Association between hyperglycemia, heart failure and mortality in stroke patients

Background:  Acute hyperglycemia predicts increased mortality after stroke. The aim of our study was to determine if acute stroke patients with hyperglycemia suffer from increased rate of in-hospital adverse events which could influence survival such as pneumonia, heart failure and myocardial infarction.
Methods:  In a retrospective study with prospective follow-up, 689 patients with first-ever ischaemic stroke and high frequency of cardiovascular diseases were eligible. Follow-up period was 1–7 years (14 308 person-months).
Results:  The frequency of in-hospital heart failure and nosocomial pneumonia was the highest in patients without pre-hospital diagnosis of diabetes mellitus and with fasting glucose ≥7 mmol/l (50% and 20.2%, respectively) and the lowest in patients without pre-hospital diagnosis of diabetes and fasting glucose ≤6.1 mmol/l (12.3% and 8.1%). On multivariate analysis fasting glucose was significantly associated with risk of in-hospital heart failure (OR: 1.12, 95% CI: 1.01–1.23), but not with pneumonia. Glucose level was an independent predictor of mortality only when statistical model did not include heart failure as a variable.
Conclusions:  In stroke patients with hyperglycermia increased rate of heart failure could be responsible for higher mortality.     

Association between stress hyperglycemia and outcomes in patients with acute ischemic stroke due to large vessel occlusion

Aims

This study aimed to evaluate the association between stress hyperglycemia ratio (SHR) and clinical outcomes at 90 days in acute ischemic stroke due to large vessel occlusion receiving endovascular treatment.

Methods

The RESCUE BT trial was a multicenter, randomized, double-blind, placebo-controlled clinical trial, consisting of 948 stroke patients from 55 centers in China. A total of 542 patients with glucose and glycated hemoglobin (HbA1C) values at admission were included in this analysis. SHR, measured by glucose/HbA1C, was evaluated as both a tri-categorical variable (≤1.07 vs. 1.08–1.29 vs. ≥1.30) and a continuous variable. The primary outcome was a favorable functional outcome (modified Rankin Scale [mRS] score ≤2) at 90 days. The secondary outcome included excellent functional outcome (mRS score ≤1) and safety outcomes, such as 90-day mortality and intracranial hemorrhage. The study was registered with Chictr.org.cn (ChiCTR-INR-17014167).

Results

Compared with patients in the lowest tertile of SHR, the highest tertile group had significantly lower odds of achieving favorable functional outcome of mRS score of 0–2 (adjusted odds ratio, 0.44; 95% confidence interval, 0.28–0.69; p < 0.001) and excellent clinical outcome of mRS score of 0–1 (adjusted odds ratio, 0.48; 95% confidence interval, 0.29–0.79; p = 0.004) at 90 days after adjusting for potential covariates. Similar results were observed after further adjustment for preexisting diabetes and Alberta Stroke Program Early Computed Tomography Score (ASPECTS).

Conclusion

Stress hyperglycemia ratio, as measured by the glucose/HbA1C, was associated with a decreased odds of achieving a favorable functional outcome in patients with acute large vessel occlusion stroke at 90 days.     

Prior transient ischemic attack is independently associated with lesser in‐hospital case fatality in acute stroke

Aim: Ischemic preconditioning has been well established in healthy human hearts, but limited information is available about its occurrence or its integrity in the brain. The aim of the present study was therefore to investigate whether a prior cerebral ischemic episode (stroke or transient ischemic attack [TIA]) is able to confer protection against ischemic stroke, reflected by in‐hospital case fatality. Methods: A total of 2874 acute stroke patients included in the prospective, hospital‐based Debrecen Stroke Database were studied, of whom 673 had previous stroke and 195 had prior TIA. Results: Following adjustment for active confounders, TIA but not stroke in the history was associated with decreased odds for in‐hospital case fatality (odds ratio, 0.53; 95% confidence interval: 0.29–0.98; P = 0.041). The fitness of the final multiple regression model was good (Hosmer–Lemeshow goodness‐of‐fit χ² statistic (P = 0.328). Conclusion: TIA may have an ischemic preconditioning effect in the human brain.     

