Relation Between the Metabolic Syndrome and Ischemic Stroke or Transient Ischemic Attack

Prevalence of metabolic syndrome in a rural area of Brazil

CONTEXT AND OBJECTIVE

Metabolic syndrome (MS) is recognized worldwide as an important public health concern. However, little information is available for rural populations in Brazil. The aim was to determine the prevalence and risk factors associated with MS in a rural village in Brazil in 2004.

DESIGN AND SETTING

Cross-sectional population-based study, in Virgem das Graças, a rural community in the Jequitinhonha Valley, State of Minas Gerais.

METHODS

MS was the dependent variable, defined as any three of these risk factors: arterial hypertension, high glucose or triglyceride concentrations, low high-density lipoprotein cholesterol and abdominal obesity. MS prevalence, according to selected socioeconomic and demographic variables (age, skin color, marital status, schooling and smoking habits), was determined in 251 subjects aged 20-88 years. Multivariate logistic regression was used to estimate odds ratios (OR) and 95% confidence intervals.

RESULTS

MS prevalence was 21.6% (7.7% for men and 33.6% for women); the age-adjusted prevalence was 19.0%. The highest prevalences were observed for women > 60 years of age (52.9%) and women with body mass index (BMI) >or= 25 kg/m(2) (64%). Age, sex and BMI were associated risk factors for MS, while skin color was only significantly associated with MS for women. The models were adjusted for age, smoking habits, marital status, skin color and schooling.

CONCLUSIONS

BMI and age were independently associated factors for MS in this rural community. These findings provide important evidence on the prevalence of MS as a public health problem, particularly for women and overweight individuals.

Antihypertensive therapy in patients with metabolic syndrome

PURPOSE OF REVIEW

It is amply recognized that the presence of metabolic syndrome is associated with subclinical cardiac, vascular and kidney damage, with an increased risk for cardiovascular and cerebrovascular disease and type 2 diabetes, and, as a consequence, with higher rates of cardiovascular mortality. Metabolic syndrome can be considered as a prediabetic state very frequently associated with arterial hypertension, requiring pharmacological therapy.

RECENT FINDINGS

All antihypertensive therapies have been shown to reduce the risk of total major cardiovascular events. Recently, the relevance of the type of hypertensive therapy used to treat hypertensive patients in facilitating the development of diabetes has been demonstrated in different trials. The recognition of the risk present in hypertensive patients with metabolic syndrome for developing diabetes reinforces the need to consider the ideal antihypertensive therapy, either mono or combination, in these patients.

SUMMARY

This brief review contains the available evidence showing that an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker is the most suitable therapy to be started in these patients, alone or in combination, due to their capacity to prevent or retard the development of diabetes, and the strong relationship between metabolic syndrome and arterial hypertension, focusing on the advantages and disadvantages of different antihypertensive drugs.

Serum Uric Acid as an Independent Predictor of Early Death After Acute Stroke

BACKGROUND

The prognostic significance of uric acid (UA) levels in acute stroke is unclear, so the objective of this study was to determine the association between levels of serum UA (SUA) and mortality in acute stroke.

METHODS AND RESULTS

Consecutive patients (n=435) presenting with ischemic stroke and intracerebral hemorrhage were included in the study. The length of stay in hospital and the occurrence of death were recorded. On univariate analysis, the occurrence of death was associated with older age, smoking, presence of congestive heart failure or atrial fibrillation, absence of hyperlipidemia, and intracerebral hemorrhage as the index event. Furthermore, glucose, urea, creatinine and SUA at admission were significantly higher in patients who died, whereas total and high-density-lipoprotein cholesterol were significantly lower. On multiple logistic regression analysis, the independent relationship between higher SUA levels and death was confirmed (odds ratio (OR), 1.37; 95%confidence interval (CI), 1.13-1.67; p=0.001). The only other variables independently associated with the occurrence of death were urea concentration and presence of atrial fibrillation. If urate was >7.8 mg/dl (0.47 mmol/L), then there would be a high probability of early death (87%).

CONCLUSIONS

Elevated levels of SUA are independently associated with an increased risk of early death in acute stroke.

