Prognosis of Ischemic Stroke With Newly Diagnosed Diabetes Mellitus According to Hemoglobin A1c Criteria in Chinese Population

Associations of diabetes status and glucose measures with outcomes after endovascular therapy in patients with acute ischemic stroke: an analysis of the nationwide TREAT-AIS registry

Background

Hyperglycemia affects the outcomes of endovascular therapy (EVT) for acute ischemic stroke (AIS). This study compares the predictive ability of diabetes status and glucose measures on EVT outcomes using nationwide registry data.

Methods

The study included 1,097 AIS patients who underwent EVT from the Taiwan Registry of Endovascular Thrombectomy for Acute Ischemic Stroke. The variables analyzed included diabetes status, admission glucose, glycated hemoglobin (HbA1c), admission glucose-to-HbA1c ratio (GAR), and outcomes such as 90-day poor functional outcome (modified Rankin Scale score ≥ 2) and symptomatic intracranial hemorrhage (SICH). Multivariable analyses investigated the independent effects of diabetes status and glucose measures on outcomes. A receiver operating characteristic (ROC) analysis was performed to compare their predictive abilities.

Results

The multivariable analysis showed that individuals with known diabetes had a higher likelihood of poor functional outcomes (odds ratios [ORs] 2.10 to 2.58) and SICH (ORs 3.28 to 4.30) compared to those without diabetes. Higher quartiles of admission glucose and GAR were associated with poor functional outcomes and SICH. Higher quartiles of HbA1c were significantly associated with poor functional outcomes. However, patients in the second HbA1c quartile (5.6-5.8%) showed a non-significant tendency toward good functional outcomes compared to those in the lowest quartile (<5.6%). The ROC analysis indicated that diabetes status and admission glucose had higher predictive abilities for poor functional outcomes, while admission glucose and GAR were better predictors for SICH.

Conclusion

In AIS patients undergoing EVT, diabetes status, admission glucose, and GAR were associated with 90-day poor functional outcomes and SICH. Admission glucose was likely the most suitable glucose measure for predicting outcomes after EVT.

Increased Two-Hour Post-Load Plasma Glucose Fluctuation Corresponds with Worse Clinical Prognoses among Acute Ischemic Stroke Patients without a History of Diabetes Mellitus

INTRODUCTION

This study aimed to evaluate the relationship between 2-h post-load minus fasting plasma glucose (2hPG-FPG) and 1-year clinical outcomes, such as death, stroke recurrence, and modified Rankin Scale (mRS) ≥2-3 among acute ischemic stroke (AIS) patients without diabetes mellitus (DM) history.

METHODS

1,214 AIS patients without DM history, obtained from ACROSS-China, were divided into 4 quartiles, based on 2hPG-FPG measurements obtained 14 days post-admission. Four models were constructed using multivariate Cox and logistic regression analyses, based on the inclusion of age, gender, trial of ORG 10172 in acute stroke treatment, NIH Stroke Scale scores (model 1), plus 10 other clinical parameters (model 2), plus newly diagnosed DM (NDDM) post-admission (model 3), plus 2hPG and FPG (model 4). Associations found from those 4 models between 2hPG-FPG and 1-year clinical outcomes were confirmed via stratification, multiplicative interaction, sensitivity, and restricted cubic spline analyses.

RESULTS

The highest quartile of 2hPG-FPG, after adjusting for variables, such as stroke severity (model 2), was independently associated with death, stroke recurrence, and mRS ≥2-3 (odds ratio [OR] = 3.95, 2.96, 4.15, and 4.83, respectively, all p < 0.0001). Increased 2hPG-FPG remained independently associated with mRS ≥2-3 in models 3-4, as well as increased mRS ≥2 under stratification analyses among both non-NDDM and NDDM patients.

CONCLUSION

2hPG-FPG is a relatively specific indicator of poorer 1-year clinical prognoses among AIS patients, independent of NDDM, 2hPG, and FPG post-hospital admission. Therefore, the oral glucose tolerance test could be a useful approach for detecting a higher likelihood for developing poorer prognoses among patients without DM history.

Association between diabetes duration and 1-year prognosis of stroke: A national registry study

BACKGROUND AND PURPOSE

Diabetes mellitus is a strong independent risk factor for stroke recurrence. However, the association between diabetes duration and the prognosis of stroke remains uncertain. We aimed to characterize whether an association exists between diabetes duration and stroke outcomes in patients with ischemic stroke or transient ischemic attack (TIA).

METHODS

Between 2015 and 2018, 14,674 patients with ischemic stroke or TIA within 7 days and older than 18 years from the Third China National Stroke Registry (CNSR-III) were included in this analysis. Diabetes duration at baseline was collected by face-to-face interviews and further categorized into groups of without diabetes, diabetes < 4, 4 to <8 and ≥8 years. The association between diabetes duration and clinical outcomes, including stroke recurrence, poor function outcome (modified Rankin Scale score of 3-6), and all-cause mortality at the 1-year follow-up after stroke onset, was evaluated by a multivariable Cox proportional hazard regression model, competing risk model and logistic regression model with adjustment for demographic and clinical features.

