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

Aims Individuals without standardized modifiable risk factors (SMuRF), which implicitly include those with diabetes, have been paradoxically reported to experience higher mortality following acute coronary syndromes (ACS). We aim to clarify the independent impact of diabetes on 30-day mortality after ACS and explore how grouping it with other SMuRF might obscure its true effect.Methods and results We analyzed 70 953 first-time ACS patients using inverse probability weighting to adjust for potential confounding. Mortality within 30 days post-ACS was the primary outcome. Diabetic patients without other SMuRF showed a significantly higher 30-day mortality compared with those without any SMuRF, with relative risks (RRs) of 1.29 for women (95% CI, 1.06-1.57) and 1.40 for men (95% CI, 1.16-1.69). When diabetes was combined with other SMuRF, its impact on mortality was diluted. Diabetic patients who were also smokers had RRs of 1.39 in women (95% CI, 0.92-2.09) and 0.89 in men (95% CI, 0.68-1.17), those with hypercholesterolaemia had RRs of 0.91 in women (95% CI, 0.66-1.25) and 0.75 in men (95% CI, 0.53-1.06) and those with hypertension showed RRs of 1.14 in women (95% CI, 0.99-1.32) and 1.12 in men (95% CI, 0.96-1.31).Conclusion Diabetes independently increases 30-day mortality risk in ACS. Aggregating it with other SMuRF masks this risk due to dilution bias, highlighting the need for individualized risk factor assessment strategies.