Type 2 diabetes and risk of non-embolic ischaemic stroke in Japanese men and women

Relationship between serum creatinine to cystatin C ratio and subclinical atherosclerosis in patients with type 2 diabetes

INTRODUCTION

Sarcopenia index (SI), calculated by (serum creatinine/cystatin C)×100, is reported to be associated with sarcopenia. Few studies reported the association between SI and subclinical atherosclerosis. We evaluated the association between SI and subclinical atherosclerosis, assessed by brachial-ankle pulse wave velocity (baPWV).

RESEARCH DESIGN AND METHODS

One hundred seventy-four patients with type 2 diabetes were included in this cross-sectional study. The relationship between SI and baPWV was assessed by Pearson's correlation coefficient. To calculate area under the receiver operator characteristic (ROC) curve (AUC) of SI for the presence of subclinical atherosclerosis, which was defined as baPWV >1800 cm/s, ROC analysis was performed. Logistic regression analyses were performed to assess the effect of SI on the prevalence of subclinical atherosclerosis adjusting for covariates.

RESULTS

Mean age, duration of diabetes, baPWV, and SI were 66.9 (10.1) years, 17.7 (11.6) years, 1802 (372) cm/s, and 77.6 (15.8), respectively. There was an association between SI and baPWV (men; r=-0.25, p=0.001, and women; r=-0.37, p=0.015). The optimal cut-off point of SI for the presence of subclinical atherosclerosis was 77.4 (sensitivity=0.72, specificity=0.58, p<0.001, AUC 0.66 (95% CI: 0.57 to 0.74)). In addition, SI was associated with the prevalence of subclinical atherosclerosis (adjusted OR 0.95, 95% CI: 0.91 to 0.99, p=0.015).

CONCLUSIONS

SI is associated with the prevalence of subclinical atherosclerosis in patients with type 2 diabetes.

Association between 25 Hydroxyvitamin D Concentrations and Lipid Profiles in Japanese with Type 2 Diabetes Mellitus

Low 25 hydroxyvitamin D (25(OH)D) levels are closely associated with the risk of cardiovascular disease. Vitamin D deficiency is more common in patients with type 2 diabetes mellitus than in the general population. In addition, vitamin D status is lower in patients with the metabolic syndrome than in those without the syndrome. Therefore, we examined the association between lipid profiles and 25(OH)D levels. In this case control study, 285 type 2 diabetic patients who attended the Manda Memorial Hospital from March to October 2017 were selected and 25(OH)D, total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, and triglyceride (TG) levels, were obtained. Multiple regression analysis revealed that the association between 25(OH)D concentrations and TG levels was statistically significant (p<0.01) after adjusting for age, sex, body mass index, estimated glomerular flow rate (eGFR), insulin use, duration of diabetes mellitus, glycosylated hemoglobin (HbA1c), alcohol consumption, current smoking, and sampling timing. The serum 25(OH)D level was inversely associated with the TG level after the adjustment for the characteristics of Japanese patients with type 2 diabetes mellitus.

Trigger finger is associated with risk of incident cardiovascular disease in individuals with type 2 diabetes: a retrospective cohort study

INTRODUCTION

Trigger finger is one of the complications affecting the upper extremity in patients with diabetes. Diabetes is also a well-known risk factor that predisposes individuals to cardiovascular diseases (CVDs). This retrospective cohort study aimed to establish the association between trigger finger and the patients with incident CVD with type 2 diabetes.

MATERIALS AND METHODS

Trigger finger was diagnosed by palpating a thickened tendon during flexion or on the manifestation of a locking phenomenon during extension or flexion of either finger. The relationship between trigger finger and other clinical parameters or complications of diabetes was examined by a comparative analysis. Cox regression analysis was used to evaluate the association between trigger finger and incidence of CVD. We calculated the propensity scores using sex, body mass index, age, smoking status, duration of diabetes, estimated glomerular filtration rate, hypertension, dyslipidemia, and hemoglobin A1c as the number of patients with incident CVD during the follow-up period was low.

RESULTS

Among the 399 patients with type 2 diabetes, 54 patients had trigger finger. Patients with trigger finger were significantly older in age and had been suffering from diabetes for a longer duration. They also displayed worse renal function and glycemic control, along with a higher incidence of hypertension, neuropathy and nephropathy. During the average 5.66±1.12 years of follow-up, a total of 18 incidents occurred. According to the Cox regression analysis, trigger finger was shown to be associated with enhanced risk of the incidence of CVD after adjustment for the covariates (adjusted HR=3.33 (95% CI 1.25 to 8.66), p=0.017).

CONCLUSIONS

Trigger finger is associated with the risk of incident CVD in patients with type 2 diabetes. Thus, clinicians must consider these factors at the time of diagnosis of such patients.

Association of Red Meat Intake with the Risk of Cardiovascular Mortality in General Japanese Stratified by Kidney Function: NIPPON DATA80

The consumption of red meat has been recommended for individuals with reduced kidney function. However, red meat intake was recently suspected to increase cardiovascular disease (CVD) risk. We evaluated the association of red meat intake with CVD mortality risk in Japanese with/without reduced kidney function. Overall, 9112 participants of a Japanese national survey in 1980, aged ≥30 years, were followed for 29 years. Red meat intake was assessed using weighed dietary record. Cox proportional hazards models were used to estimate the hazard ratio (HR) of CVD mortality according to sex-specific tertiles of red meat intake. We also performed stratified analyses with/without reduced kidney function defined as estimated glomerular filtration rate less than 60 mL/min/1.73 m². Red meat intake was not associated with CVD mortality risk in men and women. In stratified analyses, the HR of the highest compared with the lowest tertile of red meat intake was lower only in women with reduced kidney function (0.67, 95% confidence interval 0.46-0.98). In conclusion, there were no clear associations between red meat intake and CVD mortality risk in Japanese population; however, a higher intake of red meat was associated with lower risk of future CVD mortality in women with reduced kidney function.

Sex differences in stroke co-morbidities

Males and females possess distinct biological differences that manifest in diverse risk profiles for acute and chronic diseases. A well-documented example of this is ischemic stroke. It has been demonstrated that older females have greater prevalence of, and worse outcome after, ischemic stroke than do males and younger females. Loss of estrogen after menopause is heavily implicated as a contributing factor for this phenomenon; however, there is mounting evidence to suggest that certain risk factors tend to occur more often in older females, such as hypertension and atrial fibrillation, while others more adversely affect females than they do males, such as diabetes and smoking. Sex-specific risk factors, such as oral contraceptive use and menopause, could also contribute to the discrepancy in stroke prevalence and outcome. Additionally, there is evidence to suggest that females tend to present with more nontraditional symptoms of acute stroke than do males, making it more difficult for clinicians to correctly identify the occurrence of a stroke, which may delay the administration of thrombolytic intervention. Finally, certain sociodemographic factors, such as the fact that females were more likely to live alone prior to stroke, may contribute to poorer recovery in females. This review will explore the various co-morbidities and sociodemographic factors that contribute to the greater prevalence of and poorer outcome after stroke in older females and will highlight the critical need for considering sex as a predisposing biological variable in stroke studies.

Malnutrition assessed by controlling nutritional status is correlated to carotid atherosclerosis in patients with type 2 diabetes

Diabetes and malnutrition sometimes overlap. Little is known about the relationship between malnutrition and subclinical atherosclerosis in patients with type 2 diabetes. This cross-sectional study investigated this relationship in patients with type 2 diabetes. We evaluated the relationships between malnutrition assessed by controlling nutritional status (CONUT) score and subclinical atherosclerosis assessed by carotid intima-media thickness (IMT) and carotid plaque scores in 461 consecutive patients with type 2 diabetes. Nutritional assessment indicated that 38% of patients were malnourished (CONUT ≥3). Carotid IMT and carotid plaque scores were significantly higher in patients with malnutrition. Multivariate linear regression analyses revealed that a high CONUT score (CONUT ≥3) was correlated with mean IMT (β = 0.196, p = 0.043) and max IMT (β = 0.243, p = 0.011) in patients taking statins and was also correlated with mean IMT (β = 0.287, p = 0.004), max IMT (β = 0.308, p = 0.002), and plaque score (β = 0.190, p = 0.044) in patients not taking statins after adjusting for age, sex, duration of diabetes, body mass index, hemoglobin A1c, creatine, smoking, and hypertension. Our results demonstrate a relationship between malnutrition and subclinical atherosclerosis in patients with type 2 diabetes.

