Relationship between stress hyperglycemia ratio of one-year mortality in patients with heart failure: Analysis of the MIMIC-IV database

Yimeng Wang; Wei Xu; Jingyang Wang; Yuyuan Shu; Yinjing Xin; Yanmin Yang

doi:10.1371/journal.pone.0328812

Peer Review History

Original SubmissionApril 23, 2025
Decision Letter - Fuad Abdu, Editor Dear Dr. yang, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Please submit your revised manuscript by Jun 28 2025 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'. 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Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols . We look forward to receiving your revised manuscript. Kind regards, Fuad Abdu Academic Editor PLOS ONE Journal requirements: When submitting your revision, we need you to address these additional requirements. 1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf 2. 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Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. Is the manuscript technically sound, and do the data support the conclusions? Reviewer #1: Partly Reviewer #2: Yes Reviewer #3: Yes Reviewer #4: Yes ******** 2. Has the statistical analysis been performed appropriately and rigorously? -->?> Reviewer #1: Yes Reviewer #2: Yes Reviewer #3: Yes Reviewer #4: Yes ****** 3. Have the authors made all data underlying the findings in their manuscript fully available??> The PLOS Data policy Reviewer #1: Yes Reviewer #2: Yes Reviewer #3: Yes Reviewer #4: Yes ****** 4. Is the manuscript presented in an intelligible fashion and written in standard English??> Reviewer #1: Yes Reviewer #2: No Reviewer #3: Yes Reviewer #4: Yes ****** Reviewer #1: General Comments This study used the MIMIC-IV database to investigate the association between the stress hyperglycemia ratio (SHR) and 1-year mortality in patients with heart failure (HF). SHR was found to be independently associated with 1-year mortality regardless of diabetes status, suggesting its potential as a prognostic indicator for patients with heart failure. However, several concerns remain that need to be addressed. Major Comments (1) There is no explanation for the SHR cutoff (0.964) based on ROC analysis or clinical validity. Please specify the method used to determine the cutoff (e.g., Youden index or references to previous literature). (2) Infections (presence of sepsis), cancer, liver disease, nutritional status, and other factors may influence the outcome but may not have been included in the analysis. Consideration of these confounding factors should be added to the Discussion section. (3) Diabetes diagnosis appears to have been based on ICD codes, but complementary definitions using measured blood glucose or HbA1c levels should also be considered. The limitations of diabetes classification using ICD codes should be mentioned in the Limitations section. (4) Previous studies have reported U-shaped or J-shaped relationships between SHR and prognosis, but this study interprets the relationship as a linear increase in risk. Please discuss the reasons for this interpretation and explain why the shape of the RCS is consistent or inconsistent with other studies. (5) In some patients with heart failure, particularly those with severe cases admitted to the intensive care unit (ICU), systemic inflammatory response and sepsis may occur simultaneously, and these conditions have been reported to significantly impact prognosis and pathophysiology. The involvement of sepsis-associated myocardial dysfunction is increasingly recognized as a critical factor determining the deterioration of hemodynamics. (Sci Rep. 2021;11:18823.) Considering the systemic inflammation and catabolic stress observed in heart failure and sepsis, SHR may not only reflect blood glucose fluctuations but also indicate the extent of inflammatory load. In fact, elevated SHR may serve as an alternative marker for microcirculatory dysfunction and blood flow imbalance common to heart failure and sepsis. As mentioned earlier, findings regarding SHR in critically ill patients admitted to the ICU should be interpreted within a broader clinical framework that includes infection, inflammatory processes, cardiac dysfunction, and hemodynamic abnormalities in the context of heart failure and sepsis. Please incorporate the above content into the Discussion section. Minor comments (1) The consistency of labels and legends in figures and tables should also be reviewed (e.g., explicit titles for Figure 4a) and b) would be helpful). Reviewer #2: Wang et al. Have focused on the relationship between Stress hyperglycemia ratio of one-year mortality in patients with heart failure. They found higher level of SHR was associated with elevated one year mortality in HF patients both with and without DM. The results were credible. I have several Minor comments: 1. 1. Please indicate whether of your present study was sufficient support your results. 