Diabetes mellitus is a risk factor for first ever and recurrent strokes. Sugar control is important to prevent strokes and its recurrence. Strict sugar control in acute stroke setting is not useful. Moderate sugar control is preferred.
2. My Talk Would Cover:
Diabetes as a risk factor for stroke,
Sugar control in patients with acute stroke,
Sugar control in post-stroke patients,
3. Diabetes: Risk factor for stroke
Type 2 DM is associated with 2- to 3-fold increase in
the risk of stroke.
About 10% of newly diagnosed T2DM patients
develop stroke within the first 5 years of diagnosis,
The absolute risk of stroke is higher in older people
(1% in 30-44 years versus 20% for >75 years old),
However, the relative risk of stroke (as compared to
general population) is higher in younger people (5.6
times)
(Stroke,2007)
4. Factors in T2DM Predicting an
Increased Stroke Risk (1)
Proteinuria (OR: 3.23)
High systolic BP (OR:3.1)
High diastolic BP (OR: 3.3)
FBS > 200 mg% (OR: 1.8)
HbA1C> 9.5% (OR: 1.7)
(Stroke, 1999)
5. Factors in T2DM Predicting an
Increased Stroke Risk (2)
Hyperuricemia: Hazard ratio of 1.9 above mean uric
acid >5 mg% (Stroke, 1998)
Age>60 (Hazard ratio 4.8 versus those <50)
(Arch Int Med, 1999)
6. Diabetes as a Risk Factor for
Stroke in Women
Systematic review and meta-analysis of 64 cohort
studies between 1966 to 2013,
Pooled maximum-adjusted RR was 2.3 in women and
1.8 in men,
Compared with men with Type 2 DM, women with
Type 2 DM had a 27% greater risk of stroke. (Lancet,
2014)
Compared with men with Type 1 DM, women with
Type 1 DM had a 37% greater risk of stroke. (Lancet
Diabetes Endocrinol, 2015)
7. Prediabetes and Risk of Stroke
Prediabetes defined as FBS 100-125 m% did not
show an increase in risk of stroke,
Prediabetes defined as FBS 110-125 m% showed a
modest increase in risk of stroke (RR 1.21, p=0.03),
Impaired glucose tolerance resulted in modest
increase in the risk of stroke (RR 1.26, P<0.001),
(BMJ, 2012)
8. Hyperglycemia and Acute
Stroke (1)
Among patients admitted with stroke, 40-50% have
diabetes mellitus (Stroke, 2009)
Additional 20% have hyperglycemia without any
history of diabetes, termed as stress hyperglycemia,
So, a total 0f 60-70% of patients with acute stroke
have hyperglycemia at admission.
Admission plasma glucose>110 mg% and HbA1C>
6.2% are good predictors of (undiagnosed) diabetes
mellitus in patients with acute stroke, (Age Ageing,
2004)
9. Hyperglycemia and Acute
Stroke (2)
Patients with hyperglycemia and acute stroke have
prolonged hospital stay and incur higher
hospitalization costs (Neurology 2002)
Hyperglycemia at admission in patients with stroke
results in poor functional outcome at 3 months
(Neurology,1999)
Hyperglycemia independently increases the risk of
death at 90 days, 1 year and 6 years after stroke (all
p<0.01) (Neurology 2002)
10. Hyperglycemia and Acute
Stroke (3)
Hyperglycemia leads to: a) Lesser salvage of
mismatch tissue from infarction and b) Increase in
infarct size/volume over time, thus resulting in poorer
outcomes, as based on MRI diffusion-perfusion
studies
Acute hyperglycemia increases brain lactate
production and facilitates conversion of hypoperfused
at-risk tissue into infarction.
(Ann Neurology 2002)
11. Sugar Control in Acute Stroke
Setting
Strict sugar control would lower the sugars, thereby,
improving functional outcomes; however, it may also
result in hypoglycemia, resulting in brain damage.
GIST-UK trial: Patients with blood sugar between 108-
306 mg% were treated with G-K-I infusions to
maintain capillary glucose between 70-125 mg%.
No difference in mortality or severe disability was
seen at 90 days after stroke, as compared to placebo
group.
(Lancet Neurol 2007)
12. Tight Sugar Control Leads to
More Hypoglycemia
Glucose regulation in acute stroke patients (GRASP)
trial (Stroke, 2009)
3 arms- tight control (70-110 mg%), loose control (70-
200mg%) and control usual care (70-300mg%)
Insulin infusion was used to achieve the targets,
The overall rates of hypoglycemia (<55 mg%) were
5% in loose and control usual care groups, whereas it
was 30% in the tight group.
13. Intensive Insulin Therapy leads to
Larger Infarct growth
INSULINFARCT study (Stroke, 2012)
180 patients with MRI proven ischemic stroke (NIHSS
score 5-25) were enrolled.
Received intensive insulin therapy (IIT) or usual
subcutaneous insulin for 24 hours
95% within IIT group and 67% in subcutaneous insulin
group had sugar within 126 mg%
Infract growth was lower in subcutaneous insulin group
Functional outcome and death rates were similar at 90
days.
14. American Stroke Association
Guideline
Maintain plasma glucose levels within 140 to 180
mg% in the first 24 hours,
Close monitoring should be done to detect
hypoglycemia,
For patients being considered for IV thrombolysis,
blood sugar should be within 50-500 mg% range.
(Stroke,2013)
15. Sugar Control in Post-stroke
Period
Sugar control is important in patients with stroke to
prevent recurrence of stroke,
Diabetes mellitus and age are two most important
predictors for stroke recurrence,
About 9% of recurrent strokes are attributable to
diabetes mellitus,
Diabetes is also linked to the presence of multiple
infarcts on brain scan.
Goal for HbA1C level is less than 7%.
(Stroke, 2006)
16. CONCLUSIONS
Diabetes and prediabetes are important risk factors for
stroke,
Majority of patients with acute stroke have
hyperglycemia,
Hyperglycemia worsens the outcome in stroke patients,
IIT is not useful in acute stroke setting,
Moderate sugar control is advisable in acute stroke
setting,
HbA1C should be less than 7% in post-stroke patients.