RESULTS

Among the 14,674 patients included, the average age was 62.0 years, and 68.5% were male. There were 1419 (9.7%) patients who had stroke recurrence, 1912 (13.0%) who had poor function outcome, and 478 (3.3%) who had all-cause mortality at the 1-year follow-up. After adjusting for potential covariates, a diabetes duration ≥8 years was associated with an increased risk of 1-year stroke recurrence (adjusted hazards ratio [HR], 1.31; 95% CI, 1.05-1.64; p = .02) in comparison to those without Diabetes mellitus. Using a competing risk regression model, a diabetes duration ≥8 years was a significant risk factor for stroke recurrence (HR, 1.31; 95% CI, 1.12-1.53). In contrast, there was no significant association between diabetes duration < 4, 4 to <8 years and clinical outcomes.

CONCLUSIONS

Long-term diabetes duration (≥8 years), but not short-term diabetes duration, was associated with an increased risk of 1-year stroke recurrence in patients with ischemic stroke or TIA.

Combined Oral Triglyceride and Glucose Tolerance Test After Acute Ischemic Stroke to Predict Recurrent Vascular Events: The Berlin “Cream&Sugar” Study

Background:

Elevated triglyceride and glucose levels are associated with an increased cardiovascular disease risk including ischemic stroke. It is not known whether the response to a combined oral triglyceride and glucose challenge after ischemic stroke improves identification of patients with increased risk for recurrent vascular events.

Methods:

The prospective, observational Berlin “Cream&Sugar” study was conducted at 3 different university hospital sites of the Charité–Universitätsmedizin Berlin, Germany, between January 24, 2009 and July 31, 2017. Patients with first-ever ischemic stroke were recruited 3 to 7 days after stroke. An oral triglyceride tolerance test (OTTT) and consecutive blood tests before (t 0 ) as well as 3 (t 1 ), 4 (t 2 ), and 5 hours (t 3 ) after OTTT were performed in fasting patients. An oral glucose tolerance test was performed in all nondiabetic patients 3 hours after the start of OTTT. Outcomes of the study were recurrent fatal or nonfatal stroke as well as a composite vascular end point including stroke, transient ischemic attack, myocardial infarction, coronary revascularization, and cardiovascular death assessed 1 year after stroke. Cox regression models were used to estimate hazard ratios and corresponding 95% CIs between patients with high versus low levels of triglyceride and glucose levels.

Results:

Overall 755 patients were included; 523 patients completed OTTT and 1-year follow-up. Patients were largely minor strokes patients with a median National Institutes of Health Stroke Scale score of 1 (0–3). Comparing highest versus lowest quartiles of triglyceride levels, neither fasting (adjusted hazard ratio t0 , 1.24 [95% CI, 0.45–3.42]) nor postprandial triglyceride levels (adjusted hazard ratio t3 , 0.44 [95% CI, 0.16–1.25]) were associated with recurrent stroke. With regard to recurrent vascular events, results were similar for fasting triglycerides (adjusted hazard ratio t0 , 1.09 [95% CI, 0.49–2.43]), however, higher postprandial triglyceride levels were significantly associated with a lower risk for recurrent vascular events (adjusted hazard ratio t3 , 0.42 [95% CI, 0.18–0.95]). No associations were observed between fasting and post–oral glucose tolerance test blood glucose levels and recurrent vascular risk. All findings were irrespective of the diabetic status of patients.

CONCLUSIONS:

In this cohort of patients with first-ever‚ minor ischemic stroke, fasting triglyceride or glucose levels were not associated with recurrent stroke at one year after stroke. However, higher postprandial triglyceride levels were associated with a lower risk of recurrent vascular events which requires further validation in future studies. Overall, our results do not support the routine use of a combined OTTT/oral glucose tolerance test to improve risk prediction for recurrent stroke.

Prevalence and In-hospital outcomes of diabetes among acute ischemic stroke patients in china: results from the Chinese Stroke Center Alliance

Background

Patients with ischemic stroke and diabetes are classified as extreme risk for secondary prevention, with much attention and specific management. However, the up-to-date information regarding the burden of diabetes in acute ischemic stroke (AIS) patients is lacking in China, and evidence for an association between diabetes and in-hospital outcomes after AIS remains controversial.

Methods

This quality improvement study was conducted at 1,476 participating hospitals in the Chinese Stroke Center Alliance between 2015 and 2019. Prevalence of diabetes was evaluated in the overall study population and different subgroups. The association between diabetes and in-hospital outcomes in AIS patients was analyzed by using multivariable logistic regression analysis and propensity score-matched analysis.