Elevated gamma‐glutamyl transferase levels are associated with stroke recurrence after acute ischemic stroke or transient ischemic attack

AimsGamma‐glutamyl transferase (GGT) is considered a marker of oxidative stress in vivo. In this study, we aimed to examine the association of serum GGT levels with 3‐month and 1‐year stroke recurrence in patients with acute ischemic stroke or transient ischemic attack (TIA).MethodsWe conducted a large and multicenter cohort study. Participants with ischemic stroke or TIA who had a baseline GGT measurement were enrolled in the China National Stroke Registry‐3 study from August 2015 to March 2018. They were divided into four groups according to sex‐specific quartiles of GGT levels. The effect of GGT on stroke recurrence and other vascular events was examined during the 1‐year follow‐up period. Multivariate Cox regression models were performed to evaluate the association. Discrimination tests were used to examine the degree to which incorporating GGT into the conventional model predicted stroke adverse outcomes.ResultsA total of 12,504 patients were enrolled. At both the 3‐month and 1‐year follow‐ups, patients in the highest quartile group of GGT levels exhibited a higher risk of stroke recurrence [HR 1.32 (95% CI 1.07–1.63), HR 1.34 (95% CI 1.13–1.60)], ischemic stroke [HR 1.37 (95% CI 1.10–1.71), HR 1.37 (95% CI 1.14–1.64)], and combined vascular events [HR 1.34 (95% CI 1.09–1.65), HR 1.34 (95% CI 1.13–1.59)] than those in the lowest quartile group. Moreover, the Kaplan–Meier curves revealed that the incidence rates of stroke adverse outcomes were quite different in the four groups. The highest quartile group showed the highest cumulative incidence, while the lowest quartile group showed the lowest cumulative incidence. After applying discrimination tests, adding GGT into the conventional model resulted in slight improvements in predicting stroke adverse outcomes (NRI: 10%–14%).ConclusionThis study demonstrated that elevated GGT levels were positively associated with an increased risk of stroke adverse outcomes, namely, recurrence, ischemic stroke, and combined vascular events.     

Low serum magnesium is associated with poor functional outcome in acute ischemic stroke or transient ischemic attack patients

Aim

The association between magnesium and outcomes after stroke is uncertain. We aimed to investigate the association of serum magnesium with all-cause mortality and poor functional outcome.

Methods

We included patients with acute ischemic stroke (AIS) or transient ischemic attack (TIA) from the China National Stroke Registry III. We used Cox proportional hazards model for all-cause mortality and logistic regression model for poor functional outcome (modified Rankin Scale [mRS] 2–6/3–6) to examine the relationships.

Results

Among the 6483 patients, the median (interquartile range) magnesium was 0.87 (0.80–0.93) mmol/L. Patients in the first quartile had a higher risk of mRS score 3–6/2–6 at 3 months (adjusted odds ratio [OR]: 1.30; 95% confidence interval [CI]: 1.02, 1.64; adjusted OR: 1.29; 95% CI: 1.04–1.59) compared with those in the fourth quartile. Similar results were found for mRS score 26 at 1 year. The age- and sex-adjusted hazard ratio (HR) with 95% CI in first quartile magnesium was 1.40 (1.02–1.93) for all-cause mortality within 1 year, but became insignificant (HR: 1.03; 95% CI: 0.71–1.50) after adjusting for potential variables.

Conclusions

Low serum magnesium was associated with a high risk of poor functional outcome in patients with AIS or TIA.     

Association of non‐diabetic hyperglycemia with autonomic shift in acute ischaemic stroke

