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Assessment of triglyceride glucose index as biochemical marker of severity in coronary artery disease
*Corresponding author: Mandala Indira, Department of Biochemistry, Rangaraya Medical College, Kakinada 533003, Andhra Pradesh, India. dr.indiramandal@gmail.com
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Received: ,
Accepted: ,
How to cite this article: Rushitha A, Indira M, Rajendra C. Assessment of triglyceride glucose index as biochemical marker of severity in coronary artery disease. RMC Glob J. 2026;2:80-6. doi: 10.25259/RMCGJ_32_2025
Abstract
Objectives:
Cardiovascular disease (CVD) is a major cause of morbidity and mortality across the world, posing serious public health challenges and also placing an economic burden on patients. According to the World Health Organization (WHO), cardiovascular diseases are one of the major causes of death in India and worldwide, resulting in a global burden. The present study is undertaken to estimate the triglyceride glucose (TyG) index in patients having coronary artery disease (CAD) with adverse outcomes and compare them to age-matched controls.
Material and Methods:
A total of 60 patients with coronary artery disease were included in the study, who were classified into group A and B based on their outcomes. Patients who are diagnosed with STEMI (ST-elevated myocardial infarction [MI]) and NSTEMI (non-ST-elevated myocardial infarction) with clinical features, electrocardiogram (ECG) abnormalities, or raised troponin I values. Major adverse cardiovascular and cerebrovascular events are identified as fatal MI, revascularization, stroke, and rehospitalization. The vacutainer is then centrifuged at 3000-5000 rpm for 15 minutes for the separation of serum. The serum is aliquoted into labeled Eppendorf tubes. They are analyzed immediately and stored in refrigeration at -40 °C until completion of the study process. The study was carried out in a 24-hour laboratory, the department of Biochemistry, and samples were obtained from the department of Cardiology, Government General Hospital, Rangaraya Medical College. Data collected - age, sex, blood glucose levels, serum triglyceride levels, and triglyceride glucose index.
Results:
The results of the study showed that the mean blood glucose levels and TyG index were increased in patients with adverse outcomes (Group A) compared with patients with stable outcomes (Group B) (p = 0.014). In this study of 60 patients diagnosed with coronary artery disease, 51.66% (n = 31) had adverse outcomes (Group A), whereas the remaining 48.33% (n = 29) had stable outcomes (Group B). The mean value of the TyG index in Group A was 9.69, while in Group B it was 9.15. The p-value was 0.014, indicating that the difference was statistically significant at the 5% level. The TyG index is calculated from serum glucose and serum triglyceride (TG) levels using the formula ln [(FBS × TG)/2]. The TyG index is considered a reliable marker of insulin resistance, as it combines the diagnostic potential of fasting blood glucose and serum triglycerides. The TyG index was calculated based on the serum glucose and triglyceride levels using the aforementioned formula, and the values were recorded. On comparison, the TyG index was 9.69 ± 0.88 in Group A and 9.15 ± 0.76 in Group B.
Conclusion:
Our present study showed that increased serum triglyceride levels in patients with coronary artery disease may lead to adverse complications like increased blood glucose levels in patients with coronary artery disease leads to adverse outcomes. The TyG has been shown to have a tendency for increased values in case of adverse outcomes. Thus, the present study suggests that regular monitoring of the triglyceride glucose index in patients with coronary artery disease may help in the early detection of CAD.