Metabolic syndrome increases the risk of ischemic stroke in women

BACKGROUND

Metabolic syndrome is a characterized by a cluster of cardiovascular risk factors, including visceral obesity, insulin resistance, dyslipidemia, and hypertension. The criteria for diagnosing metabolic syndrome differ among ethnic groups, due in part to differences in eating habits and body build. Little is known about the relationship between metabolic syndrome and ischemic stroke in Asian countries. The aim of this study was to investigate the relationship between metabolic syndrome and first-time ischemic strokes.

SUBJECTS & METHODS

Study subjects were 1,493 Japanese adults aged 55 years-old or older with no diabetes mellitus, no history of stroke and no neurological abnormalities, who participated in a voluntary neurological health screening at the Institute of Shimane Health Science, Japan (767 men, 62.0 +/- 5.9 years old at entry and 726 women, 61.8 +/- 5.1 years old at entry). All subjects were given an annual clinical stroke questionnaire. Clinical details of patients who reported strokes were confirmed with the attending physicians. Each subject was evaluated for an average of 6.4 +/- 3.8 years. Metabolic syndrome was defined using the modified criteria for Japanese population published in April 2005.

RESULTS

Metabolic syndrome was diagnosed in 11.0% of men and 1.1% of women. Adjusting for age and smoking, female subjects with metabolic syndrome had a 23.1-fold increased risk of suffering ischemic strokes [95% confidence interval (CI), 2.7-196], whereas metabolic syndrome did not increase the risk of ischemic stroke in men.

CONCLUSIONS

Metabolic syndrome is more likely to influence a risk for ischemic stroke in women than in men.

The significance of multiple risk factors for early carotid atherosclerosis in Japanese subjects

OBJECTIVE

The aim of this study was to assess the significance of multiple risk factors for early carotid atherosclerosis in the Japanese population.

METHODS

The relation between traditional vascular risk factors and serum high-sensitivity CRP (hs-CRP) or atherosclerotic lesions in the carotid arteries detected by B-mode ultrasonography was evaluated.

PATIENTS

The subjects were 1,880 persons (1,240 men and 640 women, mean age 55+/-10 years old) without ischemic stroke, infection or collagen diseases.

RESULTS

In the men, the odds ratio (OR) for atherosclerotic lesion was increased at 1.90 (95% CI: 1.05-3.43, P=0.032) in those with one risk factor, 2.42 (1.36-4.32, P=0.002) in those with two, and 2.95 (1.69-5.16, P<0.001) in those with three or more. In the women, the OR was similarly increased 1.93 (95% CI: 1.04-3.56, P=0.035) for one risk factor, 2.31 (1.23-4.33, P=0.009) for two, and 3.52 (1.80-6.87, P<0.001) for three or more. The mean hs-CRP concentration increased significantly with the increasing number of risk factors (men and women, P<0.001) and with the degree of carotid arterial stenosis (men, P=0.011; women, P=0.008).

CONCLUSION

Multiple risk factors are more predictive than a single risk factor for early carotid atherosclerosis in the Japanese population.

Hypertension--a treatable component of the cardiometabolic syndrome: challenges for the primary care physician

Patients with the cardiometabolic syndrome (CMS) have an adverse cardiovascular risk factor profile, placing them at increased risk of stroke, coronary artery disease, chronic kidney disease, and type 2 diabetes mellitus. Although no specific treatments for CMS are available per se, prompt recognition and treatment of the individual components of the condition can prevent or delay the development of comorbidities. Primary care physicians are ideally positioned to identify patients with CMS and implement early intervention strategies. Hypertension contributes to many complications of CMS, and rigorous blood pressure control will help to delay or prevent end-organ vascular damage. Achieving blood pressure control to current guideline standards should be eagerly sought in the majority of patients through a combination of lifestyle modifications and appropriate pharmacologic therapy. Antihypertensive drug choice should be personalized, taking into account the CMS determinants present and any compelling indications for specific agents. As an initial approach, a thiazide diuretic is suitable for most cases of uncomplicated hypertension, although many patients will require additional antihypertensives from other classes to achieve their blood pressure goal. It is predicted that, due to the increase in unhealthy lifestyles, the prevalence of CMS will rise in the coming years. Therefore, by meeting the challenge of attaining and maintaining blood pressure control in patients with CMS, primary care physicians have the unique opportunity to markedly improve the health of the nation.

