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The paradox of SMURF-less outcomes and its implication for diabetes

Edina Cenko1, Olivia Manfrini1,2, Jinsung Yoon3

  • 1Department of Medical and Surgical Sciences, University of Bologna, Via Massarenti 9, Bologna 40138, Italy.

European Heart Journal. Quality of Care & Clinical Outcomes
|January 29, 2026
PubMed
Abstract

Insights

Diabetes independently increases 30-day mortality risk in acute coronary syndromes (ACS). Combining diabetes with other modifiable risk factors masks this increased risk, necessitating individualized assessments.

Area of Science:

  • Cardiology
  • Public Health
  • Epidemiology

Background:

  • Acute coronary syndromes (ACS) paradoxically show higher mortality in individuals without standardized modifiable risk factors (SMuRF), including those with diabetes.
  • The independent impact of diabetes on post-ACS mortality requires clarification.
  • Grouping diabetes with other SMuRF may obscure its true effect on mortality.

Purpose of the Study:

  • To determine the independent effect of diabetes on 30-day mortality after ACS.
  • To investigate how combining diabetes with other SMuRF influences observed mortality risks.

Main Methods:

  • Analysis of 70,953 first-time ACS patients.
  • Utilized inverse probability weighting for confounding adjustment.
  • Primary outcome: 30-day mortality post-ACS.

Main Results:

  • Diabetic patients without other SMuRF had significantly higher 30-day mortality (RR 1.29 women, 1.40 men).
  • Combining diabetes with other SMuRF diluted its impact on mortality.
  • Specific RRs for diabetic patients with smoking, hypercholesterolemia, or hypertension showed varied effects, often masking the independent risk.

Conclusions:

  • Diabetes is an independent risk factor for increased 30-day mortality in ACS patients.
  • Aggregating diabetes with other SMuRF leads to dilution bias, masking the true mortality risk.
  • Individualized risk factor assessment is crucial for managing ACS patients with diabetes.
Keywords:
Acute coronary syndromesCoronary heart diseaseMortalityOutcomesStandardized modifiable risk factors

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