Keywords
HTG
IFNg
NSTEMI
STEMI
Ty G index
INTRODUCTION
According to the World Health Organization (WHO), cardiovascular diseases are one of the major causes of death in India and worldwide, resulting in a global burden. Cardiovascular disease (CVD) is driven by multiple contributing factors, including glycemic abnormality and lipid disorder.1 India accounts for one-fifth of CVD-related deaths worldwide, especially in the younger population. The results of Global Burden of Disease study state that age-standardized CVD death rate of 272 per 100000 populations in India which is much higher than that of global average of 235.2 Hypertriglyceridemia (HTG) is a common dyslipidemia and the association of triglyceride (TG) with CVD risk remains controversial3,4 accumulation of TG in the liver may cause fatty liver disease, which can increase the risk of Type 2 diabetes mellitus (T2DM).5 It has been demonstrated that lowering TG, such as fibrates do, can significantly attenuate the process of developing insulin resistance.6 Macrophage foam cell and the endothelial cell inflammatory signaling continue for promoting the recruitment of a larger number of monocytes and the immune cells into the sub-endothelial space. Fibrous fatty lesions may regress less than fatty streaks. With the increase in cell volume of the intima, there is vascular remodeling so that the lumen is only partially occluded, leading to lessening clinical events resulting from occlusion. Vulnerable plaque results from the heightened, unresolved inflammatory status of the lesion foam cell core. Antigen-specific activation of T helper 1 (Th-1) cells produces interferon gamma (IFNg), resulting in a proinflammatory macrophage phenotype.7,8 The proinflammatory macrophage foam cells exhibit increased inflammatory cytokine secretion and apoptosis susceptibility. There is less secretion of anti-inflammatory cytokines, transforming growth factor-beta (TGF-β) and interleukin-10 (IL-10). Proinflammatory macrophages have impaired atheroprotective functions that include cholesterol efflux and efferocytosis (phagocytosis of dead cells).9 The defective efferocytosis of inflammatory apoptotic macrophages may result in secondary necrosis, leading to an enlarged necrotic core composed of leaked oxidative and inflammatory components. This unresolved inflammation leads to thinning of the fibrous cap resulting from the increased smooth muscle cell death, enhanced extracellular matrix degradation, and decreased extracellular matrix production. Areas of thin fibrous cap are prone to rupture, exposing prothrombotic components to platelets, and the pro-coagulation factors lead to thrombus formation and clinical events like impaired glucose tolerance as shown in Figure 1 and diabetes mellitus, which correlates with a high risk of CVD.10
The application of the triglyceride glucose (TyG) index as a biochemical marker of atherosclerosis in patients with CVD may be influenced by conditions such as diabetes and hyperlipidemia, which are associated with an increased risk of cardiovascular disease [Figure 2]. The TyG index is a useful predictor of metabolic syndrome, which contributes to cardio-metabolic risk.11
TyG = ln [serum TG (mg/dl)× FBS (mg/dl)/2].
The normal range of the TyG index ranges from 4 to 8
The normal range of fasting blood sugar levels is 70 – 100 mg / dL
The normal range of serum triglyceride levels is < 150 mg / dL
The TyG index is widely used as an indicator of insulin resistance.12 It was observed that an increase in TyG index is linked with an excessive risk of serious, negative cardiac and cerebrovascular events in patients with ST-segment elevation myocardial infarction (STEMI), who underwent percutaneous coronary intervention (PCI), and the risk of ischemic stroke correlates with a proportional and linear growth of TyG index.13 Since cardiovascular disease is a dynamic and progressive disease, and the beginning of treatment should rely on the individual case of each patient, the use of indicators such as the TYG index as prognostic markers is less certain.14
Aim of study
The present study aims to determine the triglyceride glucose (TyG) index as a prognostic factor of developing adverse cardiovascular events in patients with coronary artery disease (CAD).
Objectives
The objectives of this study are to determine the fasting blood sugar (FBS) levels and serum triglyceride levels in patients with coronary artery disease. The study also aims to evaluate the TyG index in the study population and to compare TyG index levels with the occurrence of Major Adverse Cardiovascular and Cerebrovascular Outcomes (MACCE), thereby assessing the relationship between the TyG index and adverse cardiovascular and cerebrovascular events in patients with coronary artery disease.
MATERIAL AND METHODS
Data collection
Cases were recruited during hospital admission. Patients diagnosed with coronary artery disease who met the study’s eligibility criteria were approached for participation. The study’s purpose, procedures, potential risks, and anticipated benefits were explained to each eligible patient. Written informed consent was obtained from all patients before enrollment in the study.
The demographic information (age and gender) of cases and controls was noted in the data collection tables.
Sample collection
Study patients were advised to fast overnight, and a blood sample is collected in the morning in a labeled red-topped vacutainer for HsTn I (highly sensitive troponin I), glucose, and triglycerides under strict aseptic conditions.