Health Inequalities Among Elderly Type 2 Diabetes Mellitus Patients in Japan

The influence of socioeconomic status (SES) on health inequalities has received much attention worldwide. This study examined the effect of SES on the following older type 2 diabetes mellitus patient health outcomes: oral hypoglycemic agent (OHA) medication adherence (proportion of days covered, PDC), risk of hospitalization for diabetic macrovascular complications, and in-hospital death. A retrospective cohort design using 2013–2016 claims data was used. Subjects were 58,349 diabetes patients aged >74 years in 2013. Age, sex, residential area, and comorbidities were controlled for. Logistic regression was conducted to assess the effects of income on PDC; survival analysis was used to assess the effects on hospitalization and in-hospital death. Regressions were conducted separately by sex. Compared with the lowest income group, adjusted PDC odds ratios for medium- and high-income males, respectively, were 1.35 (95% CI: 1.27–1.43) and 1.41 (95% CI: 1.30–1.54); females: 1.17 (95% CI: 1.11–1.23) and 1.24 (95% CI: 1.13–1.35). Adjusted hazard ratios (AHRs) for male hospitalization were 0.88 (95% CI: 0.80–0.96) and 0.88 (95% CI: 0.79–0.99); females: 1.00 (95% CI: 0.93–1.07) and 0.95 (95% CI: 0.83–1.08). AHRs for male in-hospital death were 0.83 (95% CI: 0.75–0.91) and 0.62 (95% CI: 0.54–0.70); females: 0.94 (95% CI: 0.87–1.02) and 0.77 (95% CI: 0.65–0.92). Results revealed sex-specific health inequalities among older Japanese diabetes patients. Subjects with worse SES had significantly poorer OHA medication adherence (both sexes), higher hospitalization risk for diabetes complications (males), and higher in-hospital death risk (both sexes).

Expression of vascular infarction-related molecules after anti-vascular endothelium growth factor treatment for diabetic macular edema

To determine whether an intravitreal injection of anti-vascular endothelial growth factor (anti-VEGF) in eyes with diabetic macular edema (DME) affects the vascular infarction-related molecules (VIRMs). Nineteen eyes with DME were treated with 0.5 mg of intravitreal ranibizumab (IVR), and 22 eyes with DME were treated with 2 mg of intravitreal aflibercept (IVA). Blood was collected before, 1 week and 1 month after the injections. Aqueous humor was collected before and 1 month after the injections. The concentration of the VIRMs (cardiac myoglobin, cardiac troponin, intercellular adhesion molecule, monocyte chemotactic protein-1, matrix metalloproteinase-8, placental growth factor [PlGF], tenascin-C, tissue inhibitor of metalloproteinase-1, thrombospondin-2, vascular cell adhesion molecule-1, and VEGF) were determined by the multiplex assay. After the single injection of both types of anti-VEGF agents, the concentration of aqueous VEGF decreased significantly (P < 0.01). The plasma VEGF was reduced significantly at 1 week after the IVA (93.7 ± 17.6 to 39.5 ± 11.6 pg/ml; P < 0.01) but no significant change was seen after IVR (120.2 ± 11.3 to 137.4 ± 17.7 pg/ml). No significant changes were detected for the other VIRMs in the plasma and aqueous. A single intravitreal injection of anti-VEGF for DME does not significantly affect the concentration of several VIRMs.

Type 2 diabetes in midlife and risk of cerebrovascular disease in late life: a prospective nested case-control study in a nationwide Swedish twin cohort

AIMS/HYPOTHESIS

We aimed to examine the association between midlife type 2 diabetes mellitus and cerebrovascular disease (CBD) in late life, and further to explore whether genetic and early-life familial environmental factors (such as shared childhood socioeconomic status and adolescent environment) play a role in this association.

METHODS

In this prospective nested case-control study based on the Swedish Twin Registry, 33,086 twin individuals who were born in 1958 or earlier and were CBD-free before the age of 60 were included. Midlife (40-59 years) type 2 diabetes was ascertained from self-report, the National Patient Registry (NPR) and glucose-lowering medication use. CBD diagnosis (cerebral infarction, occlusion of cerebral arteries, subarachnoid haemorrhage, intracerebral haemorrhage and unspecified CBD) and onset age were identified from the NPR. Late-life CBD was defined as CBD onset age ≥60 years. Generalised estimating equation (GEE) models were used to analyse unmatched case-control data (adjusted for the clustering of twins within a pair). Conditional logistic regression was used in co-twin matched case-control analyses in CBD-discordant twin pairs.

RESULTS

Of all the participants, 1248 (3.8%) had midlife type 2 diabetes and 3121 (9.4%) had CBD in late life. In GEE models adjusted for age, sex, education, BMI, smoking, alcohol consumption, marital status, hypertension and heart disease, the ORs (95% CIs) of type 2 diabetes were 1.29 (1.03, 1.61) for cerebral infarction, 2.03 (1.20, 3.44) for occlusion of cerebral arteries, 0.52 (0.12, 2.21) for subarachnoid haemorrhage and 0.78 (0.45, 1.36) for intracerebral haemorrhage. In multi-adjusted conditional logistic regression, the OR of the type 2 diabetes-cerebral infarction association was 0.96 (0.51, 1.80). The differences in ORs from the GEE and co-twin control analyses were not statistically significant (p = 0.780).

CONCLUSIONS/INTERPRETATION

Midlife type 2 diabetes is significantly associated with increased risk of cerebral infarction and occlusion of cerebral arteries, but not intracerebral haemorrhage or subarachnoid haemorrhage in late life. Genetic and early-life familial environmental factors do not appear to account for the type 2 diabetes-cerebral infarction association, but further clarification is needed.

Association between diabetes mellitus and the risk for major cardiovascular outcomes and all-cause mortality in women compared with men: a meta-analysis of prospective cohort studies

OBJECTIVE

Previous studies have reported sex differences in associations between diabetes mellitus (DM) and the risk of developing coronary heart disease (CHD) and stroke; however, the risk for cardiac death and all-cause mortality in women compared with men has not been reported. Therefore, this quantitative meta-analysis was performed to provide reliable estimates of sex differences in the effect of DM on major cardiovascular outcomes and all-cause mortality, irrespective of DM type.

DESIGN

Meta-analysis.

DATA SOURCES

The PubMed, Embase and the Cochrane Library databases were systematically searched in April 2018.

ELIGIBILITY CRITERIA

Investigations designed as prospective cohort studies that examined the association between DM and major cardiovascular outcomes and all-cause mortality stratified according to sex were included.

DATA EXTRACTION AND SYNTHESIS

Data extraction and quality assessment were independently performed by 2 of the authors, and the relative risk ratio (RRR) obtained using a random effects model was used to measure sex differences in the associations of DM with major cardiovascular outcomes and all-cause mortality.

RESULTS

Thirty prospective cohort studies that reported data from 1 148 188 individuals were included. The pooled women-to-men RRR suggested that female sex was associated with an increased risk for CHD (RRR 1.52(95% CI 1.32 to 1.76); p<0.001), stroke (RRR 1.23(95% CI 1.09 to 1.39); p=0.001), cardiac death (RRR 1.49(95% CI 1.11 to 2.00); p=0.009) and all-cause mortality (RRR 1.51(95% CI 1.23 to 1.85); p<0.001). In addition, sex differences for the investigated outcomes in the comparison between DM and non-DM patients were variable after stratification of studies according to publication year, country, sample size, assessment of DM, follow-up duration, adjustment for important cardiovascular risk factors and study quality.

