Association of the stress hyperglycemia ratio and clinical outcomes in patients with stroke: A systematic review and meta-analysis

Abstract

ObjectiveStress hyperglycemia (SH) is common in patients with acute diseases, such as stroke and myocardial infarction. Stress hyperglycemia ratio (SHR) is calculated by glucose/glycated hemoglobin and has been widely used for evaluating SH. But whether SHR is associated with clinical outcomes in stroke patients remains unclear so far. Although many studies have shown that higher SHR means poor outcomes, there is still no absolute evidence that SHR plays a critical role in stroke patients. Hence, we performed a systematic review and meta-analysis aiming to investigate the association between SHR and clinical outcomes in stroke patients.MethodsWe performed a comprehensive literature search of the PubMed, Embase, Cochrane Library databases, Clinicaltrials.gov, and WHO-ICTRP. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), we performed our study. The Newcastle-Ottawa Scale (NOS) tool was used to examine the potential bias of included studies. The endpoints including poor outcome, mortality, neurological deficit, hemorrhagic transformation (HT), and infectious complications were statistically analyzed.ResultsSixteen retrospective studies met the eligibility criteria, and a number of 183,588 patients were included. Our meta-analysis demonstrated a significant increase in the incidence of poor outcome, according to assessment by the modified Rankin Scale (mRS) ≥ 3 points [odds ratio (OR) 2.53, 95% confidence interval (CI) 1.99–3.22, P < 0.00001, I2 = 68%], mortality (OR 1.96, 95% CI 1.58–2.44, P < 0.00001, I2 = 61%), neurological deficit (OR 1.99, 95% CI 1.47–2.70, P < 0.00001, I2 = 75%), hemorrhagic transformation (HT) (OR 3.70, 95% CI 2.69–5.08, P < 0.00001, I2 = 0%), and infectious complications [(Pneumonia) OR 2.06, 95% CI 1.57–2.72, P < 0.00001, I2 = 24%; (Urinary tract infection) OR 2.53, 95% CI 1.45–4.42, P = 0.001, I2 = 57%] in stroke patients with higher SHR. However, no significant influence was observed for recanalization rate (OR 0.86, 95% CI 0.54–1.38, P = 0.53, I2 = 0%).ConclusionWith or without diabetes, no matter whether undergoing intravenous thrombolysis or mechanical thrombectomy, higher SHR significantly increased the occurrence of poor outcomes, mortality, neurological deficit, HT, and infectious complications. The recanalization rate was not statistically significant between the two groups. More attention must be paid in clinical practice to SH. Future investigation should focus on the diagnostic value of SHR and the early control of hyperglycemia. Meanwhile, whether SHR could become a novel and promising target for early intervention is worthy of attention in further research. Besides, the influence of the dynamic change of glucose-to-HbA1c ratio, namely SHR, on intracerebral hemorrhage outcomes requires further investigation in future research. Although no randomized double-blind studies have been conducted, the available massive sample studies reflect the actual situation in the clinic and assist clinical decision makers.Systematic review registrationhttps://www.crd.york.ac.uk/prospero/, identifier: CRD42022345587.

The association between neutrophil counts and neutrophil-to-lymphocyte ratio and stress hyperglycemia in patients with acute ischemic stroke according to stroke etiology

“…SHR, defined as FBG/HbA1c ratio, was used to represent the state of stress hyperglycemia. SHR was associated with functional outcome, complications, HT, and stroke recurrence in AIS patients (9,18,36). Although the pathogenic mechanisms are not so clear, it was proposed that hyperactivated stress could trigger BBB breakdown, oxidative stress response, inflammation and cytokine release in stroke (19).…”

“…A number of studies used the stress hyperglycemia ratio (SHR) as a tool to evaluate stress hyperglycemia (15,16). Moreover, many studies have been found that SHR is associated with poor prognosis in AIS patients (17)(18)(19). Recent evidence revealed that elevated SHR was a clinical predictor of stroke-associated pneumonia (9).…”

Fasting blood glucose-to-glycated hemoglobin ratio for evaluating clinical outcomes in patients with ischemic stroke

“…Although a range of evidence suggests that stress hyperglycemia is a marker of poor outcomes in patients with AIS ( 14 – 21 ), this relationship is controversial when stroke severity is considered in further analysis ( 8 ). However, a recent meta-analysis found that stress hyperglycemia could reflect the extent of ischemic damage and lead to poor clinical outcomes in patients with stroke ( 22 ). This finding was consistent with part of our results that stress hyperglycemia is more common in patients with severe stroke, similar to that observed in a previous study ( 23 ).…”

Association of the systemic immune-inflammation index (SII) and clinical outcomes in patients with stroke: A systematic review and meta-analysis

“…2) Intervention: mechanical thrombectomy, intravenous thrombolysis, or none of the above. 3) Comparisons: relative low SII vs. relative high SII, and the grouping definition is the same as our previous study ( 12 ). 4) Outcomes: the mRS ≥ 3 points or > 3 points at follow-up was defined as poor outcome, and we categorized stroke severity as NIHSS≥ 5 points.…”