2. Inflammation is an important factor in blood glucose stress. Should inflammation analysis be included in this study� 3. What is the difference between in-hospital mortality rate and 1-year follow-up mortality rate� 4.Is there a difference in subgroups of heart failure� 5.Throughout the manuscript there are a considerable number of grammar errors. To improve the readability of the manuscript, it has to undergo linguistically and grammatical changes. I would suggest using a copy-editing service for copywriting, language checking and proofreading. Reviewer #3: Dear Authors, Thanks for your interesting subject and work. That's an important issue in patients with heart failure, in my point of view it's better that at the end of discussion, you mention about the clinical importance of the work. Reviewer #4: Dear author, I have reviewed your article with great care and pleasure. The introduction, methods, results and discussion sections of your article are written in a fluent, understandable and well-ordered manner. It was seen that the tables and figures are readable, clear and understandable. The points that I will criticize negatively about your article are as follows: 1) The center where the ethics were obtained, the ethics date and the ethics number should be stated. 2) The introduction section is short and superficial. It would be better for your article if you explained heart failure a little more and mentioned the conditions that affect the diagnosis, treatment, prognosis and mortality of heart failure. 3) It would be good to add examples from previous studies conducted in terms of heart failure prognosis and mortality in the introduction section and increase the number of your references. 4) In your method section, you should also state how you made the diagnosis and classification of heart failure and which diagnostic tools you used. 5) Your inclusion and exclusion criteria in the method section are very simple. You should specify them in more detail. I liked your study in general terms. ****** what does this mean? ). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy Reviewer #1: No Reviewer #2: No Reviewer #3: Yes: zahra khajali Reviewer #4: Yes: Azmi Eyiol ******** [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/ . PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org . Please note that Supporting Information files do not need this step. https://doi.org/10.1371/journal.pone.0328812.r001
Revision 1
22 Jun 2025 Author Response Dear Editors and Reviewers, Thank you very much for providing us with the opportunity to revise our manuscript. We are grateful to the editor and reviewers for their constructive comments and helpful suggestions. Responding to the critics, we have conducted additional analyses as requested. We also improved our expression in the background and discussion. We believe that our manuscript has been substantially improved and hope it is now acceptable for the Thrombosis Journal. I assure you that all authors have read and approved the submission of the revised manuscript. Also, this work, containing the original research, has not been under consideration for publication elsewhere. Please let me know if you have any further questions. With warmest regards, Yanmin Yang Emergency and Critical Care Center, Fuwai Hospital, National Center for Cardiovascular Diseases of China, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China E-mail: yyminfuwai@163.com The main corrections in the paper and the responses to the reviewer’s comments are as follows (All the text in bold font is the original comments from the editor/reviewers, and our response is in normal font): Reviewer #1: General Comments This study used the MIMIC-IV database to investigate the association between the stress hyperglycemia ratio (SHR) and 1-year mortality in patients with heart failure (HF). SHR was found to be independently associated with 1-year mortality regardless of diabetes status, suggesting its potential as a prognostic indicator for patients with heart failure. However, several concerns remain that need to be addressed. Major Comments (1) There is no explanation for the SHR cutoff (0.964) based on ROC analysis or clinical validity. Please specify the method used to determine the cutoff (e.g., Youden index or references to previous literature). Thank you for your insightful comment. We have added the relevant information in the methods section to make it easier for readers to understand. (page 4, line 87-88) First, we used restricted cubic spline (RCS) to analyze the data and observe the trend. When the stress hyperglycemia ratio (SHR) exceeded 0.964, the one-year mortality risk increased with the rising SHR, with a hazard ratio greater than 1 (Fig. 1). Therefore, we set 0.964 as the cutoff for group classification, which could offer valuable insights for clinical practice in the future. Moreover, we have analyzed the cutoff (0.964) on ROC, the UAC (0.560, 95% CI: 0.537-0.583). Although the prediction value of this cutoff was moderately good, it also presented its efficiency in mortality prediction. (2) Infections (presence of sepsis), cancer, liver disease, nutritional status, and other factors may influence the outcome, but may not have been included in the analysis. Consideration of these confounding factors should be added to the Discussion section. Thank you for your suggestion to include the variables that might influence SHR and the interpretation of results. We have added the relevant references in the discussion section. (page 14, line 254-259; page 14, line 276) (3) Diabetes diagnosis appears to have been based on ICD codes, but complementary definitions using measured blood glucose or HbA1c levels should also be considered. The limitations of diabetes classification using ICD codes should be mentioned in the Limitations section. Thanks for your comments. We