CONCLUSIONS

Findings of the present study suggested that women with DM had an extremely high risk for CHD, stroke, cardiac death and all-cause mortality compared with men with DM.

Hypercholesterolemia and Lifetime Risk of Coronary Heart Disease in the General Japanese Population: Results from the Suita Cohort Study

Aim: Lifetime risk (LTR) is a measure of disease burden, which presents the probability of occurrence of a specific disease in the remaining lifetime of a group of people for a given index age. This measure is useful for presenting the risk dynamics of a disease at the population level, which constitutes important public health information toward prevention. To date, there have been no studies investigating the LTR for coronary heart diseases (CHDs) in relation to hypercholesterolemia in Asian populations. Therefore, we estimated the LTR of CHDs according to serum low-density lipoprotein cholesterol (LDL-C).

Methods: The participants included in this study were 2,559 men and 2,848 women, enrolled in the Suita Cohort Study of urban residents followed up from 1989 to 2007 for a total of 69,823 person-years. We estimated the sex- and index-age-specific LTR for the first CHD event among participants with or without hypercholesterolemia (LDL-C ≥ 160 mg/dL), accounting for the competing risk for mortality.

Results: For men with hypercholesterolemia, the LTR was 47.2% (95% confidence interval [CI]: 29.3–65.1%) and 44.5% (95% CI: 21.4–68.5%) for those aged 45 and 75, respectively. The LTRs of women with hypercholesterolemia were also higher than of those without hypercholesterolemia. However, their LTRs were lower for all index ages compared to men. These results did not differ for hypercholesterolemia defined by non-high-density lipoprotein cholesterol.

Conclusions: The presence of hypercholesterolemia increases the LTR for CHDs in the Japanese population, especially in men. This estimate can be used in preventive knowledge translation efforts at the population level.

Sex-specific clinical outcomes of impaired glucose status: A long follow-up from the Tehran Lipid and Glucose Study

AIMS

To investigate the sex-specific associations of prediabetes with major clinical outcomes including incident type 2 diabetes, chronic kidney disease, hypertension, coronary heart disease, stroke and all-cause mortality.

METHODS

Among 8498 Iranian adults from the Tehran Lipid and Glucose Study, aged ≥30 years and without diagnosed type 2 diabetes, gender-interactions were assessed for each outcome, followed by sex-separated multivariate-adjusted Cox proportional hazard models to calculate hazard ratios and 95% confidence intervals (CIs) of different prediabetes categories, including impaired fasting glucose (IFG), defined by the American Diabetes Association (ADA) and World Health Organization (WHO), as fasting plasma glucose of 5.6-6.9 mmol/L and 6.1-6.9 mmol/L, respectively, and impaired glucose tolerance, defined as 2-h post challenge plasma glucose of 7.8-11 mmol/L.

RESULTS

Sex-specific associations existed for men between IFG-ADA and chronic kidney disease (hazard ratio: 1.28, 95% CI 0.99-1.65; p_interaction = 0.008) and between IFG-WHO and stroke (hazard ratio: 2.15, 95% CI 1.08-4.27; p_interaction = 0.21); and for women between IFG-ADA and hypertension (hazard ratio: 1.24, 95% CI 1.04-1.48; p_interaction = 0.06) and between impaired glucose tolerance and coronary heart disease (hazard ratio: 1.57, 95% CI 1.14-2.16; p_interaction = 0.05). Among both genders, all prediabetes definitions were associated with type 2 diabetes but none with mortality.

CONCLUSIONS

The hazards of prediabetes definitions may differ between genders depending on the outcome of interest. IFG-WHO among men and impaired glucose tolerance among women are particularly important because of their association with incident stroke and coronary heart disease, respectively. Considering these sex differences could improve personalized management of prediabetes.

The Circulatory Risk in Communities Study (CIRCS): A Long-Term Epidemiological Study for Lifestyle-Related Disease Among Japanese Men and Women Living in Communities

The Circulatory Risk in Communities Study (CIRCS) is an ongoing community-based epidemiological study of lifestyle-related disease involving dynamic prospective cohorts of approximately 12,000 adults from five communities of Japan: Ikawa, Ishizawa and Kita-Utetsu (Akita Prefecture), Minami-Takayasu (Osaka Prefecture), Noichi (Kochi Prefecture), and Kyowa (Ibaraki Prefecture). One of the most notable features of CIRCS is that it is not only an observational cohort study to identify risk factors for cardiovascular diseases (CVD), such as stroke, coronary heart disease, and sudden cardiac death, but it also involves prevention programs for CVD. Using basic, clinical, epidemiological, and statistical techniques, CIRCS has clarified characteristics of CVD and the related risk factors to develop specific methodologies towards CVD prevention in Japanese middle-aged or older adults for more than half a century.

Evaluation of Lenticulostriate Arteries Changes by 7 T Magnetic Resonance Angiography in Type 2 Diabetes

AIM

Progress in neuroimaging techniques allows us to investigate the microvasculature characteristics including lenticulostriate arteries (LSA), which are closely associated with lacunar infarction. Because ischemic stroke is a more critical health problem in East Asian than in other populations, in order to clarify pathological changes underlying cerebral small vessel disease (SVD), we projected an imaging analysis of LSA using high-resolution brain magnetic resonance imaging (MRI) in middle-aged Japanese subjects with type 2 diabetes.

METHODS

Twenty-five subjects with type 2 diabetes and 25 non-diabetic control subjects underwent 7 Tesla (7 T) brain MRI. The prevalences of SVD and LSA structural changes were determined in each group.

RESULTS

SVD prevalence did not differ significantly between the type 2 diabetes and control groups. The average numbers of stems, as well as numbers of branches, of LSA were significantly smaller in diabetic subjects than non-diabetic control subjects. The signal intensity of LSA was markedly decreased, indicating reduced blood flow in type 2 diabetes.

CONCLUSION

In spite of the prevalence of SVD being similar, structural changes and decreased signal intensity of LSA were highly detected in diabetic subjects compared with non-diabetic controls, suggesting that 7 T MRA enables us to determine LSA impairment prior to the development of SVD. Early detection of LSA impairment allows us earlier interventions aimed at the prevention of atherosclerotic events.

Burden of high blood pressure as a contributing factor to stroke in the Japanese community-based diabetic population

Diabetes mellitus is characterized by alterations in blood glucose (BG) metabolism, and glycated hemoglobin (HbA₁c) has been widely used as a marker of the BG concentration. Diabetes often coexists with high blood pressure (BP). High BP and hyperglycemia are well-known risk factors of stroke. We examined the extent to which the increased risk of stroke in diabetic individuals is attributable to BP and BG using prospectively collected data from the Japanese general population. During an average 8.3 ± 2.2 years of follow-up, out 1606 diabetic individuals aged ≥40 years who were free of cardiovascular disease, 119 participants (7.4%) developed stroke. In multivariable analysis, a significant difference in the risk of incident stroke was noted among the BP categories, including normotension (BP1), prehypertension (BP2), and hypertension (BP3; P for trend = 0.001). By contrast, no difference was noted among the BG categories, including HbA₁c levels <7.0% (HB1), 7.0–7.9% (HB2), and ≥8.0% (HB3; P for trend = 0.430). Compared with the category that included both BP1 and HB1, the population-attributable fraction (PAF) for stroke incidence was 52.0% from the BP2 and BP3 categories and 24.1% from the HB2 and HB3 categories, and the increased incidence from the HB2 and HB3 categories was mostly caused from coexistent BP2 and BP3 categories. In conclusion, in the Japanese community-based diabetic population, concomitant BP elevation largely contributes to the increased incidence of stroke and links BG elevation, as indicated by HbA₁c, to the increased risk of stroke.