Sample processing
After properly mixing the sample in a Vacutainer, it is left at room temperature for 15-20 minutes for clot formation. The vacutainer is then centrifuged at 3000-5000 rpm for 15 minutes for the separation of serum. The serum is aliquoted into labeled Eppendorf tubes. They are analyzed immediately and stored in refrigeration at -40 °C until completion of the study process.
Biochemical analysis
Beckman Colter Access 2 and AU 480 clinical chemistry analyzers are used for analysis. The instruments are calibrated, and calibration is checked by using appropriate controls.
Serum HsTn I: It will be estimated in serum using Paramagnetic particle enhanced electrochemiluminescent immunoassay in Access 2.
Serum triglyceride: It will be estimated using the GPOPOD coupled enzymatic reaction in the automated analyzer AU 480.
Serum glucose: It will be estimated using the hexokinase method in an automated analyzer.
TyG index is calculated from serum triglycerides and glucose by using
Formula TyG = ln [serum TG/ddll) ×/dl) × FBS (mg/dl)/2]
Statistical analysis
All variables will be tested for normal distribution. Continuous variables are expressed as mean ± SD. The study population is divided into two groups (one group with adverse outcomes and the other group without any adverse outcomes). The Mann-Whitney U test is used to compare the means between two groups.
Study location
This cross-sectional study was conducted over a two-month period, from October 2024 to November 2024. The study was carried out collaboratively by the Clinical Laboratory, the Department of Biochemistry, and the Department of Cardiology.
Study population
Patients diagnosed with STEMI or NSTEMI based on clinical presentation, ECG findings, and/or elevated troponin I levels. Major adverse cardiovascular and cerebrovascular events are identified as fatal MI, revascularization, stroke, and rehospitalization.
Sample population and size
The study population consisted of 60 patients diagnosed with coronary artery disease (CAD).
Inclusion Criteria
The study included patients diagnosed with coronary artery disease (CAD), aged between 30 and 90 years. Patients who were willing to participate in the study and provided written informed consent were included.
Exclusion Criteria
Individuals who were unwilling to participate in the study or did not provide written informed consent were excluded. Patients with known renal or hepatic insufficiency, a history of long-standing autoimmune disorders, or hypertriglyceridemia secondary to inherited hyperlipoproteinemia were also excluded from the study.
RESULTS
Data collected - age, sex, blood glucose levels, serum triglyceride levels, and TYG index.
In a study of 60 volunteers who are diagnosed with coronary artery disease, 51.66% (n = 31) are presented with adverse outcomes of the disease, whereas the remaining 48.33% (n = 29) are presented with stable outcomes. The study population is divided into Group A and Group B based on the outcomes of the disease. Group A comprises patients with adverse outcomes who are 31 in number, whereas Group B comprises patients with stable outcomes who are 29 in number. The prevalence of the disease among both groups is high at the age of 51 to 70 years, consisting of 17 patients from Group A and 18 patients from Group B, a total of 35 (58.33%). Hence, patients with stable outcomes are comparatively more numerous than patients with adverse outcomes. It is noted that prevalence is low for the age group 31 to 50 years, consisting of 5 from Group A and 5 from Group B, a total of 10 patients (16.66%). The age group 71 to 90 consists of 9 patients with adverse outcomes and 6 with stable outcomes, for a total of 15(25%). Sex wise comparison between the two groups indicates that both females and males are almost equally in number in both groups. 16 out of 29 females have adverse outcomes, and the remaining 13 have stable outcomes. Among males (n = 31), 15 (48.4%) experienced adverse outcomes, while 16 (51.6%) had stable outcomes, as shown in Table 1.
