Prognostic significance of stress hyperglycemia ratio in patients undergoing percutaneous coronary intervention: a dose–response meta-analysis

BACKGROUND: Stress hyperglycemia is common during percutaneous coronary intervention (PCI) and is associated with worse outcomes. The stress hyperglycemia ratio (SHR), which standardizes acute glucose levels to chronic glycemic status, may provide superior prognostic information compared with admission glucose alone. OBJECTIVE: To systematically evaluate the association between SHR and clinical outcomes in PCI patients and to quantify the exposure-response relationship. DATA SOURCES: PubMed, Embase, Cochrane Library, Web of Science, Scopus, and ClinicalTrials.gov were searched from inception to August 5, 2025. STUDY SELECTION: Observational studies reporting SHR prior to PCI and subsequent clinical outcomes were included. DATA EXTRACTION: Two investigators independently extracted study characteristics, SHR definitions, and adjusted effect estimates. Risk of bias was assessed using ROBINS-I (Risk Of Bias In Non-randomized Studies of Interventions), and certainty of evidence was evaluated with the Grading of Recommendations Assessment, Development and Evaluation framework. DATA SYNTHESIS: Thirteen studies comprising 41 096 PCI patients were included. Elevated SHR was associated with increased risks of all-cause mortality, major adverse cardiac and cerebrovascular events (MACCE), cardiovascular mortality, recurrent myocardial infarction, and stroke, but not with repeat revascularization. Sensitivity analyses yielded consistent results. The dose-response analysis suggested an approximately linear dose-response pattern between SHR and MACCE. LIMITATIONS: Most studies were observational, SHR definitions varied, and residual confounding cannot be excluded. The limited number of studies restricted the interpretability of dose-response analyses. CONCLUSIONS: Elevated SHR was associated with an increased risk of adverse outcomes after PCI. The dose-response analysis suggested an approximately linear dose-response pattern between SHR and MACCE. However, these findings should be interpreted cautiously given the observational nature of the evidence and the limited number of studies for certain analyses. PROSPERO REGISTRATION NUMBER: CRD420251045853.