addressed the potential bias introduced in this study due to classification based on ICD codes in the limitations section(page 14, line 277) (4) Previous studies have reported U-shaped or J-shaped relationships between SHR and prognosis, but this study interprets the relationship as a linear increase in risk. Please discuss the reasons for this interpretation and explain why the shape of the RCS is consistent or inconsistent with other studies. Thanks for your valuable comments. We have discussed the differences between our study and other published studies. �page 13, line 221-232� In brief, we hypothesized that the differences arose due to the distinct populations. (5) In some patients with heart failure, particularly those with severe cases admitted to the intensive care unit (ICU), systemic inflammatory response and sepsis may occur simultaneously, and these conditions have been reported to significantly impact prognosis and pathophysiology. The involvement of sepsis-associated myocardial dysfunction is increasingly recognized as a critical factor determining the deterioration of hemodynamics. (Sci Rep. 2021;11:18823.) Considering the systemic inflammation and catabolic stress observed in heart failure and sepsis, SHR may not only reflect blood glucose fluctuations but also indicate the extent of inflammatory load. In fact, elevated SHR may serve as an alternative marker for microcirculatory dysfunction and blood flow imbalance common to heart failure and sepsis. Thanks for your suggestions. We added sepsis and tumor status to the baseline characteristics and adjusted for them in the multivariate Cox analysis (Table 1 and Table 3). Furthermore, we performed a sensitivity analysis based on patients with systemic inflammatory response syndrome (SIRS) and the simplified acute physiology score (SAPS) II to exclude the potential influence of inflammation and sepsis on the results. (supplementary table S1) We also added this content to the discussion section. (page 12; line 200-201; page 14, line 254-256) As mentioned earlier, findings regarding SHR in critically ill patients admitted to the ICU should be interpreted within a broader clinical framework that includes infection, inflammatory processes, cardiac dysfunction, and hemodynamic abnormalities in the context of heart failure and sepsis. Please incorporate the above content into the Discussion section. Thank you for your suggestion. We have added the relationship between SHR and other critical illnesses in the discussion section to remind readers that the interpretation of SHR should be approached with caution. (page 14, line 254-256) Minor comments (1) The consistency of labels and legends in figures and tables should also be reviewed (e.g., explicit titles for Figure 4a) and b) would be helpful). Thank you for your suggestions. We have reviewed the consistency of labels and legends in the figures and tables to ensure accuracy. Reviewer #2: Wang et al. Have focused on the relationship between Stress hyperglycemia ratio of one-year mortality in patients with heart failure. They found higher level of SHR was associated with elevated one year mortality in HF patients both with and without DM. The results were credible. I have several Minor comments: 1. 1. Please indicate whether of your present study was sufficient support your results. Thanks for your constructive suggestion. We have validated the findings of our study in discussion section. (page 14, line 266-270) 2. Inflammation is an important factor in blood glucose stress. Should inflammation analysis be included in this study� Thanks for your suggestions. Regarding the methods, we extracted variables reflecting the inflammatory status, such as the Sequential Organ Failure Assessment (SOFA) score, the Systemic Inflammatory Response Syndrome (SIRS) score, and the level of C-reactive protein. However, due to missing values exceeding 50%, we did not include these variables in our study. Nevertheless, inspired by your suggestion, we added sepsis and tumor status to the baseline characteristics and adjusted for them in the multivariate Cox analysis (Table 1 and Table 3). 3. What is the difference between in-hospital mortality rate and 1-year follow-up mortality rate� Thank you for your valuable comment regarding differences between in-hospital mortality and 1-year mortality. We assumed that in-hospital mortality was associated with short-term adverse events, representing deaths that occurred during the admission period, while 1-year mortality was linked to long-term adverse events. Therefore, we presented both results. (Table 2) 4. Is there a difference in subgroups of heart failure� Thanks for your comment regarding the statistical analysis. We have added the subgroup analysis. There were no interaction differences between acute heart failure and chronic heart failure (Figure 5). 