Results

Of 838,229 patients with AIS, 286,252 (34.2%) had diabetes/possible diabetes. The prevalence of diabetes/possible diabetes was higher in women than in men (37.6% versus 32.1%). Patients with diabetes/possible diabetes had higher rates of adverse in-hospital outcomes than those without. Multivariable analysis revealed a significant association between diabetes/possible diabetes and adverse in-hospital outcomes (all-cause mortality: odds ratio [OR], 1.30 [95% confidence interval [CI], 1.23–1.38]; major adverse cardiovascular events (MACEs): OR, 1.08 [95% CI, 1.06–1.10]) in AIS patients. The excess risk of in-hospital outcomes still remained in AIS patients with diabetes/possible diabetes after propensity score-matching analysis (all-cause mortality: OR, 1.26 [95% CI, 1.17–1.35]; MACEs: OR, 1.07 [95% CI, 1.05–1.10]).

Conclusion

Diabetes was highly prevalent among AIS patients in China and associated with worse in-hospital outcomes. Greater efforts to increase targeted approach to secondary prevention treatments of diabetes in AIS patients are warranted.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00415-022-11112-z.

Prognostic Significance of Admission Glucose Combined with Hemoglobin A1c in Acute Ischemic Stroke Patients with Reperfusion Therapy

Background: Elevated admission glucose and hemoglobin A1c (HbA1c) levels have been suggested to be associated with 90-day functional outcomes in acute ischemic stroke (AIS) patients with endovascular thrombectomy (EVT). However, whether the prognostic significance of admission glucose and that of HbA1c have a joint effect on patients with intravascular thrombolysis (IVT) and/or EVT remains unclear. This study aimed to explore the association between admission glucose combined with HbA1c and outcomes in patients with reperfusion therapy. Methods: Consecutive AIS patients treated with IVT and/or EVT between 2 January 2018 and 27 February 2021 in West China hospital were enrolled. Admission glucose and HbA1c levels were measured at admission. Participants were divided into four groups according to admission glucose level (categorical variable: <7.8 and ≥7.8 mmol/L) and HbA1c level (categorical variable: <6.5% and ≥6.5%): normal glucose and normal HbA1c (NGNA), normal glucose and high HbA1c (NGHA), high glucose and normal HbA1c (HGNA), and high glucose and high HbA1c (HGHA). The primary outcome was an unfavorable functional outcome defined as a modified Rankin Scale (mRS) ≥ 3. The secondary outcome was all-cause mortality at 90 days. Results: A total of 519 patients (mean age, 69.0 ± 13.4 years; 53.8% males) were included. Patients in the HGHA group had a significantly increased risk of unfavorable functional outcome (OR, 1.81; 95%CI, 1.01–3.23) and mortality (OR, 1.75; 95%CI, 1.01–3.06) at 90 days compared with those in the NGNA group after adjustment for confounders. There was no significant association between NGHA (OR, 0.43; 95%CI, 0.12–1.53) or HGNA (OR, 1.46; 95%CI, 0.84–2.56) and outcomes compared to the NGNA group. Conclusion: The combination of high admission glucose and high HbA1c level was significantly associated with unfavorable functional outcome and mortality at 90 days in AIS patients with reperfusion therapy.

Diabetes As an Independent Risk Factor for Stroke Recurrence in Ischemic Stroke Patients: An Updated Meta-Analysis

INTRODUCTION

Stroke and its recurrence and diabetes will increase in incidence as the population ages globally. This study explores the relationship between diabetes and stroke recurrence to understand if diabetes is an independent predictor for stroke recurrence in ischemic stroke (IS) patients.

METHODS

We conducted a systematic review and meta-analysis of studies on the effect of diabetes on stroke recurrence among patients with IS. We searched population-based studies published before 15th February 2021 in PubMed and EMBASE following PRISMA guidelines. Random-effects estimates of the pooled hazard ratio (HR) and 95% confidence intervals (CIs) of each study were generated. A funnel plot and an Egger test were performed to evaluate publication bias. All statistical analyses were conducted in the R software 4.0.1 and Stata 16.0.

RESULTS

The search identified 3,121 citations, of which 27 studies met inclusion criteria. Diabetes was associated with a significant risk of stroke recurrence in all IS patients (pooled HR, 1.50; 95% CI: 1.36-1.65; I2 = 61.0%). Similar results were found in lacunar stroke patients with diabetes (pooled HR, 1.65; 95% CI: 1.41-1.92; I2 = 22.0%). Moreover, we found that the risk of recurrent IS among patients of IS with diabetes was higher than that in those without diabetes (pooled HR, 1.53; 95% CI: 1.30-1.81; I2 = 74.0%).

CONCLUSION

Diabetes is an independent risk factor for stroke recurrence among patients with IS.