Different impact of the metabolic syndrome on left ventricular structure and function in hypertensive men and women

Metabolic syndrome (MS) is increasingly recognized as an important cardiovascular risk factor in hypertension, but its influence on left ventricular (LV) mass and function in the 2 genders has not been specifically addressed. Among 618 nondiabetic, untreated hypertensive subjects, echocardiographically detected LV mass was significantly greater in subjects with MS. A significant interaction was observed between sex and the MS (P<0.003 for the multiplicative interaction term). Compared with women without the MS, those with the syndrome had a 24% greater LV mass (49.5+/-12 versus 40.0+/-10 g x m(-2.7); P<0.001), whereas the difference was only 9% in men (50.3+/-12 versus 46.1+/-10 g x m(-2.7); P=0.003). A greater prevalence of LV hypertrophy was found in women (37% versus 14%; P<0.001) but not in men (39% versus 29%; P=0.09) with the MS. After adjustment for the effect of age, body mass index, 24-hour systolic blood pressure, and several confounders, the MS was independently associated with a greater LV mass index in women (regression coefficient, 4.80; P<0.001) but not in men. Women with the MS also had a greater LV relative wall thickness (0.42+/-0.07 versus 0.39+/-0.07; P=0.004) and a depressed afterload-corrected midwall fractional shortening (94.0+/-12% versus 101.0+/-13%; P<0.001) than women without the syndrome, whereas no differences emerged in men. We conclude that, in untreated hypertension, MS has a different impact on LV hypertrophy and function in men and women. The effect of MS is more pronounced in women and is partly independent from the effect of several hemodynamic and nonhemodynamic determinants of LV mass.

Influence of Metabolic Syndrome and General Obesity on the Risk of Ischemic Stroke

BACKGROUND AND PURPOSE

In 2005, the National Cholesterol Education Program Adult Treatment Panel III (NCEP-ATP III) guideline lowered the fasting glucose cut point used to define metabolic syndrome (MS). This study investigated the influence of MS on ischemic stroke (IS) risk using both the original and revised definitions. In addition, because abdominal obesity is the measure of obesity used in the guideline to define MS, we also investigated whether general obesity (GOB) should be considered in the definition of MS.

METHODS

Baseline data from 3453 adults (> or =20 years of age) in the Cardiovascular Diseases Risk Factor Two-Township Study were linked to insurance claim and death certificate records. The 2001 and 2005 NCEP-ATP III definitions were used with Asian and Taiwanese specific cut-off values for waist circumference and body mass index. Hazard ratios of MS and GOB on IS were calculated using Cox models, and the Kaplan-Meier method was used to derive free-of-IS survival curves.

RESULTS

During 10.4 years of follow-up, 132 persons developed IS. Hazard ratios of subjects with 1 to 2 and > or =3 MS component disorders were 2.69 and 4.30, respectively, under the 2001 definition, and 3.16 and 5.15, respectively, under the 2005 definition (all P values <0.05). MS subjects with GOB had reduced survival at a borderline significance level. Adding GOB in the MS definition did not significantly alter the number of subjects with MS nor the ability to predict stroke risk. Replacing abdominal obesity with GOB in MS definition reduced the number slightly and increased the hazard ratio.

CONCLUSIONS

MS predicted IS and the 2005 NCEP definition showed a stronger dose-response relationship with IS. Adding GOB to the existing MS definition had limited benefit.

Disorders of glucose metabolism in acute stroke patients: an underrecognized problem

OBJECTIVE

To determine the prevalence of disturbances in glucose metabolism in patients with acute stroke.

RESEARCH DESIGN AND METHODS

Consecutively admitted acute stroke patients (n = 286) were screened for glucose tolerance according to the standardized World Health Organization protocol in the 1st and 2nd week after the stroke event. In addition, we repeatedly measured fasting capillary blood glucose during the first 10 days.