5.Throughout the manuscript there are a considerable number of grammar errors. To improve the readability of the manuscript, it has to undergo linguistically and grammatical changes. I would suggest using a copy-editing service for copywriting, language checking and proofreading. Thank you for your constructive suggestions. We have revised the language and grammar throughout the entire text by a native speaker. Reviewer #3: Dear Authors, Thanks for your interesting subject and work. That's an important issue in patients with heart failure, in my point of view it's better that at the end of discussion, you mention about the clinical importance of the work. Thanks for your constructive comments. At the end of the discussion, we added the potential usage of SHR in clinical practice. (page 14,line 266-270) Reviewer #4: Dear author, I have reviewed your article with great care and pleasure. The introduction, methods, results and discussion sections of your article are written in a fluent, understandable and well-ordered manner. It was seen that the tables and figures are readable, clear and understandable. The points that I will criticize negatively about your article are as follows: 1) The center where the ethics were obtained, the ethics date and the ethics number should be stated. Thanks for your valuable comments. Since the data was extracted from a publicly established database and approved in accordance with the Declaration of Helsinki. Ethics approval dates and numbers were not applicable. (page 3, line 62-63, 65-66) 2) The introduction section is short and superficial. It would be better for your article if you explained heart failure a little more and mentioned the conditions that affect the diagnosis, treatment, prognosis and mortality of heart failure. Thank you for your comments on the introduction section. We have revised this part and refined the background information related to heart failure. (page 3, line 40-41,55-56) 3) It would be good to add examples from previous studies conducted in terms of heart failure prognosis and mortality in the introduction section and increase the number of your references. Thank you for your constructive suggestion. We have revised the introduction section and increased the number of references. (W. Zhang, Y. Zhang, J. Tang, X. Wang, C. Meng, J. Wu, et al. The changing landscape of heart failure drug clinical trials in china, 2013-2023[J]. Drug Des Devel Ther, 2025, 19: 2597-2608. [3]M. Saotome, T. Ikoma, P. Hasan, Y. Maekawa. Cardiac insulin resistance in heart failure: The role of mitochondrial dynamics[J]. Int J Mol Sci, 2019, 20(14): U. Attanasio, V. Mercurio, S. Fazio. Insulin resistance with associated hyperinsulinemia as a cause of the development and worsening of heart failure[J]. Biomedicines, 2024, 12(12): J. Zhu, W. Liu, L. Chen, B. Liu. Stress hyperglycemia ratio: A novel predictor of left ventricular dysfunction in peripartum cardiomyopathy[J]. J Matern Fetal Neonatal Med, 2025, 38(1): 2464181.) 4) In your method section, you should also state how you made the diagnosis and classification of heart failure and which diagnostic tools you used. Thank you for your comments. We have added the criteria for the diagnosis of heart failure, which were based on the International Classification of Diseases (ICD)-9 and ICD-10, in the methods section. The details of the ICD codes and associated diseases are provided in Supplementary Table S1. We have classified heart failure into chronic and acute heart failure according to ICD codes. 5) Your inclusion and exclusion criteria in the method section are very simple. You should specify them in more detail. Thank you for your valuable suggestions regarding the inclusion and exclusion criteria. We have provided more details on the criteria for this study (page 4, line 72-74). We did consider age as an exclusion criterion; however, since no patients were excluded based on this criterion, we chose not to mention it. (Supplementary Figure S1) Attachments Attachment Submitted filename: renamed_423c7.docx https://doi.org/10.1371/journal.pone.0328812.r002
Decision Letter - Fuad Abdu, Editor Dear Dr. yang, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Please submit your revised manuscript by Aug 13 2025 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'. A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'. An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'. If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols . Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols . We look forward to receiving your revised manuscript. Kind regards, Fuad Abdu Academic Editor PLOS ONE Journal Requirements: Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice. [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author Reviewer #1: (No Response) Reviewer #2: All comments have been addressed Reviewer #3: All comments have been addressed Reviewer #4: All comments have been addressed ******** 2. Is the manuscript technically sound, and do the data support the conclusions??> Reviewer #1: Yes Reviewer #2: Yes Reviewer #3: Yes Reviewer #4: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? -->?> Reviewer #1: Yes Reviewer #2: Yes Reviewer #3: Yes Reviewer #4: Yes ****** 4. Have the authors made all data underlying the findings in their manuscript fully available??> The PLOS Data policy Reviewer #1: Yes Reviewer #2: Yes Reviewer #3: Yes Reviewer #4: Yes ****** 5. Is the manuscript presented in an intelligible fashion and written in standard English??