Interaction of diabetes and smoking on stroke: a population-based cross-sectional survey in China

OBJECTIVES

Diabetes and smoking are known independent risk factors for stroke; however, their interaction concerning stroke is less clear. We aimed to explore such interaction and its influence on stroke in Chinese adults.

DESIGN

Cross-sectional study.

SETTING

Community-based investigation in Xuzhou, China.

PARTICIPANTS

A total of 39 887 Chinese adults who fulfilled the inclusion criteria were included.

METHODS

Participants were selected using a multistage stratified cluster method, and completed self-reported questionnaires on stroke and smoking. Type 2 diabetes mellitus (DM2) was assessed by fasting blood glucose or use of antidiabetic medication. Interaction, relative excess risk owing to interaction (RERI), attributable proportion (AP) and synergy index (S) were evaluated using a logistic regression model.

RESULTS

After adjustment for age, sex, marital status, educational level, occupation, physical activity, body mass index, hypertension, family history of stroke, alcohol use and blood lipids, the relationships between DM2 and stroke, and between smoking and stroke, were still significant: ORs were 2.75 (95% CI 2.03 to 3.73) and 1.70 (95% CI 1.38 to 2.10), respectively. In subjects with DM2 who smoked, the RERI, AP and S values (and 95% CIs) were 1.80 (1.24 to 3.83), 0.52 (0.37 to 0.73) and 1.50 (1.18 to 1.84), respectively.

CONCLUSIONS

The results suggest there are additive interactions between DM2 and smoking and that these affect stroke in Chinese adults.

Nonfasting Glucose and Incident Stroke and Its Types - The Circulatory Risk in Communities Study (CIRCS)

BACKGROUND

The effect of postprandial glucose on the risk of cardiovascular disease has been emphasized, but it is controversial whether nonfasting glucose is related to incident stroke and its types.Methods and Results:We investigated the associations of nonfasting glucose with incident stroke and its types among 7,198 participants aged 40-74 years from the Circulatory Risk in Communities Study, enrolled in 1995-2000. We estimated multivariable hazard ratios (HR) using Cox proportional hazard models. Over a median follow-up of 14.1 years, 291 cases of total stroke (ischemic strokes: 191 including 109 lacunar infarctions) were identified. Nonfasting glucose concentration was associated with greater risk of incident total stroke, ischemic stroke and lacunar infarction when modeled categorically (for prediabetic type: 7.8-11.0 mmol/L vs. normal type: <7.8 mmol/L among all subjects, HR for lacunar infarction was 2.02, 95% confidence interval (CI): 1.19, 3.43) or continuously (per one standard deviation increment among all subjects, HR for lacunar infarction was 1.29, 95% CI: 1.15, 1.45). Diabetic type showed similar results. Population attributable fractions of nonfasting hyperglycemia were 13.2% for ischemic stroke and 17.4% for lacunar infarction.

CONCLUSIONS

Nonfasting glucose concentration, either as a diagnosis of prediabetic and diabetic types or as a continuous variable, proved to be an independent predictor significantly attributed to incident total stroke, especially ischemic stroke and lacunar infarction, in the general population.

The effects of vildagliptin compared with metformin on vascular endothelial function and metabolic parameters: a randomized, controlled trial (Sapporo Athero-Incretin Study 3)

BACKGROUND

Dipeptidyl peptidase-4 (DPP-4) inhibitors may have protective effects in the early stage of atherosclerosis in patients with type 2 diabetes, although similar effects in advanced atherosclerosis were not shown in recent randomized placebo-controlled studies. Therefore, we investigated the efficacy of DPP-4 inhibitor on endothelial function and glycemic metabolism compared with high-dose metformin.

METHODS

In this multicenter, open-labeled, prospective, randomized, parallel-group comparison study, patients with type 2 diabetes treated with low-dose metformin (500-750 mg/day) were enrolled and randomly assigned to a vildagliptin, a DPP-4 inhibitor, add-on group (Vilda) or a double dose of metformin group (high Met) for 12 weeks. Flow-mediated dilation (FMD) and serum metabolic markers were assessed before and after treatment. In addition, glycemic control and metabolic parameters were also assessed.

RESULTS

Ninety-seven subjects (aged 58.7 ± 11.0 years; body mass index, 25.9 ± 4.4 kg/m2; HbA1c, 7.3 ± 0.5%; FMD, 5.8 ± 2.6%) were enrolled. Eight subjects dropped out by the end of the study. There were no significant differences between the two groups in baseline characteristics. After 12 weeks, HbA1c was significantly improved in the Vilda group compared with the high Met group (- 0.80 ± 0.38% vs. - 0.40 ± 0.47%, respectively; p < 0.01). However, there were no significant differences in FMD (- 0.51 [- 1.08-0.06]% vs. - 0.58 [- 1.20-0.04]%). Although the apolipoprotein B/apolipoprotein A1 ratio was significantly reduced in the Vilda group compared with baseline (0.66-0.62; p < 0.01), the change did not differ significantly between the two groups (- 0.04 vs. 0.00; p = 0.27). Adiponectin levels were significantly increased in the Vilda group compared with the high Met group (0.75 μg/mL vs. 0.01 μg/mL; p < 0.01).

CONCLUSIONS

Regardless of glycemic improvement, combination therapy of vildagliptin and metformin did not affect endothelial function but may exert favorable effects on adipokine levels and lipid profile in patients with type 2 diabetes without advanced atherosclerosis.

Relationship between limited joint mobility of hand and carotid atherosclerosis in patients with type 2 diabetes

AIM

Limited joint mobility (LJM) of hand, which is one of a complication of diabetic hand, has a close association with diabetic microangiopathy. However, it remains to be elucidated about the relationships between LJM of hand and subclinical atherosclerosis in patients with type 2 diabetes. Therefore, we conducted a cross-sectional study to evaluate the relationships between LJM of hand and carotid intima-media thickness (IMT) and plaque score in patients with type 2 diabetes.

METHODS

We evaluated the relationships between LJM of hand, and carotid IMT and plaque score, evaluated by carotid ultrasound examination, in 341 consecutive patients with type 2 diabetes. LJM of hand was diagnosed using a 'prayer sign' or 'table test'.

RESULTS

LJM of hand was present in 72 patients. Carotid IMT and plaque score were higher in patients with LJM of hand than those in patients without (1.45±0.66vs. 1.14±0.68mm, P=0.013 and 8.0±5.3vs. 5.4±4.8mm, P<0.001). Multivariate linear regression analysis revealed that LJM of hand was positively correlated with plaque score (β=0.423, P=0.043) after adjusted for age, sex, durations of diabetes, body mass index, hemoglobin A1c, creatinine, uric acid, smoking, hypertension and dyslipidemia.

CONCLUSIONS

Our results demonstrate a relation between LJM of hand and subclinical atherosclerosis, especially plaque score, in patients with type 2 diabetes. Diagnosis of diabetic hand is simple and non-invasive, and thus is a useful method for assessment of subclinical atherosclerosis in patients with type 2 diabetes.

Hypertension with diabetes mellitus: significance from an epidemiological perspective for Japanese

The prevalence of both hypertension and diabetes mellitus is increasing worldwide. Both diseases lead to severe complications such as cardiovascular and chronic kidney diseases, which increase the risk of death over a long period of time. Therefore, the prevention and aggravation of hypertension and diabetes mellitus are major challenges. Because few review articles have focused on the epidemiological perspective of hypertension and diabetes mellitus, we reviewed major observational studies mainly from Japan and from Western countries that have reported on the prevalence of hypertension and diabetes mellitus, the binominal risk of hypertension and diabetes mellitus, and the risk of their coexistence. Our investigation found that approximately 50% of diabetic patients had hypertension, and approximately 20% of hypertensive patients had diabetes mellitus. Those with either hypertension or diabetes mellitus had a 1.5- to 2.0-fold higher risk of having both conditions. These results were similar for both Japan and Western countries. Although comparing the results between Japan and Western countries was difficult because the risks were estimated using widely varying statistical analyses, it was revealed that the coexistence of hypertension and diabetes mellitus certainly increased the risk of complications regardless of the country. The definition, prevalence and medical treatment of hypertension and diabetes mellitus will change in the future. For early intervention based on the latest evidence to prevent severe complications, it is important to accumulate epidemiological knowledge of hypertension and diabetes mellitus and to update the evidence for both Japan and other countries.