Newly diagnosed diabetes has high risk for cardiovascular outcome in ischemic stroke patients

We investigated cardiovascular outcomes in ischemic stroke patients with newly diagnosed diabetes mellitus (DM) compared with those of patients with previously known DM and no DM using the glycosylated hemoglobin (HbA1c) criteria. The relationship between new DM diagnosis and cardiovascular risk remains unclear to date. We performed post hoc analysis using the data of participants from the Prevention of Cardiovascular events in iSchemic Stroke patients with high risk of cerebral hemOrrhage (PICASSO) trial. Newly diagnosed DM was defined as HbA1c of ≥ 6.5% without known DM history. The outcome was the incidence of composite cardiovascular events, including stroke (ischemic and hemorrhagic), myocardial infarction, and cardiovascular death. In total, 1306 patients were included; 38 patients (2.9%) had newly diagnosed DM; 438 patients (33.5%), known DM; and 830 patients (63.6%), no DM. In patients with newly diagnosed DM, known DM, and no DM, the incidence of ischemic stroke was 8.93, 3.79, and 2.64 per 100 person-years (log-rank test; p = 0.0092), while that of composite cardiovascular events was 8.93, 5.92, and 3.87 per 100 person-years (p = 0.025), respectively. Newly diagnosed DM was an important risk factor for ischemic stroke and composite cardiovascular events after ischemic stroke.

Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT01013532.

Glycated Hemoglobin as a Marker for Predicting Outcomes of Patients With Stroke (Ischemic and Hemorrhagic): A Systematic Review and Meta-Analysis

Background: Glycated hemoglobin (HbA1c) has emerged as a useful biochemical marker reflecting the average glycemic control over the last 3 months, and the values are not affected by short-term transient changes in blood glucose levels. However, its prognostic value in the acute neurological conditions such as stroke is still not well-established. The present meta-analysis was conducted to assess the relationship of HbA1c with outcomes such as mortality, early neurological complications, and functional dependence in stroke patients.

Methods: A systematic search was conducted for the PubMed, Scopus, and Google Scholar databases. Studies, either retrospective or prospective in design that examined the relationship between HbA1c with outcomes of interest and presented the strength of association in the form of adjusted odds ratio/hazard ratios were included in the review. Statistical analysis was done using STATA version 13.0.

Results: A total of 22 studies (15 studies on acute ischemic stroke and seven studies on hemorrhagic stroke) were included in the meta-analysis. For patients with acute ischemic stroke, each unit increase in HbA1c was found to be associated with an increased risk of mortality within 1 year, increased risk of poor functional outcome at 3 months, and an increased risk of symptomatic intracranial hemorrhage (sICH) within 24 h of admission. In those with HbA1c ≥ 6.5%, there was an increased risk of mortality within 1 year of admission, increased risk of poor functional outcomes at 3 and 12 months as well as an increased risk of symptomatic intracranial hemorrhage (sICH) within 24 h of admission. In patients with hemorrhagic stroke, each unit increase in HbA1c was found to be associated with increased risk of poor functional outcome within the first 3 months from the time of admission for stroke. In those with HbA1c ≥ 6.5%, there was an increased risk of poor functional outcome at 12 months.

Conclusions: The findings indicate that glycated hemoglobin (HbA1c) could serve as a useful marker to predict the outcomes in patients with stroke and aid in the implementation of adequate preventive management strategies at the earliest.

Stress hyperglycemia may have higher risk of stroke recurrence than previously diagnosed diabetes mellitus

We aim to evaluate the risk of stroke recurrence among non-diabetes mellitus (non-DM), previously diagnosed diabetes mellitus (PDDM), newly diagnosed diabetes mellitus-related hyperglycemia (NDDM-RH) and stress hyperglycemia after minor stroke or TIA. Totally, 3026 patients with baseline fasting glucose and glycated albumin from the CHANCE trial (Clopidogrel in High-Risk Patients with Acute Nondisabling Cerebrovascular Events) were included. Patients were classified as non-DM, PDDM, NDDM-RH and stress hyperglycemia according to the status of glucose metabolism. The primary outcome was stroke recurrence during 90-day follow up. Cox regression was performed to estimate the relationship between the status of glucose metabolism and risk of 90-day stroke recurrence. Compared with PDDM, NDDM-RH had a similar risk of 90-day stroke recurrence (hazard ratios [HR]1.39, 95% confidence intervals [CI] 0.94-2.04), while stress hyperglycemia had approximately a 5.3-fold increased risk of 90-day stroke recurrence after adjusted for confounding covariates (HR 5.32, 95% CI 3.43-8.26). Parallel results were found for 90-day recurrent ischemic stroke and composite events. Compared with PDDM in minor stroke or TIA, a parallel risk of 90-day stroke recurrence were observed for NDDM-RH, while stress hyperglycemia might relate to higher risk of 90-day stroke recurrence.

Clarifying the effects of diabetes on the cerebral circulation: Implications for stroke recovery and beyond

Given the sheer increased number of victims per year and the availability of only one effective treatment, acute ischemic stroke (AIS) remains to be one of the most under-treated serious diseases. Diabetes not only increases the incidence of ischemic stroke, but amplifies the ischemic damage, upon which if patients with diabetes suffer from stroke, he/she will confront increased risks of long-term functional deficits. The grim reality makes it a pressing need to intensify efforts at the basic science level to understand how diabetes impairs stroke recovery. This review retrospects the clinical and experimental studies in order to elucidate the detrimental effect of diabetes on cerebrovascular circulation including the major arteries/arterioles, collateral circulation, and neovascularization to shed light on further exploration of novel strategies for cerebral circulation protection before and after AIS in patients with diabetes.

