Among nondiabetic patients with first-onset ST-elevation myocardial infarction (STEMI), stress hyperglycaemia is more likely to occur in older patients but is associated with the greatest risk of mortality in younger patients, according to local research.
In a cohort of 8,779 nondiabetic patients with first-onset STEMI from the Singapore Myocardial Infarction Registry (SMIR), 19.6 percent had stress hyperglycaemia, defined as stress hyperglycaemia ratio (SHR) of ≥1.51, reported first author Hon Jen Wong from the NUS Yong Loo Lin School of Medicine and colleagues. [J Diabetes Investig 2026 Aug 26:10.1111/jdi.70429]
Patients with stress hyperglycaemia were more likely to be older (median age, 61 vs 58 years), be nonsmokers (44 percent vs 37 percent), have lower BMI (median, 24.1 vs 24.5 kg/m2) and haemoglobin levels (median, 14.4 vs 14.7 g/dL), were less likely to report typical symptoms of STEMI such as chest pain (77 percent vs 92 percent) and diaphoresis (57 percent vs 63 percent), and tended to have advanced heart failure at presentation (Killip class IV: 17 percent vs 3.9 percent).
Additionally, in-hospital complications including cardiogenic shock, left ventricular systolic dysfunction, arrhythmias, and stroke occurred more frequently among patients with stress hyperglycaemia than among those without stress hyperglycaemia.
Factors associated with greater odds of stress hyperglycaemia were older age at STEMI onset (40–59 vs <40 years: odds ratio [OR], 1.65; 60–79 vs <40 years: OR, 1.93; ≥80 vs <40 years: OR, 1.77; p=0.008) and more advanced heart failure on admission (Killip class III vs I: OR, 2.98; Killip class IV vs I: OR, 4.53; p=0.009).
Increased mortality
Wong and colleagues noted that the development of stress hyperglycaemia was associated with a significantly increased risk of short- and long-term all-cause mortality across all age groups. However, the risk estimates at 30 days, 1–2 years, and 10 years were greatest in the <40-year age group and progressively decreased in each older age group (40–59 years, 60–79 years, and ≥80 years; p<0.001 for interaction).
The hazard ratios (HRs) for all-cause mortality at 30 days were 7.50 in the <40-year age group, 6.68 in the 50–59-year age group, 2.65 in the 60–79-year age group, and 2.07 in the ≥80-year age group. The HRs for 1-year mortality were 5.20, 5.26, 2.30, and 1.78 in the respective age groups, while the HRs for 10-year mortality were 4.38, 3.13, 1.85, and 1.42, respectively.
“Our findings are consistent with the hypothesis that ageing is associated with greater stress glycaemic responses to acute illness. This likely reflects cumulative metabolic vulnerability in older adults, arising from a multifactorial interplay of diminished insulin secretion, increased insulin resistance, and impaired counter-regulatory responses involving catecholamines, cortisol, growth hormone, and inflammatory cytokines,” Wong and colleagues explained.
The authors noted that the greater mortality risk associated with stress hyperglycaemia in younger patients may partly relate to their lower baseline mortality risk, such that a comparable absolute increase in risk translates into a larger relative effect. Conversely, hyperglycaemia may reflect underlying frailty and comorbidity in older patients, functioning more as a marker of overall vulnerability rather than a specific contributor to adverse outcomes, they said.
Clinical practice implications
In light of the findings, Wong and colleagues said: “Stress hyperglycaemia should be recognized as an important, age-dependent marker of risk in STEMI.”
Routine assessment of SHR, which has been shown to predict adverse cardiovascular outcomes more reliably than admission glucose alone, may help clinicians identify high-risk patients who could benefit from closer haemodynamic and metabolic monitoring, they added.
In terms of managing stress hyperglycaemia, “current guidelines do not distinguish stress hyperglycaemia from pre-existing diabetes, offering only broad inpatient glucose targets without clear differentiation by clinical context or illness severity… [The] recommendations favour moderate rather than intensive glucose control to avoid iatrogenic hypoglycaemia,” Wong and colleagues said.
The authors emphasized that while recommendations favour moderate rather than intensive glucose control to avoid iatrogenic hypoglycaemia, clinicians should individualize treatment strategies according to a patient’s physiology.
“Younger patients, in whom hyperglycaemia may act as a direct driver of myocardial injury, might benefit from closer metabolic surveillance and earlier intervention, whereas older or frail patients may require more permissive goals. This functional rather than chronological risk-based approach aligns with the precision-medicine paradigm increasingly advocated in acute cardiac care,” they said.