Paradoxical Mortality Benefit but Increased Procedural and Ischemic Risk in Prediabetic Patients with Chronic Total Occlusion: A National Inpatient Sample Analysis (2016–2022)

Background The impact of prediabetes on outcomes in chronic total occlusion (CTO) hospitalizations remains unclear. We evaluated the association between prediabetes and in-hospital mortality, complications, and procedural interventions using a nationally representative dataset. Methods We queried the National Inpatient Sample (NIS, 2016–2022) to identify adult hospitalizations with a diagnosis of CTO. Patients were stratified by prediabetes status, and 1:1 propensity score matching was performed to balance sociodemographic and comorbid covariates (Fig. 1). Multivariable-adjusted and matched logistic regression models were used to assess the primary outcome, which was all-cause in-hospital mortality, and secondary outcomes were ischemic stroke, major adverse cardiovascular events (MACE), and use of mechanical circulatory support (MCS). Results Among 269,475 CTO hospitalizations, 7,825 (2.9%) had prediabetes (Table 1). After matching (n = 1,494 per group), baseline characteristics were well-balanced. In the matched cohort, prediabetic patients had significantly lower odds of in-hospital mortality compared to those without prediabetes (OR 0.52, 95% CI: 0.31–0.87; p = 0.013). However, they demonstrated significantly higher odds of intra-aortic balloon pump (IABP) use (OR 2.20, 95%; p < 0.001) and coronary artery bypass grafting (CABG) (OR 2.08, 95% CI: 1.65–2.61; p < 0.001), suggesting hemodynamic instability in prediabetes patients. Ischemic stroke rates were higher (OR 1.38, 95% CI: 1.02–1.86; p = 0.037). No significant differences were observed in acute kidney injury, dialysis, or mechanical ventilation. MACE was lower in unadjusted (OR 0.81, 95% CI: 0.70–0.95; p = 0.009) but was not significant after matching (OR 1.01, 95% CI: 0.80–1.26; p = 0.955). (Table 2) Conclusions Despite higher use of advanced interventions and increased ischemic stroke risk, prediabetic patients hospitalized with CTO exhibited lower in-hospital mortality. This paradox demonstrates the complex interplay between early dysglycemic mileu, coronary pathophysiology, and supports the need for better risk stratification. Further prospective studies with longer follow-up durations are warranted to understand the long-term impact of prediabetes in advanced coronary disease.