Twenty-Year Temporal Trends in Risk of Ischemic Stroke in Incident Type 2 Diabetes: A Danish Population-Based Cohort Study

Abstract

OBJECTIVE We examined temporal trends in risk of first-time ischemic stroke in patients with incident type 2 diabetes mellitus (T2DM) and no prior atherosclerotic cardiovascular disease (ASCVD). RESEARCH DESIGN AND METHODS Using nationwide health registries, we identified all patients with incident T2DM without a prior hospital diagnosis of ASCVD from 1996 to 2015 in Denmark. Patients were assigned to 5-year periods based on the date of T2DM diagnosis and were followed for 5 years. Each patient was matched by sex and age with up to three individuals from the general population. Temporal trends in ischemic stroke were examined using Cox regression to compute hazard ratios (HRs). Temporal use of prophylactic cardiovascular medications was also assessed. RESULTS The study comprised 288,825 patients with incident T2DM and 782,232 general population individuals. From 1996–2000 to 2011–2015, the 5-year risk of first-time ischemic stroke was approximately halved in the T2DM cohort (5.2% vs. 2.7%; sex- and age-adjusted HR 0.52 [95% CI 0.49–0.55]). Patients diagnosed in 2011–2015 had increased risk of ischemic stroke compared with individuals in the general population; however, the risk difference narrowed over time (5.2% vs. 2.9% in 1996–1999 [difference 2.3%]; 2.7% vs. 2.0% in 2011–2015 [difference 0.7%]). Use of prophylactic cardiovascular medications increased markedly during the overall study period, especially use of statins (5% to 50%) and multiple antihypertensive drugs (18% to 33%). CONCLUSIONS From 1996 to 2015, the 5-year risk of first-time ischemic stroke was approximately halved in patients with incident T2DM and no prior ASCVD, coinciding with markedly increased use of prophylactic cardiovascular medications.

Diabetes and Stroke: What Are the Connections?

“…Intensive multiple risk factor intervention has been shown to significantly reduce the occurrence of first stroke as well as the number of recurrent cerebrovascular events among people with T2D [ 53 ]. In a recently reported Danish cohort study of patients with T2D and no prior atherosclerotic cardiovascular disease (ASCVD), the 5-year risk of first-time ischemic stroke was approximately halved in the period from 1996 to 2015 [ 54 ]. This reduction in risk coincided with a marked increase in the use of prophylactic cardiovascular medications, including statins and antihypertensive drugs [ 54 ].…”

“…In a recently reported Danish cohort study of patients with T2D and no prior atherosclerotic cardiovascular disease (ASCVD), the 5-year risk of first-time ischemic stroke was approximately halved in the period from 1996 to 2015 [ 54 ]. This reduction in risk coincided with a marked increase in the use of prophylactic cardiovascular medications, including statins and antihypertensive drugs [ 54 ]. Neurologists who care for people who have had a stroke are typically involved in the treatment of atrial fibrillation, carotid stenosis, hypertension, and hyperlipidemia, but not as often in the management of diabetes.…”

Incidence and Trends in Ischemic Stroke and Mortality in Patients with and Without Type 2 Diabetes in Taiwan 2000-2018

“…5,6 In many countries, the risk of ischemic stroke from diabetes has decreased. 7,[18][19][20][21][22][23] However, it remains about the same in some countries, 9 and in others, it has increased. 11 The varying trends in the incidence of ischemic stroke in different countries may be related to different definitions of diabetes and stroke, the control of risk factors, and differences in environmental and genetic factors.…”

“…This finding is consistent with previous studies. 5,6,20,22 However, from 2000 to 2018, the decline in stroke incidence rate increased in people with diabetes under 60 compared to those without diabetes. Therefore, in Taiwan, the relative risk of experiencing an ischemic stroke has gradually decreased among individuals under 60 with diabetes compared to those without the disease.…”

Advances in secondary prevention mechanisms of macrovascular complications in type 2 diabetes mellitus patients: a comprehensive review

“…Statins and other lipid-lowering medications have been established as the most effective pharmacological agents for the prevention and treatment of ASCVD. Clinical studies have shown a significant increase in the use of these medications, particularly statins, which have been found to reduce the two-year risk of a first ischemic stroke by approximately half in T2DM patients without prior ASCVD [ 175 ]. Comprehensive management of lipid abnormalities, including those of LDL-C and lipoproteins, is considered central to mitigating cardiovascular risk factors and reducing cardiovascular risk [ 5 , 176 ].…”