH and its implications for patient outcomes highlighted the multifaceted nature of this condition and underscored the need for tailored approaches to patient management.
Despite the study’s significant contributions, certain limitations were acknowledged, such as its observational nature, lack of long-term outcome data, and the absence of glycemic variability assessment during hospitalization. These limitations underscored the need for further research to validate the findings and explore the long-term implications of SIH in acute ICH patients.
In conclusion, the study provided valuable insights into the complex interplay between SIH and in-hospital outcomes among acute ICH patients. By elucidating the predictive value of HbA1c-adjusted SIH indicators like SHR, the study offered a more nuanced understanding of patient prognosis and underscored the importance of tailored approaches to patient management in this population. Further research is warranted to validate these findings and explore their implications for long-term patient outcomes.
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