Hypertensive diabetic patients: incidence of cardiovascular and renal outcomes in a historical cohort over 11 years

BACKGROUND

Diabetics have increased risks for cardiovascular disease (CVD) and mortality, reducing their life expectancy by up to 15 years. Type 2 diabetes mellitus specifically increases the risk for cardiovascular mortality nearly fivefold. When hypertension is combined with diabetes, the risk of CVD is even greater.

OBJECTIVE

Identify non-fatal cardiovascular outcomes and renal function impairment in a cohort of hypertensive patients in regular treatment in a reference treatment center, over 11 years of follow-up.

METHODS

Historical cohort of hypertensive patients in regular treatment for at least 11 years in a specialized service for hypertension treatment. The exposed group was hypertensive diabetic patients at the beginning of the cohort, and the non-exposed group had hypertension without diabetes. The cohort began in 2004, with follow-ups in 2009 and 2015. Variables used: gender, race, age, physical activity, alcohol consumption, smoking, blood pressure, body mass index, glycated hemoglobin, diabetes and hypertension diagnosis times, treatment time in specialized service, non-fatal cardiovascular outcomes, and renal impairment assessed by creatinine clearance.

RESULTS

139 patients participated in the study (55 diabetic hypertensive; 84 non-diabetic hypertensive), with an initial (2004) mean hypertension treatment time of 5.8 years. Females were the majority (75.5%) in both groups. Groups were similar regarding socio-demographic variables, but the group of hypertensive diabetic patients had higher frequency of obesity and uncontrolled BP, which persisted in all follow-ups. In 11 years of follow-up (2004-2015), the diabetic group had more cardiovascular events, with increased risk of acute myocardial infarction (RR 95% CI 1.6 12.2-95.0), stroke (RR 95% CI 1.3-6.1 27.7) and complications requiring hospitalization (RR 95% CI 1.6 2.2-3.0). Worsened renal function occurred more often in the non-exposed group, but in the end, the proportion of renal function loss was similar between groups.

CONCLUSIONS

Exposure to type 2 diabetes increased the risk of new cardiovascular outcomes over 11 years of follow-up of hypertensive patients. Diabetes by itself increased the risk of cardiovascular outcomes, justifying more intensive actions in this population.

Diabetes mellitus and white matter hyperintensity

White matter hyperintensity (WMH) is a brain lesion detected as a high-intensity area in magnetic resonance imaging T2 and fluid-attenuated inversion recovery images, and it has been suggested that WMH reflects damage to small vessels in periventricular and subcortical areas. Although WMH has been linked to the incidence of stroke, more recently it has been clarified that WMH is also associated with progression of cognitive decline and functional disability, which are components of so-called geriatric syndrome. In addition to hypertension, which is the classical risk factor for WMH, evidence has been accumulating to suggest that diabetes mellitus could also be associated with WMH progression, and some studies have shown that WMH severity is correlated with cognitive decline in patients with diabetes. The factors that accelerate WMH formation in elderly patients with diabetes remain poorly defined. It is considered that insulin resistance is an exacerbating factor, but the effects of hypertension, dyslipidemia or other vascular risk factors have yet be clarified, and further studies are required.

Dietary sodium-to-potassium ratio as a risk factor for stroke, cardiovascular disease and all-cause mortality in Japan: the NIPPON DATA80 cohort study

OBJECTIVES

To evaluate the impact of dietary sodium and potassium (Na-K) ratio on mortality from total and subtypes of stroke, cardiovascular disease (CVD) and all causes, using 24-year follow-up data of a representative sample of the Japanese population.

SETTING

Prospective cohort study.

PARTICIPANTS

In the 1980 National Cardiovascular Survey, participants were followed for 24 years (NIPPON DATA80, National Integrated Project for Prospective Observation of Non-communicable Disease And its Trends in the Aged). Men and women aged 30-79 years without hypertensive treatment, history of stroke or acute myocardial infarction (n=8283) were divided into quintiles according to dietary Na-K ratio assessed by a 3-day weighing dietary record at baseline. Age-adjusted and multivariable-adjusted HRs were calculated using the Mantel-Haenszel method and Cox proportional hazards model.

PRIMARY OUTCOME MEASURES

Mortality from total and subtypes of stroke, CVD and all causes.

RESULTS

A total of 1938 deaths from all causes were observed over 176 926 person-years. Na-K ratio was significantly and non-linearly related to mortality from all stroke (p=0.002), CVD (p=0.005) and total mortality (p=0.001). For stroke subtypes, mortality from haemorrhagic stroke was positively related to Na-K ratio (p=0.024). Similar relationships were observed for men and women. The observed relationships remained significant after adjustment for other risk factors. Quadratic non-linear multivariable-adjusted HRs (95% CI) in the highest quintile versus the lowest quintile of Na-K ratio were 1.42 (1.07 to 1.90) for ischaemic stroke, 1.57 (1.05 to 2.34) for haemorrhagic stroke, 1.43 (1.17 to 1.76) for all stroke, 1.39 (1.20 to 1.61) for CVD and 1.16 (1.06 to 1.27) for all-cause mortality.

CONCLUSIONS

Dietary Na-K ratio assessed by a 3-day weighing dietary record was a significant risk factor for mortality from haemorrhagic stroke, all stroke, CVD and all causes among a Japanese population.

Diabetes and Stroke: Epidemiology, Pathophysiology, Pharmaceuticals and Outcomes

There has been a significant increase in obesity rates worldwide with the corresponding surge in diabetes. Diabetes causes various microvascular and macrovascular changes often culminating in major clinical complications, 1 of which, is stroke. Although gains have been made over the last 2 decades in reducing the burden of stroke, the recent rise in rates of diabetes threatens to reverse these advances. Of the several mechanistic stroke subtypes, individuals with diabetes are especially susceptible to the consequences of cerebral small vessel diseases. Hyperglycemia confers greater risk of stroke occurrence. This increased risk is often seen in individuals with diabetes and is associated with poorer clinical outcomes (including higher mortality), especially following ischemic stroke. Improving stroke outcomes in individuals with diabetes requires prompt and persistent implementation of evidence-based medical therapies as well as adoption of beneficial lifestyle practices.

Do Cardiometabolic Risk Factors Relative Risks Differ for the Occurrence of Ischemic Heart Disease and Stroke?

Background:

The effects of the risk factors of ischemic heart disease (IHD) and stroke on the occurrence of these diseases differ between different populations.

Objectives:

To study the difference in the effects of different cardiovascular (CVD) risk factors on the incidence of IHD and stroke in an Iranian adult population.

Patients and Methods:

The Isfahan Cohort Study (ICS) is a longitudinal study that followed up 6323 subjects older than 35 years with no history of CVD since 2001. Of the original sample, only 5431 participants were contacted and followed up until 2011. The end points were the occurrence of IHD (defined as fatal and non-fatal myocardial infarction, unstable angina, and sudden cardiac death) and stroke. After 10 years of follow-up, 564 new cases of IHD and 141 new cases of stroke were detected. The relative risks (RRs) of cardiometabolic risk factors such as hypertension, diabetes, hypercholesterolemia, hypertriglyceridemia, high low-density lipoprotein cholesterol (LDL-C) level, low high-density lipoprotein cholesterol (HDL-C) level, current smoking, obesity, high waist-to-hip ratio, family history of CVD, and metabolic syndrome were compared between IHD and stroke patients. The ratio of relative risks (RRR) was calculated for comparing two RRs and estimated adjusted RRR was calculated by using generalized linear regression with a log link and binomial distribution.