Lipid Accumulation Product Combined With Urine Glucose Excretion Improves the Efficiency of Diabetes Screening in Chinese Adults

BACKGROUND

To compare the efficacy of lipid accumulation product (LAP) and urine glucose excretion (UGE) in predicting diabetes and evaluate whether the combination of LAP and UGE would help to improve the efficacy of using LAP alone or UGE alone in identifying diabetes.

METHODS

Data from 7485 individuals without prior history of diabetes who participated in a cross-sectional survey in Jiangsu, China, were analyzed. Each participant underwent an oral glucose-tolerance test. Operating characteristic curves (ROC) and logistic regression analyses were used to evaluate the performance of LAP and UGE in identification of newly diagnosed diabetes (NDM) and prediabetes (PDM).

RESULTS

For subjects with NDM, the area under the ROC curve was 0.72 for LAP and 0.85 for UGE, whereas for PDM, these values were 0.62 and 0.61, respectively. Furthermore, LAP exhibited a comparable sensitivity with UGE in detecting NDM (76.4% vs 76.2%, p = 0.31). In predicting PDM, LAP showed a higher sensitivity than UGE (66.4% vs 42.8%, p < 0.05). The combination of LAP and UGE demonstrated a significantly higher sensitivity than that of LAP alone and UGE alone for identification of NDM (93.6%) and PDM (80.1%). Moreover, individuals with both high LAP and high UGE had significantly increased risk of NDM and PDM than those with both low LAP and low UGE.

CONCLUSIONS

The combination of LAP and UGE substantially improved the efficacy of using LAP and using UGE alone in detecting diabetes, and may be a novel approach for mass screening in the general population.

Comparison of oral glucose tolerance test and HbA1c in detection of disorders of glucose metabolism in patients with acute stroke

Background

Diabetes is an increasingly important risk factor for ischemic stroke and worsens stroke prognosis. Yet a large proportion of stroke patients who are eventually diabetic are undiagnosed. Therefore, it is important to have sensitive assessment of unrecognized hyperglycaemia in stroke patients.

Design

Secondary outcome analysis of a randomized controlled trial focussing on parameters of glucose metabolism and detection of diabetes and prediabetes in patients with acute ischemic stroke (AIS).

Methods

A total of 130 consecutively admitted patients with AIS without previously known type 2 diabetes mellitus (T2DM) were screened for diabetes or prediabetes as part of secondary outcome analysis of a randomized controlled trial that tested lifestyle intervention to prevent post-stroke cognitive decline. Patients had the oral glucose tolerance test (OGTT) and glycated hemoglobin (HbA1c) measurements in the second week after stroke onset and after 1 year. The detection rates of diabetes and prediabetes based on the OGTT or HbA1c values were compared.

Results

By any of the applied tests at the second week after stroke onset 62 of 130 patients (48%) had prediabetes or T2DM. Seventy-five patients had results from both tests available, the OGTT and HbA1c; according to the OGTT 40 (53.3%) patients had normal glucose metabolism, 33 (44%) had prediabetes, two (2.7%) T2DM. In 50 (66.7%) patients the HbA1c results were normal, 24 (32%) in the prediabetic and one (1.3%) in the diabetic range. The detection rate for disorders of glucose metabolism was 10% higher (absolute difference; relative difference 29%) with the OGTT compared with HbA1c. After 1 year the detection rate for prediabetes or T2DM was 7% higher with the OGTT (26% relative difference).

The study intervention led to a more favourable evolution of glycemic status after 1 year.

Conclusion

The OGTT is a more sensitive screening tool than HbA1c for the detection of previously unrecognized glycemic disorders in patients with acute stroke with an at least a 25% relative difference in detection rate. Therefore, an OGTT should be performed in all patients with stroke with no history of diabetes.

Trial registrationhttp://clinicaltrials.gov. Unique identifier: NCT01109836.

Is functional disability a risk equivalent to the comorbidity of multi-vascular risk factors for cardiovascular events and all-cause death? A 5-year follow-up study

