Different Risk Factor Profiles for Ischemic and Hemorrhagic Stroke in Type 1 Diabetes Mellitus

Abstract

W orldwide, cerebrovascular disease is the second leading cause of death not only in high-income but also in lowincome countries. Patients with type 1 diabetes mellitus have a markedly increased risk of stroke compared with nondiabetic subjects, 1 and it is of note that these patients are at a high risk of stroke 10 to 15 years earlier than nondiabetic subjects. 2 Age, hypertension, atrial fibrillation, smoking, and diabetes mellitus are well-known risk factors for stroke in the general population. [2][3][4][5] In patients with type 2 diabetes mellitus, similar risk factors have been observed. 6 Furthermore, the metabolic syndrome and its components have also been shown to increase the risk of stroke, especially in patients with type 2 diabetes mellitus. Although the risk factors for stroke in patients with type 2 diabetes mellitus have been assessed in several studies, few studies on the risk factors for stroke and stroke subtypes in patients with type 1 diabetes mellitus exist. No sex difference has been observed for the risk of stroke in type 1 diabetes mellitus, which is in contrast to the general population in which premenopausal women are protected from cardiovascular disease and stroke.1,2 Stroke is usually divided into 2 subgroups: ischemic stroke and hemorrhagic stroke. Ischemic stroke can be further subgrouped into lacunar and nonlacunar infarction, whereas hemorrhagic stroke includes intracerebral and subarachnoid hemorrhage. We have earlier shown that both the severity of diabetic nephropathy (DN) and the presence of severe diabetic retinopathy (SDR) increase the risk of any stroke, ischemic stroke, lacunar infarction, and hemorrhagic stroke. 8 However, comprehensive studies on independent risk factors for each subtype of stroke are still missing.Therefore, we aimed to study the independent risk factors for stroke, and also for the subtypes ischemic stroke, lacunar Background and Purpose-Despite the fact that patients with type 1 diabetes mellitus have a markedly increased risk of experiencing a stroke, independent risk factors for stroke and its subtypes in these patients have remained unclear. Methods-A total of 4083 patients with type 1 diabetes mellitus from the Finnish Diabetic Nephropathy (FinnDiane) Study, without a history of stroke at baseline, were included. Strokes were classified based on medical files and brain imaging. At baseline, mean age was 37.4±11.8 years, duration of diabetes mellitus was 20.0 (11.0-30.0) years, and 51% were men. During 9.0±2.7 years (36 680 patient-years) of follow-up, 105 patients experienced an ischemic stroke and 44 a hemorrhagic stroke. Cox proportional hazards analyses were performed to determine independent risk factors. Results-Independent risk factors for ischemic stroke were duration of diabetes mellitus, presence of diabetic nephropathy, higher hemoglobin A 1c , higher systolic blood pressure, insulin resistance, and history of smoking, whereas sex, lipids, high-sensitivity C-reactive protein, and the metabolic syndrome were not associated with an incre...

Long‐Term Risk of Stroke in Patients With Type 1 and Type 2 Diabetes Following Coronary Artery Bypass Grafting

“…Moreover, after we subgrouped stroke (there were much fewer hemorrhagic strokes in all patient groups), the hazard ratio for hemorrhagic stroke was increased in the type 1 diabetes patients, although the total numbers were too few to make any firm interpretations of that observation. Some studies have shown an association between hyperglycemia and hemorrhagic stroke,38 and other studies have not 33. Our finding is consistent with other reports demonstrating a weak or even a lack of association between HbA1c levels and stroke in diabetes.…”

“…In diabetes, hypertension has a stronger association with stroke than hyperglycemia has 30, 31, 32. Nevertheless, the association between hyperglycemia and increased risk of stroke has been demonstrated in some,33 but not all studies2 in diabetes individuals. Long‐term studies in type 2 diabetes individuals comparing intensive versus standard glycemic control treatment have all failed to demonstrate a reduced risk of death and CVD (including fatal or nonfatal stroke) 34, 35, 36.…”

Glycated hemoglobin and risk of first episode stroke in diabetic patients with atrial fibrillation: A cohort study

“…[7][8][9]16,17 However, none of the previous studies has specifically examined the association between glycated hemoglobin and stroke risk in diabetic patients with atrial fibrillation. Glycated hemoglobin was also found to be associated with increased risk of ischemic stroke in non-diabetic patients.…”

Duration of Diabetes Mellitus and Risk of Thromboembolism and Bleeding in Atrial Fibrillation

“…We are unable to provide any plausible explanations for this observation, but a study of patients with type 1 diabetes mellitus (patients with early debut of diabetes mellitus and, therefore, with longer duration of their disease in this study) found duration of diabetes mellitus to be a risk predictor for ischemic stroke, but not hemorrhagic stroke. 37 Considering some limitations of the present bleeding analysis (few bleeding events in the longer duration category, and use of claimed prescriptions and not actual verified usage of vitamin K antagonists to identify treatment periods, making it impossible to evaluate the impact of noncompliance), further studies investigating this matter are needed. However, these results suggest that when considering commencement of anticoagulant treatment, special emphasis may be directed toward patients with longer duration of diabetes mellitus.…”