From metabolism to myocardium: the missing link of admission dysglycemia in early cardiac recovery

Admission dysglycemia is linked to adverse outcomes after ST-elevation myocardial infarction (STEMI); however, its relationship with early recovery of left ventricular (LV) function after primary percutaneous coronary intervention (PPCI), particularly when using stress-adjusted indices, remains uncertain in South Asian settings. To evaluate whether admission glycemia (glucose and hemoglobin A1c [HbA1c]) and relative indices (stress hyperglycemia ratio [SHR] and glycemic gap) are independently associated with early improvement in LV ejection fraction (LVEF) and whether these associations persist at 30–90 days and align with early major adverse cardiovascular events (MACE). A retrospective cohort of 600 consecutive STEMI patients undergoing PPCI (January 2023–December 2024) was stratified a priori into good, intermediate, or poor glycemic control. The primary outcome was follow-up LVEF within 7 days, modeled by analysis of covariance (ANCOVA) with baseline LVEF and clinical/angiographic covariates (heteroscedasticity-robust HC3 standard error). Sensitivity analyses included two-time-point mixed-effects models, continuous SHR/glycemic gap specifications (with splines), a non-diabetic subset, and adjustment for echocardiography timing. Early LVEF gains were greater with good control than with intermediate or poor control (mean change, 4.13% [SD, 4.78] vs. 2.15% (SD, 5.12) and 1.01% [5.45]; p < 0.001). In adjusted analyses, follow-up LVEF was lower in intermediate vs good by −2.42% points (95% CI, −3.38 to −1.46) and in poor vs good by −3.74% points (95% CI, −4.76 to −2.71) (both p < 0.001). Accordingly, early recovery declined stepwise with worsening admission glycemia, and the gradient persisted at 30 and 90 days in parallel with higher MACE across the strata. Accordingly, early recovery declined stepwise with worsening admission glycemia, and the gradient persisted at 30 and 90 days in parallel with higher MACE across the strata. Admission dysglycemia, including stress-adjusted indices, was associated with attenuated early LVEF recovery after PPCI, with signals persisting through 90 days and aligning with early MACE. In practice, routine HbA1c-anchored stress-adjusted profiling at presentation may refine risk stratification and support protocolized inpatient glucose management. • Higher admission glucose worsens myocardial infarction outcomes. • Stress adjusted glycemia predicts adverse cardiovascular events. • Left ventricular function may remain impaired after timely reperfusion. Does admission hyperglycemia predict early left ventricular recovery after coronary reperfusion? • First South Asian infarction cohort assessing stress adjusted and gap glucose. • Greater hyperglycemia linked to smaller early left ventricular ejection fraction gains. • Associations persisted to ninety days and aligned with early cardiovascular events. Adopt stress adjusted glycemic assessment at presentation to guide inpatient glucose care.