Background and purpose: The etiology of hyperglycemia in acute stroke remains controversial. It is unclear whether hyperglycemia arises as an epiphenomenon of stroke or as a reflection of underlying diabetes. Autonomic shift to sympathetic overactivity has been repeatedly observed in acute stroke. We hypothesize that hyperglycemia in acute stroke relates to autonomic imbalance and that the respective deleterious effects on stroke outcome may be cross‐linked. Methods: A total of 75 non‐diabetic patients with ischaemic stroke were included in a prospective study. Glucose levels at admission, fasting glucose, and glucose profiles were recorded. Autonomic function was quantified by the assessment of spontaneous baroreflex sensitivity (BRS) using a cross‐correlation method. Demographic and clinical data including stroke volumes and admission National Institute of Heath Stroke Scale scores were included into the analysis. Functional outcome at 90 days was assessed using the modified Rankin Scale. Results: Hyperglycemia was correlated with decreased BRS independent of stroke severity or volume (r = ?0.46, P < 0.001). In two separate regression models, glucose levels and BRS independently predicted unfavorable outcome at 3 months (OR = 1.06, CI = 1.02–1.11, P = 0.004 and OR = 0.75, CI = 0.56–0.99, P = 0.04). However, combining the models, only glucose levels (OR = 1.06, CI = 1.02–1.11, P = 0.004) remained independent predictor of outcome at 3 months. Conclusions: We observed an association between hyperglycemia and decreased BRS in non‐diabetic patients, suggesting that hyperglycemic reaction in acute stroke may reflect stroke‐related autonomic changes. Moreover, outcome effects of autonomic changes and hyperglycemia seem to be interdependent, putatively having the sympatho‐vagal imbalance as common underlying mechanism. The possible therapeutic relevance of this finding warrants further studies.     

Long-term mortality among young ischemic stroke patients in western Norway

OBJECTIVES: To obtain data on long-term mortality among young ischemic stroke patients compared with controls in this population-based study. MaTERIAL AND METHODS: We used Kaplan-Meier survival analysis to compare 232 patients aged 15-49 years with first-ever cerebral infarction in 1988-1997 and 453 controls followed from inclusion to death or 1 August 2005 for 2515 and 5558 person-years respectively. In a subanalysis of 192 patients, we compared risk factor variables using the Kaplan-Meier method and log-rank testing. We applied a Cox proportional hazards model to adjust for multiple risk factors. RESULTS: Forty-five patients and nine controls died during follow-up (P < 0.0005). Independent risk factors for mortality were active tumor disease (P < 0.0005), high consumption of alcohol (P < 0.0005), coronary atherosclerosis (P < 0.001), living alone (P < 0.02), seizures (P < 0.04) and smoking (P = 0.08). CONCLUSIONS: Long-term mortality was significantly increased among young stroke patients, mainly due to such lifestyle factors as high consumption of alcohol and tobacco.     

Fever is associated with doubling of odds of short‐term mortality in ischemic stroke: an updated meta‐analysis

Prasad K, Krishnan PR. Fever is associated with doubling of odds of short‐term mortality in ischemic stroke: an updated meta‐analysis.
Acta Neurol Scand: 2010: 122: 404–408.
© 2010 The Authors Journal compilation © 2010 Blackwell Munksgaard. Objective – Association between fever and ischemic stroke mortality is known, but the magnitude and independence of the association is controversial. This paper aims to determine the size of independent effect of fever on short term mortality in acute ischemic stroke. Methods – We searched the Medline and Cochrane library databases for papers studying the relationship between fever in acute ischemic stroke and short term mortality from January, 1990 to November, 2008. Two authors independently selected the studies for inclusion in the review using explicit criteria. Data was entered into software Revman 4.2.8. Heterogeneity was assessed using I² and chi‐square statistics. Odds ratios (OR) from logistic regression were combined. Magnitude of association was determined using meta‐analysis of the adjusted odds ratio using fixed effects model. Results – Six cohort studies involving 2986 patients were included. There was no significant heterogeneity among studies reporting short‐term mortality (I² = 21.2%, P = 0.28). Meta‐analysis yielded a combined OR of 2.20 (95% CI 1.59–3.03, P < 0.00001). Conclusions – This meta‐analysis suggests that fever within first 24 h of hospitalization in patients with ischemic stroke is associated with doubling of odds of mortality within one month of the onset of stroke.     

Unfavorable cerebral venous outflow is associated with futile recanalization in acute ischemic stroke patients

Background and purpose

Mechanical thrombectomy (MT) has proven to be the standard of care for patients with acute ischemic stroke due to large vessel occlusion (AIS-LVO). However, high revascularization rates do not necessarily result in favorable functional outcomes. We aimed to investigate imaging biomarkers associated with futile recanalization, defined as unfavorable functional outcome despite successful recanalization in AIS-LVO patients.