Results:

The RRs of the occurrence of IHD and stroke in diabetic patients were 1.94 and 3.26, respectively, and the difference was statistically different (P = 0.016). The RR of high LDL-C was significantly higher for IHD than for stroke (P = 0.045), while all the other risk factors showed similar RRs for IHD and stroke, with no significant difference in their RRR, including hypertension. Diabetes and hypertension had the highest RRs for IHD, followed by diabetes, metabolic syndrome, and hypertension for stroke.

Conclusions:

The effect of diabetes mellitus on stroke was more significant than on IHD, and the effect of high LDL-C level was more significant on IHD than on stroke, other risk factors, including hypertension, have similar RRs for IHD and stroke. Health care professionals need more training regarding the RRs of these risk factors in the Iranian society, and health decision makers should consider it in their future policies.

Ischemic Stroke and Its Risk Factors in a Registry-Based Large Cross-Sectional Diabetic Cohort in a Country Facing a Diabetes Epidemic

The main aim of this study is to determine the prevalence and risk factors of ischemic stroke among diabetic patients registered in the Saudi National Diabetes Registry (SNDR) database. A cross-sectional sample of 62,681 diabetic patients aged ≥25 years was used to calculate ischemic stroke prevalence and its risk factors. Univariate and multivariate logistic regression analyses were used to assess the roles of different risk factors. The prevalence of ischemic stroke was 4.42% and was higher in the older age group with longer diabetes duration. Poor glycemic control and the presence of chronic diabetes complications were associated with a high risk of ischemic stroke. History of smoking and type 2 diabetes were more frequent among stroke patients. Obesity significantly decreased the risk for ischemic stroke. Regression analysis for ischemic stroke risk factors proved that age ≥45 years, male gender, hypertension, coronary artery disease (CAD), diabetes duration ≥10 years, insulin use, and hyperlipidemia were significant independent risk factors for ischemic stroke. We conclude that ischemic stroke is prevalent among diabetic individuals, particularly among those with type 2 diabetes. Good glycemic, hypertension, and hyperlipidemia control, in addition to smoking cessation, are the cornerstones to achieve a significant reduction in ischemic stroke risk.

Impact of Metformin on the Severity and Outcomes of Acute Ischemic Stroke in Patients with Type 2 Diabetes Mellitus

BACKGROUND

Diabetes mellitus (DM) is a major risk factor for cardiovascular disease. Metformin therapy reportedly decreases the risk of stroke, but the associations between metformin treatment and neurological severity or patient prognosis have not been investigated in clinical studies. This study evaluated the effects of metformin on stroke severity and outcomes in acute ischemic stroke patients with type 2 DM.

METHODS

We examined 355 stroke patients with type 2 DM without severe renal impairment or prestroke impairment of activities of daily living who were admitted to Kyushu Medical Center between April 2010 and September 2014. Neurological severity was assessed according to the National Institutes of Health Stroke Scale (NIHSS) score on admission. Mild neurological severity was defined as an NIHSS score lower than 3 on admission, and favorable functional outcome was defined as a modified Rankin Scale score of 2 or lower at discharge.

RESULTS

On logistic regression analysis with adjustments for multiple confounding factors, pretreatment with metformin was independently associated with mild neurological symptoms (odds ratio [OR], 2.12; 95% confidence interval [CI], 1.09-4.10; P = .026). In contrast, functional outcomes showed no significant associations. Nevertheless, a benefit of prior metformin use was observed in patients with a prior history of stroke (OR, 11.3; P = .046) and in patients after excluding those with mild stroke severity (OR, 5.64; P = .042).

CONCLUSIONS

Administration of metformin in DM patients prior to stroke onset may be associated with reduced neurological severity and improved acute-phase therapy outcomes.

Impact of Diabetes on Stroke Risk and Outcomes: Two Nationwide Retrospective Cohort Studies

Several limitations existed in previous studies which suggested that diabetic patients have increased risk of stroke. We conducted this study to better understand the stroke risk and poststroke outcomes in patients with diabetes.From the claims data of Taiwan's National Health Insurance, we identified 24,027 adults with new-diagnosed diabetes and 96,108 adults without diabetes between 2000 and 2003 in a retrospective cohort study. Stroke events (included hemorrhage, ischemia, and other type of stroke) during the follow-up period of 2000 to 2008 were ascertained and adjusted risk of stroke associated with diabetes was calculated. A nested cohort study of 221,254 hospitalized stroke patients (included hemorrhage, ischemia, and other type of stroke) between 2000 and 2009 was conducted. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) were calculated for adverse events after stroke hospitalization in patients with and without diabetes.The incidences of stroke in cohorts with and without diabetes were 10.1 and 4.5 per 1000 person-years, respectively. During the follow-up period, diabetic patients had an increased risk of stroke (adjusted hazard ratio: 1.75; 95% CI: 1.64-1.86) than those without diabetes. Associations between diabetes and stroke risk were significant in both sexes and all age groups. Previous diabetes was associated with poststroke mortality (OR: 1.33; 95% CI: 1.19-1.49), pneumonia (OR: 1.30; 95% CI: 1.20-1.42), and urinary tract infection (OR: 1.66; 95% CI: 1.55-1.77). The impact of diabetes on adverse events after stroke was investigated particularly in those with diabetes-related complications.Diabetes was associated with stroke risk, and diabetic patients had more adverse events and subsequent mortality after stroke.

Gender difference in diabetes-associated risk of first-ever and recurrent ischemic stroke

OBJECTIVE

To evaluate the effect of diabetes by gender on the peak-risk of first-ever-ischemic stroke and its recurrence.

METHODS

Administrative datasets including all hospital discharges for ischemic stroke (N = 43,332) in the diabetic (N = 207,568) and non-diabetic (N = 2,808,554) population of the Tuscany region, Italy were used to calculate Hazard ratios (HR) after Cox-regression, of first-ever and recurrent ischemic strokes, between 2005 and 2011.

RESULTS

Overall, diabetes increased the HR of first-ever ischemic stroke by about 50% in both genders. However, this risk significantly declined with age and was higher in women aged 55-74 yr than in men of the same age (HR; 95% CI: 1.392; 1.228-1.579 in age-class 55-64 yr and 1.203; 1.110-1.304 in age class 65-74 yr; p < 0.001). Diabetes also increased the adjusted risk of three-year-stroke recurrence (N = 5,998) in women, independently of age, whereas this was the case in men < 70 yr.

CONCLUSIONS

Diabetes is associated with increased risk of ischemic stroke although it declines with age though at lower rate among women than men. Moreover, diabetic women have greater risk of recurrence than in men > 70 yrs old, supporting a high-risk "time-window" in postmenopausal-elderly diabetic women.

Low-carbohydrate diets and cardiovascular and total mortality in Japanese: a 29-year follow-up of NIPPON DATA80

Long-term safety of consuming low-carbohydrate diets (LCD) in Asian populations, whose carbohydrate intake is relatively high, is not known. In the present study, the association of LCD with CVD and total mortality was assessed using data obtained in the NIPPON DATA80 (National Integrated Project for Prospective Observation of Non-communicable Disease and Its Trends in the Aged 1980) during 29 years of follow-up. At baseline in 1980, data were collected from study participants aged ≥ 30 years from randomly selected areas in Japan. LCD scores were calculated based on the percentage of energy as carbohydrate, fat and protein, estimated by 3 d weighed food records. A total of 9200 participants (56% women, mean age 51 years) were followed up. During the follow-up, 1171 CVD deaths (52% in women) and 3443 total deaths (48% in women) occurred. The multivariable-adjusted hazard ratio (HR) for CVD mortality using the Cox model comparing the highest v. lowest deciles of LCD score was 0·60 (95% CI 0·38, 0·94; P(trend) = 0·021) for women and 0·78 (95% CI 0·58, 1·05; P(trend) = 0·079) for women and men combined; the HR for total mortality was 0·74 (95% CI 0·57, 0·95; P(trend) = 0·029) for women and 0·87 (95% CI 0·74, 1·02; P(trend) = 0·090) for women and men combined. None of the associations was statistically significant in men. No differential effects of animal-based and plant-fish-based LCD were observed. In conclusions, moderate diets lower in carbohydrate and higher in protein and fat are significantly inversely associated with CVD and total mortality in women.