Background/objectives: Functional disability (FD) is common after stroke and associated with the occurrence of future adverse events; however, whether FD is as strong a risk factor as comorbid vascular risk factors for cardiovascular events and death is unclear. Methods: Consecutive patients 3-6 months after index ischemic stroke were assessed at baseline and followed up for documented new cardiovascular events (recurrent stroke, acute myocardial infarction, and sudden death) and death within 5 years. Comorbidity of vascular risk factors was stratified as low or intermediate-to-high risk according to the Stroke Prognostic Instrument II. Four mutually exclusive cohorts were identified (1) intermediate-to-high risk only, n = 505, (2) FD only, n = 78, (3) both intermediate-to-high risk and FD, n = 264, and (4) low risk and no FD, n = 240. Results: The incidence of cardiovascular events was lowest in patients free of FD with low risk, followed by patients with FD alone, intermediate-to-high risk alone, and both. Compared with intermediate-to-high risk only, patients free of FD with low risk had a significantly lower adjusted hazard ratio (HR) (HR: 0.56, 95% confidence interval [CI]: 0.33-0.94), patients with FD only had a similar HR (HR: 0.47, 95% CI: 0.19 -1.18), and patients with both FD and intermediate-to-high risk had a significantly higher HR (HR: 2.13, 95% CI: 1.53-2.98) of cardiovascular events. A similar trend but a larger HR was noted for all-cause death. Conclusion: FD 3-6 months after ischemic stroke is a risk equivalent to comorbidity of conventional vascular risk factors for the incidence of cardiovascular events and mortality of all-cause death.

Relationship between hemoglobin A1c and serum troponin in patients with diabetes and cardiovascular events

Objectives

Diabetes mellitus is a group of metabolic disorders associated with high risk for cardiovascular disease. Although troponins are primarily clinically used for the diagnosis of acute coronary syndrome, they are also used in risk assessment in patients with acute coronary syndrome as well as in a number of other conditions. The aim of this review was to investigate the relationship between hemoglobin A1c and serum troponin in patients with diabetes and cardiovascular events.

Methods

Hemoglobin A1_c has been chosen as the best clinical indicator of glucose control and risk of micro and macrovascular complications. We investigated cardiac troponins as a group of markers of muscle injury which includes troponin T, troponin I and troponin C. Troponin T and I are specific for myocardial injury, compared to C which is specific for skeletal muscle.

Results

In this review, we showed that there was a causal relation between hemoglobin A1_c levels and serum troponin concentrations. Hemoglobin A1_c has shown to be a positive predictive factor of incidence, mortality and morbidity of conditions such as acute coronary syndrome, arrhythmias, stroke, pulmonary embolism and other conditions that causes troponin elevation by its release in circulation.

Conclusions

Chronic hyperglycemia decreases glomerular filtration and consequently decreases troponin elimination and also by affecting the heart microcirculation it leads to microvascular damage and consequently to ischemia which contribute to troponin concentration elevation. Furthermore, correlation between hemoglobin A1_c and troponin concentration manifests in their prognostic value for mortality.

Obesity-Stroke Paradox Exists in Insulin-Resistant Patients But Not Insulin Sensitive Patients

Background and Purpose- The underlying mechanisms of stroke-obesity paradox are still not fully understood. This study aims to investigate the contribution of insulin resistance to the association between body mass index and stroke outcomes. Methods- Patients with ischemic stroke without history of diabetes mellitus in the Abnormal Glucose Regulation in Patients With Acute Stroke Across-China registry were included. Overweight or obese was defined as body mass index ≥23, and the median of homeostasis model assessment-insulin resistance index was chosen as cutoff to define insulin resistance. Cox or logistic regression model was used to assess the interaction between body mass index and homeostasis model assessment-insulin resistance on 1-year prognosis (all-cause mortality and poor functional outcome defined as modified Rankin Scale score 3-6). Results- Of 1227 study participants, the median homeostasis model assessment-insulin resistance was 1.9 (interquartile range, 1.1-3.1) and 863 (70.3%) patients were classified as overweight or obese. Among insulin-resistant patients, overweight/obese patients experienced one-half of the risk of death after stroke than their low/normal weight counterparts (9.42% versus 17.69%, unadjusted hazard ratio, 0.50; 95% CI, 0.31-0.82), while among insulin-sensitive ones, no significant difference of mortality risk was found (7.58% versus 6.91%, 1.07; 0.57-1.99). Similar trends were observed for poor functional outcome. Results were similar after adjustments for confounders. There were significant interactions between body mass index and homeostasis model assessment-insulin resistance on the risks of mortality (P=0.045) and poor functional outcome (P=0.049). Conclusions- We observed the obesity paradox for mortality and functional outcome in insulin-resistant patients but did not find the obesity paradox in insulin-sensitive patients. Insulin resistance may be one of the mechanisms underlying the obesity paradox of the outcome in patients with ischemic stroke.

Prevalence of diabetes and its effects on stroke outcomes: A meta-analysis and literature review

AIMS/INTRODUCTION

Diabetes mellitus is an established risk factor for stroke and maybe associated with poorer outcomes after stroke. The aims of the present literature review were to determine: (i) the prevalence of diabetes in acute stroke patients through a meta-analysis; (ii) the association between diabetes and outcomes after ischemic and hemorrhagic stroke; and (iii) to review the value of glycated hemoglobin and admission glucose-based tests in predicting stroke outcomes.

MATERIALS AND METHODS

Ovid MEDLINE and EMBASE searches were carried out to find studies relating to diabetes and inpatient stroke populations published between January 2004 and April 2017. A meta-analysis of the prevalence of diabetes from included studies was undertaken. A narrative review on the associations of diabetes and different diagnostic methods on stroke outcomes was carried out.

