Acute coronary syndrome without documented standard modifiable risk factors and the stress hyperglycaemia ratio in an Indonesian percutaneous coronary intervention registry

Abstract Background Acute coronary syndrome (ACS) without standard modifiable cardiovascular risk factors (SMuRFs) and acute (stress) hyperglycaemia may both escape conventional risk assessment. Neither has been described in an Indonesian interventional population. Methods We analysed 1702 first ACS admissions in a single-centre Indonesian percutaneous coronary intervention registry (2021–2026). Patients with no documented hypertension, diabetes, dyslipidaemia or current smoking were classified as having no documented SMuRF. The stress hyperglycaemia ratio (SHR) was registry glucose divided by HbA1c-derived average glucose. Variables were audited for recording-bound heaping. Endpoints were in-hospital death and markers of index-event severity (Killip class III–IV, Killip class II–IV, ejection fraction <40%). Results In total, 204 patients (12.0%; 95% confidence interval [CI] 10.5–13.6) had no documented SMuRF, all admitted between April 2026 and July 2026; the proportion fell to 3.8% when ever-smoking replaced current smoking. These patients had a lower GRACE score and less multivessel percutaneous coronary intervention (odds ratio [OR] 0.46), but Killip class III–IV (OR 1.13, 0.80–1.60), ejection fraction <40% (1.14, 0.81–1.62) and death (0.82, 0.32–1.78) did not differ significantly. Median SHR was similar (1.27 vs 1.30, p = 0.731), but the distribution was narrower (standard deviation [SD] 0.25 vs 0.81), so the adjusted mean was lower (−0.17, −0.28 to −0.06). SHR was not associated with any severity marker. For death, the continuous estimate was inverse and non-significant (OR per SD 0.71, 0.45–1.05). Conclusions About one in eight patients had no documented SMuRF, but this estimate depended strongly on definition and recording period. SHR derived from the registry glucose value was not associated with index-event severity; these data do not support general conclusions about the prognostic value of SHR in ACS.