| Category | Group A | Group B |
|---|---|---|
| Gender | ||
| Males | 15 | 16 |
| Females | 16 | 13 |
| Age (yrs) | ||
| 31–50 | 5 | 5 |
| 51–70 | 17 | 18 |
| 71–90 | 9 | 6 |
| Hs nI (pg/mL) | 7412.11 | 6807.99 |
| Glucose (mg/dL) | 228.74 | 150.76 |
| TAG (mg/dL) | 188.06 | 151.07 |
| TyG index | 9.69 | 9.15 |
TyG index: Triglyceride glucose index, HsTnI: Highly sensitive troponin I, TAG
HsTnI was also compared between the two study populations. It was observed that the HsTnI level ranged from 7412.11 ± 9706.32 pg /mL, with a mean value of 7412.11 pg/mL. Meanwhile, the Hs tn I value in group B ranges from 6807.99 ± 9293.46 pg/mL, with a mean value of 6807.99 pg/mL. It was observed that the p-value was 0.81, indicating that the difference was not statistically significant. On comparing the triglyceride levels in the study population between group A and group B, the results are as follows: in group A, the triglyceride level ranges of 188.06 ± 96.38 mg/dL with a mean value of 188.06 mg/dL, and in group B, it ranges of 151.07 ± 73.27 mg/dL with a mean value of 151.07 mg/dL. A statistically significant difference was observed (p = 0.01), as shown in Table 2.
| Analyte | Group A (Adverse outcome) | Group B (Stable outcome) | P value |
|---|---|---|---|
| Number | 31 | 29 | — |
| Males | 15 | 16 | — |
| Females | 16 | 13 | — |
| HsTnI (pg/mL) | 7412.11 ± 9706.32 | 6807.997 ± 9293.46 | 0.81 |
| Glucose (mg/dL) | 228.74 ± 127.16 | 150.76 ± 73.27 | 0.005 |
| TAG (mg/dL) | 188.06 ± 96.38 | 151.07 ± 73.26 | 0.1 |
| TyG Index | 9.69 ± 0.88 | 9.15 ± 0.76 | 0.014 |
p <0.05 is statistically significant. TyG index: Triglyceride glucose index, HsTnI: Highly sensitive troponin I, TAG: Triacylglycerol
On comparison of glucose levels between the study groups, Group A patients had a mean glucose level of 228.74 ± 127.16 mg/dL, whereas Group B patients had a mean glucose level of 150.76 ± 73.27 mg/dL. It was observed that the values are distributed with a value of 0.005, indicating statistical significance. The main biochemical marker of the study index (TyG) is measured based on the values of glucose levels and triglyceride levels using the formula mentioned before; the values of the TyG index are recorded. On comparison, the TyG index value ranges from 9.69 ± 0.88 in group A and 9.15 ± 0.76. The mean value of the TyG index in group A is 9.69, and in group B is 9.15. As shown in Table 2, the p-value was 0.014, indicating a statistically significant difference (p <0.05). From the above observations, it is noted that complications of coronary artery disease are affected by various factors that include age, sex, blood glucose levels, TG levels, and TyG index. As shown in Figure 2, higher blood glucose levels, triglyceride levels, and the triglyceride-glucose (TyG) index were significantly associated with an increased risk of adverse outcomes in patients.
DISCUSSION
The study was conducted with the aim of associating the serum TyG index with adverse outcomes of acute myocardial infarction (AMI), such as cardiac failure, stroke, bundle branch block, prolonged hospitalization, and death. 60 diagnosed AMI patients with ECG changes and elevated hs troponin levels were recruited for the study after taking their consent. The patients were followed throughout the course of the study and were divided into two groups: Group A, comprising patients with an adverse outcome, and Group B, comprising patients with a stable outcome. Group A consisted of 31 patients, while Group B consisted of 29 patients.
Age and sex distribution
The mean age of study subjects is 60 + 11 Years. The mean age of Group A is 60 + 10 years, and the mean age of Group B is 58 + 11 years. There is no significant difference between the mean age of 2 groups. There was no significant difference in the mean age between the two groups. The highest proportion of patients in both groups belonged to the 51– 70-year age category, as shown in Figure 3. Of the 60 study patients, 31 were male and 29 were female, indicating a slight male predominance, as shown in Figure 4.