RESULTS

A total of 66 eligible articles met inclusion criteria. A meta-analysis of 39 studies (n = 359,783) estimated the prevalence of diabetes to be 28% (95% confidence interval 26-31). The rate was higher in ischemic (33%, 95% confidence interval 28-38) compared with hemorrhagic stroke (26%, 95% confidence interval 19-33) inpatients. Most, but not all, studies found that acute hyperglycemia and diabetes were associated with poorer outcomes after ischemic or hemorrhagic strokes: including higher mortality, poorer neurological and functional outcomes, longer hospital stay, higher readmission rates, and stroke recurrence. Diagnostic methods for establishing diagnosis were heterogeneous between the reviewed studies.

CONCLUSIONS

Approximately one-third of all stroke patients have diabetes. Uniform methods to screen for diabetes after stroke are required to identify individuals with diabetes to design interventions aimed at reducing poor outcomes in this high-risk population.

Interactive effect of acute and chronic glycemic indexes for severity in acute ischemic stroke patients

Background

Diabetes mellitus is a well-established risk factor for ischemic stroke and is known to increase stroke risk by 2–6 fold. Numerous studies have reported the relationship between parameters for glycemic status and stroke-related outcomes; however, studies focusing on the interaction between acute and chronic glycemic status indexes with stroke phenotype are lacking.

Methods

Acute ischemic stroke patients who were admitted to a tertiary hospital stroke center from 2002 to 2015 were consecutively enrolled in this study. Fasting blood sugar (FBS) and serum glycated hemoglobin (HbA1c) levels were recorded as acute and chronic glycemic indexes, respectively. The associations between initial stroke severity and both glycemic indexes were evaluated with consideration of the interaction between the glycemic indexes. Moreover, the distinct effects of stroke subtypes were evaluated.

Results

A total of 2595 patients were included in the final analysis. After adjustment for covariates, FBS was associated with initial stroke severity (P < 0.001), while HbA1c was not (P = 0.16). However, an interaction between FBS and HbA1c in association with initial stroke severity was observed (P < 0.001). The association between FBS and initial stroke severity was stronger, with a relatively normal HbA1c level. Among stroke subtypes, the interactions were significant for the large artery disease and cardioembolism subtypes (all, P < 0.001), but for the small vessel occlusion subtype (P = 0.63).

Conclusions

This study shows that HbA1c is an effect modifier for the association between FBS and initial stroke severity, and the interactive effect differs among stroke subtypes.

Electronic supplementary material

The online version of this article (10.1186/s12883-018-1109-1) contains supplementary material, which is available to authorized users.

Prevalence of Abnormal Glucose Regulation according to Different Diagnostic Criteria in Ischaemic Stroke without a History of Diabetes

We aimed to investigate the prevalence and distribution of abnormal glucose regulation, including prediabetes and newly diagnosed diabetes, according to different criteria in ischaemic stroke patients without a history of diabetes. Data were derived from a representative cohort across China. Prediabetes was defined as fasting plasma glucose (FPG) 5.6–6.9 mmol/L or 2-hour oral glucose tolerance test (OGTT) 7.8–11.0 mmol/L or haemoglobin A1c (HbA1c) 5.7–6.4%. Newly diagnosed diabetes was defined as FPG ≥ 7.0 mmol/L, 2 h OGTT ≥ 11.1 mmol/L or HbA1c ≥ 6.5%. Among 1251 ischaemic stroke patients, 471 (37.5%) were detected as prediabetes and 539 (43.1%) were detected as newly diagnosed diabetes. Prediabetes was present in 118 (9.4%), 290 (23.2%) and 314 (25.1%) stroke patients, and newly diagnosed diabetes was present in 138 (11.0%), 370 (29.6%), and 365 (29.2%) stroke patients, based on FPG, 2 h OGTT, and HbA1c criteria, respectively. Dependency on FPG alone would have missed 74.9% of patients in the prediabetes range and 74.4% of patients in the diabetes range. Our study demonstrated a high prevalence of prediabetes and diabetes in ischaemic stroke patients without a history of diabetes. OGTT and HbA1c helped detect the majority of prediabetes and newly diagnosed diabetes in ischaemic stroke patients.

Relationship Between Glycated Hemoglobin and Stroke Risk: A Systematic Review and Meta-Analysis

BACKGROUND

Diabetes mellitus is a major risk factor for ischemic stroke. Rising hemoglobin A_1c (HbA_1c) levels are associated with microvascular diabetes mellitus complication development; however, this relationship has not been established for stroke risk, a macrovascular complication.