RESULTS

Measurements were not performed or cancelled if patients were not fully conscious or had severe dysphagia or early complications that made transfers to other hospitals necessary (n = 48). Of the remaining 238 patients, 20.2% had previously known diabetes; 16.4% were classified as having newly diagnosed diabetes, 23.1% as having impaired glucose tolerance (IGT), and 0.8% as having impaired fasting glucose; and only 19.7% showed normal glucose levels. Another 47 patients (19.7%) had hyperglycemic values only in the 1st week (transient hyperglycemia) or could not be fully classified due to missing data in the oral glucose tolerance test. Patients with diabetes compared with nondiabetic subjects had more severe strokes (National Institutes of Health Stroke Scale [NIHSS] on admission: 7.2 +/- 6.6 vs. 4.6 +/- 3.1, 4.2 +/- 4.4, and 3.7 +/- 3.6 for IGT, transient hyperglycemia, and normoglycemia, respectively; P < 0.001), a worse outcome (modified Rankin scale 0-1 at discharge: 40.2 vs. 54.4, 63.8, and 72.3% for IGT, transient hyperglycemia, and normoglycemia, respectively; P < 0.001), and a higher rate of infectious complications (35.6 vs. 12.3, 21.2, and 4.2% for IGT, transient hyperglycemia, and normoglycemia, respectively; P < 0.001). In the multivariate analysis, NIHSS on admission, female sex, and the occurrence of urinary tract infection were independently associated with newly diagnosed diabetes.

CONCLUSIONS

The majority of acute stroke patients have disorders of glucose metabolism, and in most cases this fact has been unrecognized. Diabetes worsens the outcome of acute stroke. Therefore, in the post-acute phase, an oral glucose tolerance test should be recommended in all stroke patients with no prior history of diabetes.

Metabolic Syndrome and the Risk of Stroke in Middle-Aged Men

BACKGROUND AND PURPOSE

The metabolic syndrome, a clustering of disturbed glucose and insulin metabolism, obesity and abdominal fat distribution, dyslipidemia, and hypertension is associated with cardiovascular diseases. The aim of this study was to examine the relationship of metabolic syndrome, as defined by National Cholesterol Education Program (NCEP) and World Health Organization (WHO) criteria, with the risk for stroke.

METHODS

Population-based cohort study with an average follow-up of 14.3 years from eastern Finland. A total of 1131 men with no history of cardiovascular disease and diabetes at baseline participated. Sixty-five strokes occurred, of which 47 were ischemic strokes.

RESULTS

Men with the metabolic syndrome as defined by the NCEP criteria had a 2.05-fold (95% CI, 1.03 to 4.11; P=0.042) risk for all strokes and 2.41-fold (95% CI, 1.12 to 5.32; P=0.025) risk for ischemic stroke, after adjusting for socioeconomic status, smoking, alcohol, and family history of coronary heart disease. Additional adjustment for ischemic changes during exercise test, serum low-density lipoprotein cholesterol, plasma fibrinogen, energy intake for saturated fats, energy expenditure of leisure time physical activity, and white blood cell count, the results remained significant. The risk ratios among men with metabolic syndrome as defined by the WHO criteria were 1.82 (95% CI, 1.01 to 3.26; P=0.046) for all strokes and 2.16 (95% CI, 1.11 to 4.19; P=0.022) for ischemic stroke. After further adjustment, the respective risks were 2.08 (95% CI, 1.12 to 3.87; P=0.020) and 2.47 (95% CI, 1.21 to 5.07; P=0.013).

CONCLUSIONS

The risk of any stroke is increased in men with metabolic syndrome, in the absence of stroke, diabetes and cardiovascular disease at baseline. Prevention of the metabolic syndrome presents a great challenge for clinicians with respect to stroke.

The Cardiometabolic Syndrome and Cardiovascular Disease

The cardiometabolic syndrome is a prevalent metabolic disorder. Epidemiologic studies correlate the cardiometabolic syndrome with an increased risk of coronary heart disease, ischemic stroke, cardiovascular mortality, and total mortality. There is also evidence that the cardiometabolic syndrome is a risk factor for abnormalities in myocardial metabolism, cardiac dysfunction, and arrhythmias such as atrial fibrillation. Multiple imaging modalities, both invasive and noninvasive, may help physicians better define the presence or risk of cardiovascular disease in their patients with the cardiometabolic syndrome.

Diabetes and stroke: Part one—Risk factors and pathophysiology

Diabetes is a major risk factor for stroke and is associated with an increase in overall stroke mortality. The metabolic syndrome associated with insulin resistance is also a significant risk factor for stroke. The etiology of stroke in diabetics is frequently microvascular disease from fibrinoid necrosis, which causes small subcortical infarcts designated as lacunar strokes. Diabetics also have an increased incidence of large vessel intracranial vascular disease. Although strict control of blood sugar has not been shown to reduce the overall incidence of stroke in diabetics, careful management of other associated risk factors, particularly hypercholesterolemia and hypertension, are imperative for the prevention of stroke in diabetic patients.