Sex-related disparities in the incidence and outcomes of hemorrhagic stroke among type 2 diabetes patients: a propensity score matching analysis using the Spanish National Hospital Discharge Database for the period 2016–18

Abstract

Background To analyze incidence, use of therapeutic procedures, use of oral anticoagulants (OACs) and antiplatelet agents prior to hospitalization, and in-hospital outcomes among patients who were hospitalized with hemorrhagic stroke (HS) according to the presence of type 2 diabetes mellitus (T2DM) in Spain (2016–2018) and to assess the role of sex differences among those with T2DM. Methods Using the Spanish National Hospital Discharge Database we estimated the incidence of HS hospitalizations in men and women aged ≥ 35 years with and without T2DM. Propensity score matching (PSM) was used to compare population subgroups according to sex and the presence of T2DM. Results HS was coded in 31,425 men and 24,975 women, of whom 11,915 (21.12%) had T2DM. The adjusted incidence of HS was significantly higher in patients with T2DM (both sexes) than in non-T2DM individuals (IRR 1.15; 95% CI 1.12–1.17). The incidence of HS was higher in men with T2DM than in T2DM women (adjusted IRR 1.60; 95% CI 1.57–1.63). After PSM, men and women with T2DM have significantly less frequently received decompressive craniectomy than those without T2DM. In-hospital mortality (IHM) was higher among T2DM women than matched non-T2DM women (32.89% vs 30.83%; p = 0.037), with no differences among men. Decompressive craniectomy was significantly more common in men than in matched women with T2DM (5.81% vs. 3.33%; p < 0.001). IHM was higher among T2DM women than T2DM men (32.89% vs. 28.28%; p < 0.001). After adjusting for confounders with multivariable logistic regression, women with T2DM had a 18% higher mortality risk than T2DM men (OR 1.18; 95% CI 1.07–1.29). Use of OACs and antiplatelet agents prior to hospitalization were associated to higher IHM in men and women with and without T2DM. Conclusions T2DM is associated with a higher incidence of HS and with less frequent use of decompressive craniectomy in both sexes, but with higher IHM only among women. Sex differences were detected in T2DM patients who had experienced HS, with higher incidence rates, more frequent decompressive craniectomy, and lower IHM in men than in women.

Sex-related disparities in the incidence and outcomes of infective endocarditis according to type 2 diabetes mellitus status in Spain, 2016–2020

“…Is remarkable that in a previous study conducted by our group, among T2DM patients who had experienced a hemorrhagic stroke, similar sex differences were detected, finding that men presented higher incidence rates, more frequent decompressive craniectomy, and lower in-hospital mortality than women [ 44 ].…”

Diabetes and Stroke: What Are the Connections?

“…These epide-miologic studies demonstrated that diabetes is an independent risk factor for stroke. 5,[14][15][16][17][18][19][20][21][22][23][24] Furthermore, the risk of stroke is higher in people with either type 1 diabetes (T1D) (HR: 1.50; 95% CI: 1.23-1.83) or type 2 diabetes (T2D; HR: 1.76; 95% CI: 1.65-1.87) compared with people without diabetes. 14 There are also differences in risk according to the stroke type.…”

“…16 However, other studies have reported contradictory findings regarding sex differences in the risk of stroke associated with diabetes when analyzing specific age groups or stroke types (Figure 1). 15,17,22 In addition to diabetes, prediabetes-defined by the American Diabetes Association (ADA) as impaired fasting glucose (fasting plasma glucose 100-125 mg/dL [5.6-6.9 mmol/L]) and/or impaired glucose tolerance (plasma glucose levels 2 hours after 75 g of oral glucose intake of 140-199 mg/dL [7.8-11.0 mmol/L]) and/or glycated hemoglobin (HbA1c) 5.7%-6.4% (39-47 mmol/L) 25 -may be associated with a modestly higher risk of future stroke compared with those with normal glycemia. 26 Moreover, the duration of diabetes is independently associated with the risk of ischemic stroke; the risk has been reported to increase by 3% each year and triples in those who have had diabetes for ≥10 years, compared with those without diabetes.…”

“…In a meta-analysis, the adjusted relative risk of any stroke associated with diabetes was 2.28 (95% CI: 1.93–2.69) in women, whereas it was 1.83 (95% CI: 1.60–2.08) in men, when compared with individuals without diabetes [ 16 ]. However, other studies have reported contradictory findings regarding sex differences in the risk of stroke associated with diabetes when analyzing specific age groups or stroke types ( Figure 1 ) [ 15 , 17 , 22 ].…”