Risk of hospitalization for diabetic macrovascular complications and in-hospital mortality with irregular physician visits using propensity score matching

AIMS/INTRODUCTION

The objective of the present study was to evaluate the risk of diabetic macrovascular complications and in-hospital mortality among diabetic patients with irregular physician visits.

MATERIALS AND METHODS

We carried out a health insurance-based retrospective cohort study using claims data from diabetic patients who were newly hospitalized between April 2010 and September 2010 among beneficiaries of the Fukuoka National Health Insurance Organization. Regular visits were defined as physician visits for diabetes mellitus at least every 3 months between April 2009 and March 2010, whereas other visits or no visits were defined as irregular visits. We assigned 5,940 patients to the regular visit or the irregular visit groups using propensity score matching. We compared in-hospital mortality and hospitalization for diabetic macrovascular complications between the two groups by multiple logistic regression models.

RESULTS

The irregular visit group had a significantly higher risk of hospitalization for acute myocardial infarction (AMI), ischemic heart diseases (IHDs) except AMI, all IHDs, all strokes and diabetic macrovascular complications than did the regular visit group. Adjusted odds ratios for AMI, IHDs except AMI, all IHDs, all strokes, and diabetic macrovascular complications were 3.52 (95% confidence interval [CI] 1.79-6.96), 1.25 (95% CI 1.02-1.54), 1.37 (95% CI 1.12-1.66), 1.29 (95% CI 1.04-1.60), and 1.28 (95% CI 1.10-1.48), respectively.

CONCLUSIONS

The present study shows that the irregular visit group had significantly higher risks of hospitalization for IHD and stroke among diabetic patients. Insurers need to motivate diabetic beneficiaries to make regular visits to physicians.

Diabetes as a risk factor for stroke in women compared with men: a systematic review and meta-analysis of 64 cohorts, including 775,385 individuals and 12,539 strokes

BACKGROUND

Diabetes mellitus is a major cause of death and disability worldwide and is a strong risk factor for stroke. Whether and to what extent the excess risk of stroke conferred by diabetes differs between the sexes is unknown. We did a systematic review and meta-analysis to estimate the relative effect of diabetes on stroke risk in women compared with men.

METHODS

We systematically searched PubMed for reports of prospective, population-based cohort studies published between Jan 1, 1966, and Dec 16, 2013. Studies were selected if they reported sex-specific estimates of the relative risk (RR) for stroke associated with diabetes, and its associated variability. We pooled the sex-specific RRs and their ratio comparing women with men using random-effects meta-analysis with inverse-variance weighting.

FINDINGS

Data from 64 cohort studies, representing 775,385 individuals and 12,539 fatal and non-fatal strokes, were included in the analysis. The pooled maximum-adjusted RR of stroke associated with diabetes was 2·28 (95% CI 1·93-2·69) in women and 1·83 (1·60-2·08) in men. Compared with men with diabetes, women with diabetes therefore had a greater risk of stroke--the pooled ratio of RRs was 1·27 (1·10-1·46; I(2)=0%), with no evidence of publication bias. This sex differential was seen consistently across major predefined stroke, participant, and study subtypes.

INTERPRETATION

The excess risk of stroke associated with diabetes is significantly higher in women than men, independent of sex differences in other major cardiovascular risk factors. These data add to the existing evidence that men and women experience diabetes-related diseases differently and suggest the need for further work to clarify the biological, behavioural, or social mechanisms involved.

FUNDING

None.

Cellular growth factors in relation to mortality from cardiovascular disease in middle-aged Japanese: the JACC study

OBJECTIVE

Limited evidence has been available on the relationships of cellular growth factors with cardiovascular disease in population-based samples.

METHODS

We conducted a nested case-control study under a large prospective cohort study (JACC study) where a total of 39,242 subjects aged 40-79 years provided serum sample. We measured cellular growth factors [insulin-like growth factors I, II and binding protein-3 (IGF-I, IGF-II and IGFBP-3) and transforming growth factor (TGF-β1)] among cases and controls, matched for sex, age, area of residence and year of serum storage.

RESULTS AND CONCLUSIONS

During the follow-up for 9 years, there were 233 deaths from total stroke (49 subarachnoid hemorrhages, 55 intraparenchymal hemorrhages, 71 ischemic strokes), and 97 deaths from coronary heart disease. The multivariable odds ratio (95%CI) of intraparenchymal hemorrhage associated with a 1-SD increment of IGF-I (men:4 8 ng/ml, women: 61 ng/ml) was 0.31 (0.14-0.71). That of ischemic stroke associated with a 1-SD increment of TGF-β1 (men: 8.0 ng/ml, women: 10.9 ng/ml) was 0.58 (0.34-0.98). Serum IGF-II and IGFBP-3 were not associated with mortality from any outcomes. In conclusion, IGF-I was inversely associated with mortality from intraparenchymal hemorrhage while TGF-β1 was so with ischemic stroke, suggesting potential roles of cellular proliferation in the development or prognosis of stroke.

Effect of pre-diabetes on future risk of stroke: meta-analysis

OBJECTIVES

To assess the association between pre-diabetes and risk of stroke, and to evaluate whether this relation varies by diagnostic criteria for pre-diabetes.

DESIGN

Systematic review and meta-analysis of prospective studies.

DATA SOURCES

A search of Medline, Embase, and the Cochrane Library (1947 to 16 July 2011) was supplemented by manual searches of bibliographies of key retrieved articles and relevant reviews.

SELECTION CRITERIA

Prospective cohort studies that reported multivariate adjusted relative risks and corresponding 95% confidence intervals for stroke with respect to baseline pre-diabetes were included.

DATA EXTRACTION

Two independent reviewers extracted data on pre-diabetes status at baseline, risk estimates of stroke, study quality, and methods used to assess pre-diabetes and stroke. Relative risks were pooled using random effects models when appropriate. Associations were tested in subgroups representing different characteristics of participants and studies. Publication bias was evaluated with funnel plots.

RESULTS

The search yielded 15 prospective cohort studies including 760,925 participants. In 8 studies analysing pre-diabetes defined as fasting glucose 100-125 mg/dL (5.6-6.9 mmol/L), the random effects summary estimate did not show an increased risk of stroke after adjustment for established cardiovascular risk factors (1.08, 95% confidence interval 0.94 to 1.23; P = 0.26). In 5 studies analysing pre-diabetes defined as fasting glucose 110-125 mg/dL (6.1-6.9 mmol/L), the random effects summary estimate showed an increased risk of stroke after adjustment for established cardiovascular risk factors (1.21, 1.02 to 1.44; P = 0.03). In 8 studies with information about impaired glucose tolerance or combined impaired glucose tolerance and impaired fasting glucose, the random effects summary estimate showed an increased risk of stroke after adjustment for established cardiovascular risk factors (1.26, 1.10 to 1.43; P < 0.001). When studies that might have enrolled patients with undiagnosed diabetes were excluded, only impaired glucose tolerance or a combination of impaired fasting glucose and impaired glucose tolerance independently raised the future risk of stroke (1.20, 1.07 to 1.35; P = 0.002).

CONCLUSION

Pre-diabetes, defined as impaired glucose tolerance or a combination of impaired fasting glucose and impaired glucose tolerance, may be associated with a higher future risk of stroke, but the relative risks are modest and may reflect underlying confounding.