Serum glucose
The mean glucose level in Group A patients was 228.74 + 127.16 mg/dL, and in Group B patients was 150.76 + 73.27 mg/dL. There is a statistically significant difference between 2 groups with a p-value <0.05. A review study by Poznyak et al.15 titled “Effect of Glucose Levels on Cardiovascular Risk,” examined the relationship between elevated glucose levels and coronary artery disease (CAD). The authors aimed to evaluate the association between hyperglycemia and CAD and to summarize the role of elevated glucose levels as an independent risk factor for cardiovascular disease. There is an extremely high risk of death in CVD with elevated glucose levels. The mechanism by which glucose can cause increased risk is not well established. Glucose, by non-enzymatic glycosylation, enters the endothelial cells and potentiates atherosclerosis. Hyperinsulinemia observed with elevated glucose levels is linked to fibrinolysis, with increased levels of plasminogen activator inhibitor-1 also being a risk factor for the development of complications [Figure 5].
Serum triglycerides
The mean serum triglyceride level in Group A patients was 188.06 + 96.38 mg/dL, and in Group B patients was 151.07 + 73.26 mg/dL. There is no statistically significant difference in the mean triglyceride level between 2 groups, with a p-value of 0.1. According to Boullart et al.16 (2012), serum triglyceride elevation is a characteristic feature of dyslipidemia and is one of the risk factors for CAD.They concluded that elevated triglyceride (TG) levels reflect the presence of remnant lipoproteins and are associated with an increased risk of coronary artery disease. Furthermore, they emphasized that, in addition to lowering low-density lipoprotein cholesterol (LDL-C) levels, reducing serum triglyceride levels is essential for decreasing the risk of cardiovascular disease (CVD), as shown in Figure 6.
Serum Ty-G index
Ty-G index is calculated from serum glucose and serum TG levels using the formula ln [(FBS × TG)/2]. TyG index is considered a reliable marker of Insulin resistance; it combines the diagnostic potential of fasting blood glucose and serum triglycerides. Mean TyG index in Group A subjects is 9.69 + 0.88, and for Group B subjects is 9.15 + 0.76. There is a statistically significant difference in mean values between 2 groups, with a p-value of 0.014. Hao et al.[17] conducted a study titled “The prognostic value of the TyG index in patients with acute myocardial infarction.” In their study, they assessed the role of the TyG index in predicting adverse outcomes among NSTEMI patients [Figure 7]. Their findings showed a significant correlation between blood glucose levels and HF (adverse outcome), whereas no significant correlation was observed between the blood lipid profile and HF.17 This study associated increased TyG index values with HF and long-term complications in MI patients. These findings support the findings of our study, which reported increased TyG index in patients with adverse outcomes. In another study Jin et al.,18 reported that the TYG index is a marker of metabolic status, it is correlated to adverse clinical outcome in AMI and future risk of cerebrovascular accident (CVA). The mechanism behind the reason for elevated TyG risk and its association with adverse outcomes in AMI is not well established. It has been postulated that hypertriglyceridemia increases the formation of small oxidized LDL particles, which result in the acceleration of atherosclerosis. TyG index, being a marker of metabolic syndrome, is also linked to long-standing chronic inflammation, which is linked to biomolecules interferon, leukocytes, and fibrinogen, which are linked to plaque instability and hence development of complications in AMI. da Silva et al.,19 demonstrated that TyG index is associated with symptomatic coronary artery disease in patients in secondary care. Their study findings are similar to our study findings, with the increased TyG index in the symptomatic phase of CAD associated with increased adverse outcomes [Figure 8].
CONCLUSION
Our present study showed that increased serum triglyceride and blood glucose levels in patients with coronary artery disease may lead to adverse complications. The TyG index, which is calculated based on serum triglyceride levels and blood glucose levels, has been shown to have a tendency for increased values in case of adverse outcomes. The variations of these analyte levels in group A were extremely significant when compared to group B. Thus, the present study suggests that regular monitoring of the TyG index in patients with CAD may help early detection of adverse outcomes, management, and a good prognosis of the disease. Further evaluation of this biomarker, the TyG Index, may be useful in predicting the severity of coronary artery disease.
Ethical approval:
The study approved by the Institutional Review Board at Rangaraya Medical College, number 2024/116, dated 17th September 2024.
Declaration of patient consent:
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given consent for clinical information to be reported in the journal. The patient understands that the patient’s names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Conflicts of interest:
Dr. Chenna Rajendra is on the Editorial Board of the Journal.