Methods

A retrospective multicenter cohort study was made of AIS-LVO patients treated by MT. Successful recanalization was defined as modified Thrombolysis in Cerebral Infarction score of 2b–3. A modified Rankin Scale score of 3–6 at 90 days was defined as unfavorable functional outcome. Cortical Vein Opacification Score (COVES) was used to assess venous outflow (VO), and the Tan scale was utilized to determine pial arterial collaterals on admission computed tomography angiography (CTA). Unfavorable VO was defined as COVES ≤ 2. Multivariable regression analysis was performed to investigate vascular imaging factors associated with futile recanalization.

Results

Among 539 patients in whom successful recanalization was achieved, unfavorable functional outcome was observed in 59% of patients. Fifty-eight percent of patients had unfavorable VO, and 31% exhibited poor pial arterial collaterals. In multivariable regression, unfavorable VO was a strong predictor (adjusted odds ratio = 4.79, 95% confidence interval = 2.48–9.23) of unfavorable functional outcome despite successful recanalization.

Conclusions

We observe that unfavorable VO on admission CTA is a strong predictor of unfavorable functional outcomes despite successful vessel recanalization in AIS-LVO patients. Assessment of VO profiles could help as a pretreatment imaging biomarker to determine patients at risk for futile recanalization.     

HbA1c is associated with increased all-cause mortality in the first year after acute ischemic stroke

Abstract

Objectives:

To assess the association between baseline HbA1c and the poor outcomes within 1 year after acute ischemic stroke.

Methods:

Acute ischemic stroke patients with HbA1c values at baseline (n = 2186) were selected from the abnormal glucose regulation in patients with acute stroke across China study (ACROSS). Logistic regressions were performed to assess the association between HbA1c quartiles (<5·5% [37 mmol/mol], 5·5 to <6·1% [37 to <43 mmol/mol], 6·1 to <7·2% [43 to <55 mmol/mol], and ≥7·2% [≥55 mmol/mol]) and the poor outcomes within 1 year. Poor outcomes were defined as all-cause mortality (modified Rankin scale [mRS] = 6) and poor functional outcome (mRS [2–6]).

Results:

The risk for all-cause mortality was significantly increased in HbA1c level >5·5% [>37 mmol/mol] when compared to HbA1c quartile <5·5% [<37 mmol/mol] and dramatically increased to two to three times higher in the highest HbA1c quartile ≥7·2% [>55 mmol/mol] (1-year all-cause mortality model, odds ratios [ORs] were 1·07, 1·01, and 2·45, P for trend 0·009). After the further analysis with previous diabetes mellitus (DM) and post-stroke insulin use stratified, the risk of mortality was increased across the HbA1c levels (P for trend 0·020) and dramatically augmented in HbA1c ≥7·2% [>55 mmol/mol] in patients without a history of DM and without post-stroke insulin use.

Discussion:

Elevated HbA1c (from 5·5% [37 mmol/mol]) presenting pre-stroke glycemia status has a significant trend in increasing the risk of 1-year all-cause mortality. HbA1c ≥7·2% (>55 mmol/mol) is an independent risk predictor for 1-year all-cause mortality after acute first-ever ischemic stroke. Such an association might be altered by glycometabolism status.     

临床护理对2型糖尿病患者并缺血性脑卒中的影响

目的探讨针对性临床护理对2型糖尿病患者并缺血性脑卒中的影响。方法选择2012-01—2014-01我院收治的2型糖尿病并缺血性脑卒中者110例,将其随机分为研究组与对照组,每组各55例,对照组给予常规护理,研究组给予针对性临床护理干预,对比2组疗效。结果 2组患者治疗前空腹血糖、餐后2h血糖、收缩压和舒张压均高于正常值,且组间比较差异无统计学意义(P0.05),治疗后2组患者空腹血糖、餐后2h血糖、收缩压和舒张压均显著降低,且研究组上述指标显著低于对照组(P0.05)。研究组经过相应治疗及针对性临床护理干预后,总有效率为96.36%,明显高于对照组的81.82%(P0.05)。研究组Harris分值及Barthel分值均高于对照组(P0.05)。结论 2型糖尿病并缺血性脑卒中者给予针对性的临床护理干预,可以有效提高患者的肌体功能,加强日常生活能力,改善临床症状,适于临床推广。     

Association between pneumonia in acute stroke stage and 3-year mortality in patients with acute first-ever ischemic stroke

