{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,22]],"date-time":"2026-09-22T09:20:13Z","timestamp":1790068813280,"version":"4.0.1"},"reference-count":27,"publisher":"Oxford University Press (OUP)","issue":"4","license":[{"start":{"date-parts":[[2026,1,29]],"date-time":"2026-01-29T00:00:00Z","timestamp":1769644800000},"content-version":"vor","delay-in-days":1,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2026,6,23]]},"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Aims<\/jats:title>\n                    <jats:p>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.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods and results<\/jats:title>\n                    <jats:p>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\u20131.57) and 1.40 for men (95% CI, 1.16\u20131.69). 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\u20132.09) and 0.89 in men (95% CI, 0.68\u20131.17), those with hypercholesterolaemia had RRs of 0.91 in women (95% CI, 0.66\u20131.25) and 0.75 in men (95% CI, 0.53\u20131.06) and those with hypertension showed RRs of 1.14 in women (95% CI, 0.99\u20131.32) and 1.12 in men (95% CI, 0.96\u20131.31).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>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.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1093\/ehjqcco\/qcag012","type":"journal-article","created":{"date-parts":[[2026,1,24]],"date-time":"2026-01-24T12:40:15Z","timestamp":1769258415000},"page":"579-586","source":"Crossref","is-referenced-by-count":2,"title":["The paradox of SMURF-less outcomes and its implication for diabetes"],"prefix":"10.1093","volume":"12","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-8102-3324","authenticated-orcid":false,"given":"Edina","family":"Cenko","sequence":"first","affiliation":[{"name":"Department of Medical and Surgical Sciences, University of Bologna , Via Massarenti 9, Bologna 40138 , Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5652-2401","authenticated-orcid":false,"given":"Olivia","family":"Manfrini","sequence":"additional","affiliation":[{"name":"Department of Medical and Surgical Sciences, University of Bologna , Via Massarenti 9, Bologna 40138 , Italy"},{"name":"IRCCS Azienda Ospedaliero-Universitaria di Bologna Sant\u2019Orsola Hospital , Bologna , Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5481-5171","authenticated-orcid":false,"given":"Jinsung","family":"Yoon","sequence":"additional","affiliation":[{"name":"Google Cloud AI , Sunnyvale, CA ,","place":["USA"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1389-0597","authenticated-orcid":false,"given":"Maria","family":"Bergami","sequence":"additional","affiliation":[{"name":"Department of Medical and Surgical Sciences, University of Bologna , Via Massarenti 9, Bologna 40138 , Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Zorana","family":"Vasiljevic","sequence":"additional","affiliation":[{"name":"Medical Faculty, University of Belgrade , Belgrade, Serbia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6652-9036","authenticated-orcid":false,"given":"Guiomar","family":"Mendieta","sequence":"additional","affiliation":[{"name":"Department of Cardiology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain and Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC) , Madrid ,","place":["Spain"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Marija","family":"Zdravkovic","sequence":"additional","affiliation":[{"name":"Faculty of Medicine, Clinical Hospital Center Bezanijska Kosa, University of Belgrade , Belgrade, Serbia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4479-6691","authenticated-orcid":false,"given":"Marija","family":"Vavlukis","sequence":"additional","affiliation":[{"name":"University Clinic for Cardiology \u00a0 Skopje , Republic of North Macedonia"},{"name":"Faculty of Medicine, Ss. 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