Diabetes and life expectancy among Japanese - NIPPON DATA80

Life expectancy (LE) among the Japanese population with or without diabetes mellitus was estimated. LE in 40-year old men and women was 41.1 and 47.5 years in those without diabetes and 32.3 and 40.9 years in those with diabetes. The LE of 40-year old men and women with diabetes was 8.8 and 6.6 years shorter than in those without diabetes. Diabetes mellitus leads to a decrease in LE. The presence of impaired glucose tolerance also affected LE inversely.

Prognostic Values of Clockwise and Counterclockwise Rotation for Cardiovascular Mortality in Japanese Subjects

Background—

Although clockwise rotation and counterclockwise rotation are distinct findings of the ECG, their prognostic significance is rarely studied.

Methods and Results—

We studied prognostic values of clockwise and counterclockwise rotation on total, cardiovascular disease (CVD), and subtype mortality using the National Integrated Project for Prospective Observation of Noncommunicable Disease and Its Trends in the Aged, 1980–2004 (NIPPON DATA80) database with a 24-year follow-up. At baseline in 1980, data were collected on study participants aged ≥30 years from randomly selected areas in Japan. We followed 9067 participants (44% men; mean age, 51 years). During the 24-year follow-up, mortality was as follows: 2581 total, 887 CVD, 179 coronary heart disease, 173 heart failure, and 411 stroke. The multivariate-adjusted hazard ratio (HR) with the use of the Cox model including biochemical and other ECG variables revealed that clockwise rotation was significantly positively associated with heart failure in men and women combined (HR=1.79; 95% confidence interval [CI], 1.13–2.83; P =0.013), CVD in men and in men and women combined (HR=1.49; 95% CI, 1.12–1.98; P =0.007 in men; HR=1.28; 95% CI, 1.02–1.59; P =0.030 in combined), and total mortality in men and in men and women combined (HR=1.19; 95% CI, 1.00–1.49; P =0.0496 in men; HR=1.15; 95% CI, 1.00–1.32; P =0.045 in combined). Counterclockwise rotation was significantly inversely associated stroke in men and women combined (HR=0.77; 95% CI, 0.62–0.96; P =0.017), CVD in men and in men and women combined (HR=0.74; 95% CI, 0.59–0.94; P =0.011 in men; HR=0.81; 95% CI, 0.70–0.94; P =0.006 in combined), and total mortality in women (HR=0.87; 95% CI, 0.77–0.98; P =0.023).

Conclusions—

We found a significant positive association of clockwise rotation and a significant inverse association of counterclockwise rotation with CVD mortality in men and in men and women combined, independent of confounding factors including other ECG changes.

Prognostic value of ST-T abnormalities and left high R waves with cardiovascular mortality in Japanese (24-year follow-up of NIPPON DATA80)

Little is known about the prognostic value of ST-segment depression and/or T wave (ST-T abnormalities) with or without left high R waves on electrocardiogram recorded at rest for death from cardiovascular disease (CVD) in Asian populations. Japanese participants without a history of CVD and free of major electrocardiographic (ECG) abnormalities were followed for 24 years. Subjects were divided into 4 groups based on baseline ECG findings: isolated left high R waves, isolated ST-T abnormalities, ST-T abnormalities with left high R waves, and normal electrocardiogram. Cox proportional hazard model was used to estimate risk of CVD mortality in groups with ECG abnormalities compared to the normal group. Of 8,572 participants (44.4% men, mean age 49.5 years; 55.6% women, mean age 49.4 years), 1,142 had isolated left high R waves, 292 had isolated ST-T abnormalities, and 128 had ST-T abnormalities with left high R waves at baseline. Multivariable-adjusted hazard ratios of ST-T abnormalities with left high R waves for CVD mortality were 1.95 (95% confidence interval 1.25 to 3.04) in men and 2.68 (95% confidence interval 1.81 to 3.97) in women. Isolated ST-T abnormalities increased the risk for CVD death by 1.66 times (95% confidence interval 1.01 to 2.71) in men and 1.62 times (95% confidence interval 1.18 to 2.24) in women. Association of ECG abnormalities with CVD mortality was independent of age, body mass index, systolic blood pressure, serum cholesterol, blood glucose, smoking and drinking, and antihypertensive medication. In conclusion, ST-T abnormalities with or without left high R waves on electrocardiogram recorded at rest constitute an independent predictor of CVD mortality in Japanese men and women.

Associations of impaired glucose metabolism and dyslipidemia with cardiovascular diseases: what have we learned from Japanese cohort studies for individualized prevention and treatment?

Metabolic disorder is a modifiable risk factor for cardiovascular diseases (CVD), and lifestyle modification is the key to improving metabolic disorder. Diabetes mellitus has been shown to be a risk factor for coronary heart disease (CHD) and ischemic stroke in both Western and Japanese populations. An association between impaired fasting glucose and pre-hypertension found in an urban Japanese population emphasized the combined risk of CVD. Mean total cholesterol levels in Japan have been increasing in the last three decades. The Japanese evidence for the positive association of total cholesterol with CHD is similar to that in the West. Higher low-density lipoprotein cholesterol (LDL-C) levels pose an increased risk of CHD and atherothrombotic infarction, whereas lower LDL-C levels may pose an increased risk of intracerebral hemorrhage in Japan. Overall, the studies reviewed here show that impaired glucose metabolism and dyslipidemia are emerging risk factors for CVD in the Japanese population.

Adiposity and risk of cardiovascular diseases in Japan: secular trend, individual level associations and causal pathway - implications for the prevention of cardiovascular diseases in societies with rapid economic development

In Japan, overweight/obesity in adults defined as a body mass index of 25 kg/m² or over has roughly doubled among middle-aged men over the past few decades. In parallel with a population rightward shift in the degree of obesity, the proportion of hypertension attributed to overweight has increased. There is an indication that the incidence of ischemic stroke and coronary heart disease remains stable or has been increasing among men. These facts indicate that the relative importance of cardiovascular diseases (CVD) risk factors may have changed. Although it was confirmed at an individual level that the degree of obesity was positively associated with CVD incidence, there is a sizeable proportion of individuals who are at an increased CVD risk state without being overweight/obese in today’s Japan. Thus, further implementation and promotion of activities are needed to bring about meaningful changes in the obesity trend in communities that are harmonized with other domains of CVD prevention activities.

Dietary glycemic index, glycemic load, and intake of carbohydrate and rice in relation to risk of mortality from stroke and its subtypes in Japanese men and women

We assessed the relationship of the dietary glycemic index (GI), glycemic load (GL), and intake of carbohydrate and rice, and risk of mortality from stroke and its subtypes. The cohort consisted of 12,561 men and 15,301 women residing in Takayama, Japan, in 1992. At the baseline, a food frequency questionnaire was administered; and the dietary GI, GL, and intake of carbohydrates and rice were estimated. Deaths from stroke occurring in the cohort were prospectively noted until 1999 with data from the office of the National Vital Statistics. The risk of mortality from stroke was assessed with a Cox proportional hazard model after adjusting for age; body mass index; smoking status; physical activity; history of hypertension; education; and intake of total energy, alcohol, dietary fiber, salt, and total fat. The risk of stroke subtypes was assessed in the age-adjusted model. The hazard ratios of total stroke comparing the highest vs the lowest quartiles of the dietary GI were 0.78 (95% confidence interval [CI], 0.41-1.47) with P(trend) = .50 in men and 2.09 (95% CI, 1.01-4.31) with P(trend) = .10 in women. Among women, the association was also significant with the risk of ischemic stroke (hazard ratio = 2.45; 95% CI, 1.01-5.92; P(trend) = .03); and a significant positive trend was also observed between dietary GL and mortality from hemorrhagic stroke (P(trend) = .05). The current study implies that diets with a high dietary GI increase the risk of mortality from stroke among Japanese women.