Spotlight on stroke risk

Several recent studies looked at factors affecting the risk of stroke and related outcomes among patients with diabetes.

A new analysis of the ADVANCE trial, published by Hypertension on April 29, looked at whether the effects of blood pressure treatment in patients with type 2 diabetes varied by baseline blood pressure or risk for cardiovascular disease (CVD). It included 10,948 patients with diabetes and moderate to high CVD risk, and it showed that treatment with perindopril-indapamide was associated with lower risk of major vascular events (and mortality) than placebo, regardless of baseline systolic blood pressure (which was evaluated down to <120 mm Hg; P for heterogeneity, 0.85), diastolic blood pressure (down to <70 mm Hg; P=0.49), or 10-year CVD risk (categorized as above or below 20%; P=0.08). The authors noted that the observed benefit of the drugs was driven by the group of patients with baseline systolic pressures of 130 to 139 mm Hg, suggesting that patients with diabetes might benefit from more stringent blood pressure control than currently recommended by guidelines. Limitations included that this was a post hoc analysis and that the trial studied only one specific antihypertensive regimen.

Another study, published by the Journal of the American Geriatrics Society on March 26, looked at the risk of cardiovascular events and mortality among nursing home patients receiving acetaminophen. Overall, the prospective study of 5,429 patients from 175 French nursing homes found no association between acetaminophen use and mortality or any other adverse outcomes. However, among the subgroup of patients with diabetes, acetaminophen intake was associated with a significantly increased risk of stroke (odds ratio, 3.19; 95% CI, 1.25 to 8.18; P=0.0157). “Acetaminophen, in older diabetic patients, could become a triggering factor for strokes,” said the study authors, who called for additional research on this question.

Another prospective study, published by the European Journal of Clinical Investigation on March 26, focused on patients with gout. Data from a Taiwanese database from 2000 to 2009 were used to identify comorbidities associated with stroke risk in patients with gout. It found that among female patients with gout, diabetes was significantly associated with stroke risk. The authors said that management and prevention of diabetes “is crucial to reduce the risk of developing comorbidity aggregation of gout, particularly in older women with gout.” However, they did caution that the study had a number of limitations, so the findings should be interpreted with caution and verified by future studies.

Finally, a study published by Stroke on May 2 examined the obesity-stroke paradox and its association with insulin resistance. The analysis included 1,227 Chinese patients who had had an ischemic stroke and did not have a history of diabetes; 863 of them (70.3%) were overweight or obese. The study found no association between obesity and mortality after stroke among insulin-sensitive patients. However, among insulin-resistant patients, those who were overweight or obese had half the risk of death after stroke compared to their low- and normal-weight counterparts (9.42% vs. 17.69%; unadjusted hazard ratio, 0.50; 95% CI, 0.31 to 0.82). They concluded that insulin resistance “may be one of the mechanisms underlying the obesity paradox” in ischemic stroke outcomes. However, the results may not be generalizable to western populations and confirmation by a population-based study is needed, the authors said.