Use of artificial intelligence (AI)-assisted technology for manuscript preparation:
The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript, and no images were manipulated using AI.
Financial support and sponsorship: Nil.
References
- Adiposopathy, diabetes mellitus, and primary prevention of atherosclerotic coronary artery disease: Treating “sick fat” through improving fat function with antidiabetes therapies. Am J Cardiol. 2012;110:4B-12B.
- [CrossRef] [PubMed] [Google Scholar]
- Relationship of high-density lipoprotein cholesterol with periprocedural myocardial injury following elective percutaneous coronary intervention in patients with low-density lipoprotein cholesterol below 70 mg/dL. J Am Heart Assoc. 2015;4:e001412.
- [CrossRef] [PubMed] [Google Scholar]
- Epidemiology of cardiovascular disease in China: Current features and implications. Nat Rev Cardiol. 2019;16:203-12.
- [CrossRef] [PubMed] [Google Scholar]
- Plasma triglycerides predict ten-years all-cause mortality in outpatients with type 2 diabetes mellitus: A longitudinal observational study. Cardiovasc Diabetol. 2014;13:135.
- [CrossRef] [PubMed] [Google Scholar]
- Prediction of incident diabetes mellitus in middle-aged adults: The Framingham Offspring Study. Archives of internal medicine. 2007;167:1068-74.
- [CrossRef] [PubMed] [Google Scholar]
- Increased levels of triglycerides, BMI and blood pressure and low physical activity increase the risk of diabetes in Swedish women. A prospective 18-year follow-up of the BEDA study. Diabet Med. 2004;21:615-22.
- [CrossRef] [PubMed] [Google Scholar]
- Metabolic effects of troglitazone on fructose-induced insulin resistance in the rat. Diabetes. 1994;43:1435-9.
- [CrossRef] [PubMed] [Google Scholar]
- Normal triglyceride levels and coronary artery disease events: The Baltimore Coronary Observational Long-Term Study. J Am Coll Cardiol. 1998;31:1252-7.
- [CrossRef] [PubMed] [Google Scholar]
- Fasting glucose levels within the high normal range predict cardiovascular outcome. Am Heart J. 2012;164:111-6.
- [CrossRef] [PubMed] [Google Scholar]
- Third report of the National Cholesterol Education Program (NCEP) expert panel on detection, evaluation and treatment of high blood cholesterol in adults (Adult Treatment Panel III) final report. Circulation. 2002;106:3143-421.
- [CrossRef] [PubMed] [Google Scholar]
- Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III guidelines. Circulation. 2004;110:227-39.
- [CrossRef] [PubMed] [Google Scholar]
- Type 2 diabetes and myocardial infarction: Recent clinical evidence and perspective. Front Cardiovasc Med. 2021;8:644189.
- [CrossRef] [PubMed] [Google Scholar]
- Use of the triglycerideglucose index (TyG) in cardiovascular disease patients. Cardiovasc Diabetol. 2020;19:8.
- [CrossRef] [PubMed] [Google Scholar]
- High triglyceride-glucose index is associated with poor prognosis in patients with acute ST-elevation myocardial infarction after percutaneous coronary intervention. Cardiovasc Diabetol. 2019;18:150.
- [CrossRef] [PubMed] [Google Scholar]
- Effect of glucose levels on cardiovascular risk. Cells. 2022;11:3034.
- [CrossRef] [PubMed] [Google Scholar]
- Serum triglycerides and risk of cardiovascular disease. Biochim Biophys Acta. 2012;1821:867-75.
- [CrossRef] [PubMed] [Google Scholar]
- The prognostic value of the triglyceride glucose index in patients with acute myocardial infarction. J Cardiovasc Pharmacol Ther. 2023;28:10742484231181846.
- [CrossRef] [PubMed] [Google Scholar]
- Triglyceride glucose index for predicting cardiovascular outcomes in patients with coronary artery disease. J Thorac Dis. 2018;10:6137-46.
- [CrossRef] [PubMed] [Google Scholar]
- Triglyceride-glucose index is associated with symptomatic coronary artery disease in patients in secondary care. Cardiovasc Diabetol. 2019;18:89.
- [CrossRef] [PubMed] [Google Scholar]