Using routine HbA1c measurements in stroke and the associations of dysglycaemia with stroke outcomes

Association Between Raised HbA1c Levels and Hemorrhagic Transformation in Patients With Ischemic Stroke

Background

Glycated hemoglobin (HbA1c) is a commonly used indicator of glycemic control in diabetes mellitus. Uncontrolled diabetes can lead to cardiovascular complications. Ischemic strokes are often complicated by hemorrhagic transformation, which is the conversion of an infarcted area into an area of hemorrhage. The purpose of this study is to determine the association of raised HbA1c levels with the occurrence of hemorrhagic transformation in ischemic stroke.

Methods

This is a prospective, single-center cohort study of patients admitted to the Neurology and Medicine wards between June 1 and November 30, 2019. Inclusion criteria included adult patients who were admitted with acute ischemic stroke and had been tested for HbA1c on presentation. There were 110 ischemic stroke patients enrolled in our database. An HbA1c level >53 mmol/mol was considered raised. A comparison was done between the group with raised HbA1c levels and the group with target levels of HbA1c for the occurrence of hemorrhagic transformation. Brain imaging was used to diagnose hemorrhagic transformation.

Results

Out of 110 study participants with ischemic stroke, 70 (63.6%) patients had a history of prior known diabetes. The mean HbA1c levels were 7.44 ± 1.79%. A total of 77% of diabetic patients had raised HbA1c levels (>7%). Hemorrhagic transformation was seen in 21 (19.1%) patients, of whom only 38% (n=8) had raised HbA1c levels. The association between raised HbA1c and hemorrhagic transformation was not found to be statistically significant (p = 0.225).

Conclusion

In this study of patients with ischemic stroke, raised HbA1c levels were not found to be associated with hemorrhagic transformation. There is a need for larger scale studies to find out the cause and mechanism of hemorrhagic transformation in ischemic stroke.

Feasibility trial of metformin XR in people with pre-diabetes and stroke (MIPPS)-randomised open blinded endpoint controlled trial

AIMS

Pre-diabetes is a common condition that affects about 16.4% of Australian adults. Hyperglycaemia is a strong risk factor for the development of stroke. Metformin XR is an approved medication to treat type 2 diabetes in Australia but not pre-diabetes. Additionally, whether it is tolerated following a stroke is unclear. In this pilot study, we aimed to assess the feasibility of Metformin XR in people with stroke and pre-diabetes.

METHODS

In this PROBE design trial, people who had recent stroke (within 3 months) with pre-diabetes were randomized to either the active arm (n = 13) receiving usual care plus Metformin XR (500 mg daily increased to a total daily dose of 1500 mg) or the control group receiving only usual care (n = 13). At baseline & after four months of intervention, clinical and biomedical characteristics, cardiovascular risk factors and medication data were recorded. At one month and 2.5 months into the study, compliance rateandside effects were determined.

RESULTS

This trial showed that it is feasible to recruit, retain and monitor participants. However, the compliance rate was low. Adherence to metformin XR was 52% (IQR:42% to 61%) based on the remaining tablets in the container after 4 months of intervention. None of the reported side effects were deemed to be related to the study treatment and no significant differences were observed between the metformin XR and the control group.

CONCLUSION

Treatment with Metformin XR in participants admitted with stroke and with pre-diabetes is feasible and safe. Strategies are needed to improve adherence in future trials.

HbA1c and clinical outcomes after endovascular treatment in patients with posterior circulation large vessel occlusion: a subgroup analysis of a nationwide registry (BASILAR)

Background and aims

Recently, several clinical trials have shown that increased glycated hemoglobin (HbA1c) level is correlated with poor clinical outcomes in ischemic stroke patients after thrombolysis and possibly after mechanical thrombectomy. However, the effect of HbA1c on posterior circulation large vessel occlusion (PCLVO) patients treated with endovascular thrombectomy (EVT) remains unclear. This multicenter study assessed the association between the HbA1c levels and clinical outcomes in patients with PCLVO after EVT.

Methods

We studied 385 PCLVO ischemic stroke patients included in the EVT for acute basilar artery occlusion study (BASILAR). Patients were divided into a high HbA1c level group (HbA1c >6.5%) and a low HbA1c level group (HbA1c ⩽6.5%). The efficacy outcome was a 90-day favorable functional outcome (modified Rankin Scale 0-3). The safety outcomes included symptomatic intracerebral hemorrhage and mortality at 90 days after EVT.

Results

The frequency of a favorable outcome in patients with an HbA1c ⩽6.5% was significantly higher than that in the HbA1c >6.5% group (41.2% versus 26.2%, p = 0.001). In multivariate analysis with adjusted confounders, high HbA1c levels and favorable outcomes were significantly negatively correlated. There was also a significant association between high HbA1c levels and mortality after 3 months. The negative effects of high HbA1c levels on functional status after 3 months were exacerbated in patients aged ⩾65 years.

Conclusion

Our multicenter study suggests that a higher serum HbA1c level (HbA1c >6.5%) is an independent predictor of a 90-day poor outcome and mortality in patients with PCLVO after EVT, particularly in those aged ⩾65 years.Clinical Trial Registry identifier: ChiCTR1800014759.

Diabetes in ischaemic stroke in a regional Australian hospital - uncharted territory

BACKGROUND

Stroke and diabetes (DM) are significant interrelated healthcare issues but there is a dearth of data on the prevalence of DM among Australia's regional stroke population.

AIMS

We aimed to determine the prevalence of DM in stroke patients at a large regional centre, including sub-analyses on stroke subtypes, glycaemic control and renal function in ischaemic stroke (IS).

METHODS

We conducted a retrospective analysis of all patients (n = 323) with IS or transient ischaemic attack (TIA) admitted to Ballarat Base Hospital from January 2015 to December 2016. Demographic data, cardiovascular risk factors, aetiology/territory of IS, pre-morbid DM status, indicators of glycaemic control and renal impairment were recorded.

RESULTS

DM was present in 28.5% of IS and TIA patients including 4% being newly diagnosed. Among diabetic IS patients, 45.3% had poor glycaemic control (HbA1c ≥7.0%) while 16% had moderate to severe renal impairment (eGFR of <30). The majority of IS were partial anterior circulation stroke (53.4%) and cardioembolism was the commonest mechanism (43.5%). We found no significant association between DM and a specific stroke location or mechanism.

CONCLUSION

Almost a third of IS/TIA patients had DM with a significant proportion showing poor glycaemic control. The DM prevalence in our cohort was comparable to reported rates from other developed countries. While we found no association between DM and a particular stroke type or mechanism, it is likely a reflection of our cohort size. Our study demonstrated that DM, as a significant risk factor in IS, warrants early detection and better management strategies. This article is protected by copyright. All rights reserved.