The influence of pneumonia in acute stroke stage on the clinical presentation and long-term outcomes of patients with acute ischemic stroke is still controversial. We investigate the influence of pneumonia in acute stroke stage on the 3-year outcomes of patients with acute first-ever ischemic stroke. Nine-hundred and thirty-four patients with acute first-ever ischemic stroke were enrolled and had been followed for 3 years. Patients were divided into two groups according to whether pneumonia occurred during acute stroke stage or not. Clinical presentations, risk factors for stroke, laboratory data, co-morbidities, and outcomes were recorded. The result showed that a total of 100 patients (10.7%) had pneumonia in acute stroke stage. The prevalence of older age, atrial fibrillation was significantly higher in patients with pneumonia in acute stroke stage. Total anterior circulation syndrome and posterior circulation syndrome occurred more frequently among patients with pneumonia in acute stroke stage (P < 0.001 and P = 0.009, respectively). Multivariate Cox regression revealed that pneumonia in acute stroke stage is a significant predictor of 3-year mortality (hazard ratio = 6.39, 95% confidence interval = 4.03–10.11, P < 0.001). In conclusion, pneumonia during the acute stroke stage is associated with increased risk of 3-year mortality. Interventions to prevent pneumonia in acute stroke stage might improve ischemic stroke outcome.     

Relationship of initial glucose level and all‐cause death in patients with ischaemic stroke: the roles of diabetes mellitus and glycated hemoglobin level

Background and purpose: Previous studies demonstrated that post‐stroke hyperglycemia was associated with poor outcome in non‐diabetic patients. However, evidence was inconclusive amongst patients with diabetes. The aim of this study was to evaluate the relationship between initial glucose levels and mortality amongst patients with acute ischaemic stroke, and further, to assess whether the association varied by diabetes mellitus and glycated hemoglobin (HbA_1c) levels. Methods: Data were collected from the medical records of 1277 first‐ever stroke patients admitted to the emergency room between January 1, 2008 and June 30, 2009. Cox regression analysis was performed to assess the relationship between initial glucose level and mortality. Results: Compared with the lowest quartile of initial glucose level, a significant association with all‐cause death [hazard ratio (HR), 2.18; 95% CI, 1.36–3.48] and cardiovascular death (HR, 1.91; 95% CI, 1.01–3.61) was seen in the highest quartile. In non‐diabetic subgroup, those patients within the highest quartile of initial glucose level had a 3.29‐fold relative risks (RR) [95% confidence interval (CI), 1.62–6.68] for all‐cause and a 2.54‐fold RR (95% CI, 1.43–8.77) for cardiovascular death compared with those within the lowest quartile. However, the association between initial glucose levels and the risk of death was not significant amongst those with diabetes (P for interaction = 0.01). In addition, the risk amongst patients with diabetes varied by the HbA_1c levels. Conclusions: A significant association was confirmed between initial glucose level and mortality in non‐diabetic ischaemic stroke patients. The possible relationship between initial glucose level, HbA_1c level, and mortality amongst ischaemic stroke patients with diabetes warrants further research.     

Microalbuminuria and hyperthermia independently predict long-term mortality in acute ischemic stroke patients

OBJECTIVES: To investigate the association between microalbuminuria (MA) and hyperthermia in acute ischemic stroke and to evaluate their significance as the predictors of long-term mortality after stroke. MATERIAL AND METHODS: We assessed neurologic deficit, urinary albumin excretion and body temperature in 60 patients admitted within 24 h after the onset of their first ischemic stroke. Outcome was assessed by 90-day and 1-year mortality. RESULTS: MA was found in 46.7% of patients. Hyperthermia was found in 18.3% patients on Day 1 and in 25% patients on Day 2. The correlation between albuminuria on Day 2 and the body temperature on Days 1 and 2 was found (r = 0.45, and r = 0.30, respectively; both P < 0.05).The mortality was significantly higher in the group of patients with both MA and hyperthermia on Day 2 (73% vs 10% after 90 days; P < 0.0001 and 73% vs 18% after 1 year, P < 0.005). In the logistic regression analysis, albuminuria (P = 0.017), hyperthermia on Day 1 (P = 0.028) and neurologic deficit on admission (P = 0.044) independently predicted 1-year mortality after ischemic stroke. CONCLUSION: Daily urinary albumin excretion correlates with the body temperature in acute stroke patients, but the predictive power of both these variables is independent of that association.