In our study, we averaged participants’ glycemia levels into four quartiles: quartile 1 (n = 482), quartile 2 (n = 500), quartile 3 (n = 496) and quartile 4 (n = 495). We expressed categorical variables as numbers (n) and percentages (%) and assessed them using the chi-square test. Continuous variables are expressed as the mean ± standard deviation of normally distributed data. In addition, multiple imputation with multivariate imputation by chained equation was used for handling the missing values. We used univariate and multivariate regression analyses to examine the association between glycemia and multi-vessel lesions. In univariate analyses, we selected variables with a p-value <0.05, including age, gender, smoking, hypertension, DBP, HR, UA, and TG. We then adjusted for a variety of influences in multivariate analyses to validate the robustness of the results. Subgroup analyses were conducted using logistic models to determine the relationship between glycemia and multi-vessel lesions among subgroups, including gender, age, smoking status, and presence of diabetes. All analyses were performed using Free Statistics Approximation software version 1.9. A two-sided P-value of less than 0.05 was considered statistically significant.

Our study involved 2,533 patients with coronary artery disease who underwent coronary angiography. After rigorous data screening, 1,973 participants were included in the final analysis. The cohort included 1,341 men and 632 women. The mean age was 59 years, and 474 participants were defined as having multi-vessel lesions. Glycemia was categorized into four quartiles, and a description of baseline characteristics revealed significant associations between glycemia and several key factors, including gender, age, BMI,hypertension, diabetes mellitus, and prevalence of multi-vessel lesions (Table 1).

In univariate analysis, age, hypertension, diabetes mellitus, glycemia level, uric acid level, and triglycerides were significantly associated with coronary multi-vessel lesion (Table 2).

To further elucidate the relationship between participants' glycemia and multi-vessel lesions, we performed a multifactorial logistic analysis. In the unadjusted model, there was a significant correlation between glycemia and coronary multivessel disease, with a 4% increase in the risk of multi-vessel lesions for each unit increase in glycemia (OR: 1.04, P = 0.02). This relationship remained significant after adjusting for sex, age, smoking, hypertension, diastolic blood pressure, heart rate, uric acid, and triglycerides. (Adj. OR: 1.04, P = 0.039) (Table 3).

These results are clear: glycemia is an important risk factor for the development of coronary multi-vessel lesion. After adjusting for various covariates, we observed a linear relationship between glycemia and multi-vessel lesions, with the risk of developing multi-vessel lesions progressively increasing with increasing glycemia levels (Figure 2).

To clarify the relationship between glycemia and multi-vessel lesion in different age, gender and smoking status, we conducted further subgroup analyses. These showed that glycemia and multi-vessel lesion had a more significant association in males (p = 0.031) compared to females. The analyses showed a significant association between glycemia and multi-vessel lesion in those aged ≥ 45 years (p = 0.008). Furthermore, smokers showed a stronger correlation (p = 0.038) compared to non-smokers (p = 0.085). Due to the lack of information on medications taken by patients prior to admission, diabetic patients who were regularly taking hypoglycaemic medications prior to admission would have resulted in relatively low fasting glycemia values on admission, which would have had an impact on our findings. Consequently, we grouped the patients by previous diabetes or not, and found that compared to diabetic patients, blood glucose and multi-vessel lesion were yet more significantly associated among non-diabetic patients. This shows that even non-diabetics should be aware of glycemia changes. The association between glycemia and multi-vessel lesion was stronger in non-diabetics among the participants who underwent coronary angiography. Therefore, close monitoring of glycemia is essential to prevent adverse cardiovascular events, regardless of previous diagnosis of diabetes mellitus. In conclusion, the findings demonstrate the complexity of cardiovascular risk factors and their differential impact in different patient subgroups. This stratified analysis will help to develop a more personalised management strategy for patients (Figure 3 and Table 4).

The incidence of multi-vessel lesions is increasing in clinical practice and is a matter of considerable concern in current clinical cardiovascular disease research. There is a clear association between multi-vessel lesions and a wide range of adverse cardiovascular outcomes (11). Dziewierz, Siudak et al. reported that multi-vessel lesions were present in approximately 40%–65% of patients with ST-segment elevation myocardial infarction (STEMI) or complete coronary occlusion, as well as other coronary artery disease (12). A prospective randomised, multicentre, open-label and controlled clinical trial enrolled 396 patients and found that 52% had multivessel disease (13). Furthermore, Tindale A et al. demonstrated that patients with multi-vessel lesion treated with CR who developed STEMI with cardiogenic shock (defined as lactic acid ≥2 mmol/L) had a higher mortality rate (14). This finding is in line with Sorajja, Bernard J. et al., who observed that three-vessel disease significantly predicted cardiovascular mortality and risk of reinfarction (15). These findings demonstrate that multi-vessel lesion is a serious and widespread cardiovascular disease process, that the number of patients who develop multi-vessel lesions is enormous, and that understanding and managing multi-vessel lesions to avoid adverse cardiovascular events is of the utmost importance.

Glycaemia is clearly associated with several cardiovascular diseases (16). Our study definitively confirms the link between elevated glycaemia and cardiovascular disease. This observation is in line with the findings of Xiang Wang et al. who concluded that the TyG index can be a valuable predictor of CAD severity, especially for patients with prediabetes (17). Furthermore, a study by Iijima R, et al. demonstrated that Patients with diabetes often accelerate atherosclerotic thrombosis, resulting in early, widespread, and rapidly progressing coronary artery disease (18). Tong Zhao et al. concluded that hyperglycaemia was an independent predictor of severe coronary artery disease in non-diabetic patients (19). Our study definitively confirms that the association of glycemia with multi-vessel lesions is more significant in non-diabetic patients. Clinicians must be aware of this and provide appropriate early intervention to prevent adverse cardiovascular events.

It is crucial to note that our study differs from previous studies in two key ways. Firstly, we have a larger sample size. Secondly, we only include Asian populations. This is because Asia is an important region for the development of cardiovascular disease and diabetes worldwide. This may be due to unique lifestyle and genetic influences, among other factors. Expert discussions at the WHO have made it clear that, at a BMI below the existing WHO overweight threshold (≥25 kg/m²), Asians are at a much higher risk of developing type 2 diabetes and cardiovascular disease (20). It is therefore of great importance to conduct a study of diabetes and cardiovascular disease in Asia. By identifying the link between glycemia and multivessel disease, physicians will be able to more accurately assess a patient's risk of developing multivessel disease.

Our study is comprehensive, but it has limitations. Our study was a cross-sectional investigation, so even after rigorous data screening, potential confounders could not be completely eliminated. This may limit the generalisability of the findings, but we included a relatively large number of participants, and the results are still instructive for future studies to provide a basis for a deeper understanding of the relationship between diabetes mellitus and cardiovascular disease. Longitudinal studies are needed to understand the long-term effects of glycemia on cardiovascular occurrence and prognosis in patients with multivessel disease. It is also crucial to include participants from more regions and ethnicities to raise awareness of glycaemic control in all regions. Clinicians must be vigilant about the glycaemic status of their patients, as this is a key factor in the assessment and management of cardiovascular risk.