METHODS AND RESULTS

We conducted a systematic review and meta-analysis of observational cohort and nested case-control cohort studies assessing the association between rising HbA_1c levels and stroke risk in adults (≥18 years old) with and without type 1 or type 2 diabetes mellitus. Random-effects model meta-analyses were used to calculate pooled adjusted hazard ratios (HRs) and their precision. The systematic review yielded 36 articles, of which 29 articles (comprising n=532 779 participants) were included in our meta-analysis. Compared to non-diabetes mellitus range HbA_1c (<5.7%), diabetes mellitus range HbA_1c (≥6.5%) was associated with an increased risk of first-ever stroke with average HR (95% confidence interval) of 2.15 (1.76, 2.63), whereas pre-diabetes mellitus range HbA_1c (5.7-6.5%) was not (average HR [95% confidence interval], 1.19 [0.87, 1.62]). For every 1% HbA_1c increment (or equivalent), the average HR (95% confidence interval) for first-ever stroke was 1.12 (0.91, 1.39) in non-diabetes mellitus cohorts and 1.17 (1.09, 1.25) in diabetes mellitus cohorts. For every 1% HbA_1c increment, both non-diabetes mellitus and diabetes mellitus cohorts had a higher associated risk of first-ever ischemic stroke with average HR (95% confidence interval) of 1.49 (1.32, 1.69) and 1.24 (1.11, 1.39), respectively.

CONCLUSIONS

A rising HbA_1c level is associated with increased first-ever stroke risk in cohorts with a diabetes mellitus diagnosis and increased risk of first-ever ischemic stroke in non-diabetes mellitus cohorts. These findings suggest that more intensive HbA_1c glycemic control targets may be required for optimal ischemic stroke prevention.

Insulin resistance and clinical outcomes after acute ischemic stroke

Objective

In this study, we aimed to determine whether insulin resistance is associated with clinical outcomes after acute ischemic stroke.

Methods

We enrolled 4,655 patients with acute ischemic stroke (aged 70.3 ± 12.5 years, 63.5% men) who had been independent before admission; were hospitalized in 7 stroke centers in Fukuoka, Japan, from April 2009 to March 2015; and received no insulin therapy during hospitalization. The homeostasis model assessment of insulin resistance (HOMA-IR) score was calculated using fasting blood glucose and insulin levels measured 8.3 ± 7.8 days after onset. Study outcomes were neurologic improvement (≥4-point decrease in NIH Stroke Scale score or 0 at discharge), poor functional outcome (modified Rankin Scale score of ≥3 at 3 months), and 3-month prognosis (stroke recurrence and all-cause mortality). Logistic regression analysis was used to evaluate the association of the HOMA-IR score with clinical outcomes.

Results

The HOMA-IR score was associated with neurologic improvement (odds ratio, 0.68 [95% confidence interval, 0.56–0.83], top vs bottom quintile) and with poor functional outcome (2.02 [1.52–2.68], top vs bottom quintile) after adjusting for potential confounding factors, including diabetes and body mass index. HOMA-IR was not associated with stroke recurrence or mortality within 3 months of onset. The associations were maintained in nondiabetic or nonobese patients. No heterogeneity was observed according to age, sex, stroke subtype, or stroke severity.

Conclusions

These findings suggest that insulin resistance is independently associated with poor functional outcome after acute ischemic stroke apart from the risk of short-term stroke recurrence or mortality.

Insulin Resistance and Prognosis of Nondiabetic Patients With Ischemic Stroke: The ACROSS-China Study (Abnormal Glucose Regulation in Patients With Acute Stroke Across China)

BACKGROUND AND PURPOSE

Insulin resistance was common in patients with stroke. This study investigated the association between insulin resistance and outcomes in nondiabetic patients with first-ever acute ischemic stroke.

METHODS

Patients with ischemic stroke without history of diabetes mellitus in the ACROSS-China registry (Abnormal Glucose Regulation in Patients With Acute Stroke Across China) were included. Insulin resistance was defined as a homeostatis model assessment-insulin resistance (HOMA-IR) index in the top quartile (Q4). HOMA-IR was calculated as fasting insulin (μU/mL)×fasting glucose (mmol/L)/22.5. Multivariable logistic regression or Cox regression was performed to estimate the association between HOMA-IR and 1-year prognosis (mortality, stroke recurrence, poor functional outcome [modified Rankin scale score 3-6], and dependence [modified Rankin scale score 3-5]).

RESULTS

Among the 1245 patients with acute ischemic stroke enrolled in this study, the median HOMA-IR was 1.9 (interquartile range, 1.1-3.1). Patients with insulin resistance were associated with a higher mortality risk than those without (adjusted hazard ratio, 1.68; 95% confidence interval, 1.12-2.53; P=0.01), stroke recurrence (adjusted hazard ratio, 1.57, 95% confidence interval, 1.12-2.19; P=0.008), and poor outcome (adjusted odds ratio, 1.42; 95% confidence interval, 1.03-1.95; P=0.03) but not dependence after adjustment for potential confounders. Higher HOMA-IR quartile categories were associated with a higher risk of 1-year death, stroke recurrence, and poor outcome (P for trend =0.005, 0.005, and 0.001, respectively).

CONCLUSIONS

Insulin resistance was associated with an increased risk of death, stroke recurrence, and poor outcome but not dependence in nondiabetic patients with acute ischemic stroke.