Admission Random Blood Glucose, Fasting Blood Glucose, Stress Hyperglycemia Ratio, and Functional Outcomes in Patients With Acute Ischemic Stroke Treated With Intravenous Thrombolysis

Abstract

Background: Stress hyperglycemia ratio (SHR), calculated as glucose/glycated hemoglobin, has recently been developed for assessing stress hyperglycemia and could provide prognostic information for various diseases. However, calculating SHR using random blood glucose (RBG) drawn on admission or fasting blood glucose (FBG) could lead to different results. This study intends to evaluate the association between SHR and functional outcomes in patients with acute ischemic stroke (AIS) with recombinant tissue plasminogen activator (r-tPA) intravenous thrombolysis.

Methods: Data from 230 patients with AIS following thrombolytic therapy with r-tPA in the Third Affiliated Hospital of Wenzhou Medical University from April 2016 to April 2019 were retrospectively reviewed. SHR1 was defined as [RBG (mmol/L)]/[HbA1c (%)] and SHR2 was defined as [FBG (mmol/L)]/[HbA1c (%)]. The outcomes included early neurological improvement (ENI), poor function defined as a modified Rankin Scale score (mRS) of 3-6, and all-cause death in 3 months. Multivariable logistic regression was performed to estimate the association between SHR and adverse outcomes.

Results: After adjustment for possible confounders, though patients with AIS with higher SHR1 tend to have a higher risk of poor outcome and death and unlikely to develop ENI, these did not reach the statistical significance. In contrast, SHR2 was independently associated with poor functional outcome (per 0.1-point increases: odds ratios (OR) = 1.383 95% CI [1.147-1.668]). Further adjusted for body mass index (BMI), triglyceride-glucose index (TyG), and diabetes slightly strengthen the association between SHR (both 1 and 2) and adverse outcomes. In subgroup analysis, elevated SHR1 is associated with poor functional outcomes (per 0.1-point increases: OR = 1.246 95% CI [1.041-1.492]) in non-diabetic individuals and the association between SHR2 and the poor outcomes was attenuated in non-cardioembolic AIS.

Conclusion: SHR is expected to replace random or fasting glucose concentration as a novel generation of prognostic indicator and a potential therapeutic target.

Keywords: fasting blood glucose; intravenous thrombolysis; random blood glucose; stress hyperglycemia ratio; stroke.

FIGURE 1

Flow diagram showing the patient selection process.

FIGURE 2

Association between (A) SHR1 defined as [admission random blood glucose (RBG) (mmol/L)]/[HbA1c (%)], (B) SHR2 defined as [fasting blood glucose (FBG) (mmol/L)]/[HbA1c (%)] and poor clinical outcome on 3-month using restricted cubic splines with 3 knots (at the 10th, 50th, and 90th percentiles). The model was adjusted for age, sex, current smoking, hyperlipidemia, atrial fibrillation, prior stroke, systolic blood pressure (SBP), and NIHSS at admission. The solid line indicates the odds ratio while the shadow indicates 95% CIs. The vertical dashed lines indicate the 1st, 2nd, and 3rd quartiles of SHR. The horizontal dashed line is the reference line (odds ratio = 1). The reference of SHR1 was 1.35, and the reference of SHR2 was 0.92.

FIGURE 3

Subgroup analyses for the risk of poor functional outcome by (A) SHR1 defined as [admission RBG (mmol/L)]/[HbA1c (%)], (B) SHR2 defined as [FBG (mmol/L)]/[HbA1c (%)]. The above model adjusted for age, sex, current smoking, hyperlipidemia, atrial fibrillation, prior stroke, systolic blood pressure (SBP), and NIHSS at admission. In each case, the model is not adjusted for the stratification variable. BMI, body mass index; TyG, triglyceride-glucose index; NIHSS, National Institutes of Health Stroke Scale score; TOAST, Trial of Org 10172 in Acute Stroke Treatment.