> Reviewer #1: Yes Reviewer #2: Yes Reviewer #3: Yes Reviewer #4: Yes ****** Reviewer #1: Minor comments: 1) The authors' responses to the previous review were generally appropriate, and the following points have been adequately addressed: ・The rationale for the SHR cutoff was clearly stated based on RCS and ROC analysis, and the interpretation was reasonable. ・The inclusion of confounding factors such as inflammation, tumor, and sepsis in the Cox regression model, as well as sensitivity analysis using SIRS and SAPS II, is highly commendable. ・The limitations of DM and HF classification based on ICD codes are also appropriately noted. ・Differences in the shape of the RCS curve compared to previous studies are discussed in terms of differences in the study population. ・Linguistic revisions and corrections to figure labels have been made, improving the overall clarity of the paper. However, we believe that further improvements are possible in the following areas: 2) This study focuses on the association between metabolic stress, insulin resistance, and heart failure prognosis. From the perspective of metabolic abnormalities in heart failure, the following studies may provide further insights into the significance of SHR: ESC Heart Fail. 2023;10:32-43. Heart Vessels. 2021;36:965-977. J Cardiol. 2020;75:689-696. 3) Although the somewhat limited AUC of 0.56 in the ROC analysis is briefly mentioned, I feel that a more in-depth discussion on its clinical applicability and practical significance would be beneficial. Reviewer #2: Thank you for performing all the new experiments and the new data. This manuscript is substantially improved. I believe it is now acceptable for publication in Plos one in its present form. Reviewer #3: Dear Authors, Thanks for your revision. You added clinical significance of the study at the end of discussion. Reviewer #4: Dear author, I saw that you have made the necessary corrections to your article. I think that your article is a candidate for publication in its current state. ****** what does this mean? ). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy Reviewer #1: No Reviewer #2: No Reviewer #3: Yes: zahra khajali Reviewer #4: Yes: Azmi Eyiol ******** [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/ . PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org https://doi.org/10.1371/journal.pone.0328812.r003
Revision 2
3 Jul 2025 Author Response Point-to-point response Dear Editors and Reviewers, Thank you very much for providing us with the opportunity to revise our manuscript. We are grateful to the editor and reviewers for their constructive comments and helpful suggestions. Responding to the critics, we have conducted additional analyses as requested. We also improved our expression in background and discussion. We believe that our manuscript has been substantially improved and hope it is now acceptable for the Thrombosis Journal. I assure you that all authors have read and approved the submission of the revised manuscript. Also, this work containing the original research has not been under consideration for publication elsewhere. Please let me know if you have any further questions. With warmest regards, Yanmin Yang, Emergency and Critical Care Center, Fuwai Hospital, National Center for Cardiovascular Diseases of China, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China E-mail: yyminfuwai@163.com The main corrections in the paper and the responses to the reviewer’s comments are as follows (All the text in bold and underlined font are the original comments from the editor/reviewers and our response is in normal font): To reviewer 1: This study focuses on the association between metabolic stress, insulin resistance, and heart failure prognosis. From the perspective of metabolic abnormalities in heart failure, the following studies may provide further insights into the significance of SHR: ESC Heart Fail. 2023;10:32-43. Heart Vessels. 2021;36:965-977. J Cardiol. 2020;75:689-696. Thank you for your insightful comments. We have added the association between metabolic conditions and heart failure prognosis in the introduction section and have cited the references as per your recommendation. (page 3,line 45-46) Although the somewhat limited AUC of 0.56 in the ROC analysis is briefly mentioned, I feel that a more in-depth discussion on its clinical applicability and practical significance would be beneficial. Thanks for your constructive suggestions. We added a discussion on its clinical applicability and practical significance in discussion section.(Page 14, line 270-275) To reviewer 2: Special thanks for reviewer 2. To reviewer 3: Special thanks for reviewer 3. To reviewer 4: Special thanks for reviewer 4. Attachments Attachment Submitted filename: Point to point2.docx https://doi.org/10.1371/journal.pone.0328812.r004
Decision Letter - Fuad Abdu, Editor Relationship between Stress hyperglycemia ratio of one-year mortality in patients with heart failure:analysis of the MIMIC-IV database. PONE-D-25-21818R2 Dear Dr. yang, We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements. Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication. An invoice will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. Please make sure your user information is up-to-date by logging into Editorial Manager at Editorial Manager® and clicking the ‘Update My Information' link at the top of the page. If you have any questions relating to publication charges, please contact our Author Billing department directly at authorbilling@plos.org. If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. Kind regards, Fuad Abdu Academic Editor PLOS ONE Additional Editor Comments (optional): Reviewers' comments: https://doi.org/10.1371/journal.pone.0328812.r005

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