Prevalence of diabetes and/or ischaemic heart disease in classes of increasing carotid artery atherosclerosis: an ultrasonographic study.

AIMS: To evaluate the prevalence of non-diabetic subjects and diabetic patients, with or without ischaemic heart disease (IHD), in different classes of increasing carotid atherosclerotic damage. METHODS: Using high-resolution B-mode ultrasound, we studied 598 subjects without known cardiovascular disease (CVD) or diabetes, 74 diabetic patients without CVD, 74 non-diabetic subjects with IHD and 36 patients with both diabetes and IHD. Carotid atherosclerosis was classified as: normal; thickened intima-media; non-stenotic plaque; stenotic plaque. RESULTS: Compared with subjects without diabetes or CVD, the frequency of patients with diabetes without known CVD increased significantly from 'normal' to 'stenotic plaque' (4.1%, 6.4%, 13%, 14.8% for normal, thickened intima-media, non-stenotic plaque and stenotic plaque, respectively; P = 0.0057). The same figures were 6%, 7.6%, 10.2%, 23.3% (P = 0.0007) for non-diabetic subjects with IHD, and 0%, 2%, 5.6%, 15.9% (P < 0.0001) for diabetic patients with IHD. No difference was found comparing subjects with diabetes without CVD with non-diabetic patients with IHD (P = 0.56). Using polychotomous logistic regression analysis, diabetic patients without CVD and non-diabetic subjects with IHD showed a similar association with the increasing degree of carotid atherosclerosis (P = 0.59), but significantly stronger compared with subjects without diabetes or CVD (P < 0.03 for both). CONCLUSIONS: Diabetic patients without known CVD show an advanced degree of carotid atherosclerotic damage similar to non-diabetic subjects with IHD and significantly higher compared with non-diabetic subjects without CVD. Our data support the need for an aggressive early prevention of CVD in diabetic subjects.     

Cardiovascular disease in recent onset diabetes mellitus

Diabetes is associated with a marked increased risk of atherosclerotic vascular disorders, including coronary, cerebrovascular, and peripheral artery disease. Cardiovascular disease (CVD) could account for disabilities and high mortality rates in patients with diabetes. Conventional risk factors, including hyperlipidemia, hypertension, smoking, obesity, lack of exercise, and a positive family history, contribute similarly to macrovascular complications in type 2 diabetic patients and non-diabetic subjects. The levels of these factors in diabetic patients are certainly increased, but not enough to explain the exaggerated risk for macrovascular complications in the diabetic population. Furthermore, recently, macrovascular complications of diabetes have been shown to start before the onset of diabetes. Indeed, several clinical studies have confirmed the increased risk of CVD in patients with impaired glucose tolerance (IGT). Since insulin resistance-related postprandial metabolic derangements are thought to play a central role in the development and progression of CVD in patients with IGT, amelioration of postprandial metabolic disturbance is a therapeutic target for the prevention of CVD in these high-risk patients. Therefore, in this paper, we review the molecular mechanisms for the increased risk of CVD in recent onset diabetes mellitus, especially focusing on postprandial dysmetabolism. We also discuss here the potential therapeutic strategies that specially target the mechanisms responsible for vascular alterations in diabetes.     

Cardiovascular disease in type 2 diabetes: challenge for treatment and prevention

Type 2 diabetes increases the risk of cardiovascular disease (CVD) two- to fourfold compared with the risk in non-diabetic subjects. Although type 2 diabetes is associated with a clustering of risk factors (small, dense low-density lipoprotein [LDL] particles, low high-density lipoprotein [HDL] cholesterol, high triglycerides, elevated blood pressure, obesity, central obesity, hyperinsulinaemia, hyperglycaemia, etc.), the cause for an excess risk of CVD remains unknown. Recent drug treatment trials have indicated that the lowering of total and LDL cholesterol and blood pressure is similarly beneficial in diabetic and non-diabetic subjects. The treatment of hyperglycaemia reduces micro- and macrovascular complications in type 2 diabetic patients. Beta-blocking agents, angiotensin-converting enzyme inhibitors, aspirin, and thrombolytic therapy are also effective in the treatment of CVD amongst diabetic patients.     

Approaches to Decongestion in Patients with Acute Decompensated Heart Failure

Type 2 diabetes increases the risk of cardiovascular disease (CVD) from two- to four-fold. In our large Finnish population-based study published in 1998 subjects with medication for type 2 diabetes had as high a risk of fatal and nonfatal myocardial infarction (MI) during the 7- year follow-up as non-diabetic subjects with a prior MI, suggesting that type 2 diabetes is a CVD equivalent. In another large study, including all 3.3 million residents of Denmark, subjects requiring glucose-lowering therapy exhibited a CVD risk similar to that of non-diabetic subjects with a prior MI. Subsequent studies have not systematically replicated aforementioned results. Some studies have supported the concept that type 2 diabetes is a CVD equivalent only in some subgroups, and many studies have reported negative findings. This is likely to be due to many differences across the studies published, for example ethnicity, gender, age and other demographic factors of the populations involved, study design, validation of diabetes status and CVD events, statistical analyses (adjustments for confounding factors), duration of diabetes, and treatment of hyperglycemia among diabetic participants. Varying results reflect the fact that not all diabetic patients are at a similar risk for CVD. Therefore, CVD risk assessment and the tailoring of preventive measures should be done individually, taking into consideration each patient’s long-term risk of developing cardiovascular events.     

Cerebrovascular disease in diabetes mellitus: The role of carotid intima-media thickness

Background and purposeCerebrovascular disease in diabetes appears to be less considered than coronary and peripheral disease, the reason being the intrinsic difficulty in finding available diagnostic tools for its early identification. Among these, carotid artery intima-media thickness (cIMT) represents the simplest measurable parameter for pre-atherosclerotic lesions in extra-cranic arteries.MethodsThe role of cIMT as a surrogate marker of cerebral atherosclerosis and predictor of stroke, its relationship to microangiopathy and chronic inflammation, along with its role as an outcome parameter in anti-hyperglycemic therapeutical intervention trials in type 2 and 1 diabetes mellitus are discussed in this paper.Results and conclusionsCarotid IMT is increased in diabetes. It is an independent predictor of stroke, in particular of the ischemic subtype, and of stroke recurrence in diabetic, as well as in non-diabetic populations. A possible role of cIMT as a predictor of microangiopathy has also been suggested, but it needs further investigation. A weak association with chronic inflammation has been demonstrated in diabetic patients. Carotid IMT has been successfully employed as an outcome parameter for several anti-hyperglycemic therapeutic trials.However data on cIMT as a predictor of cerebrovascular disease are scarce in diabetic patients, particularly in type 1 diabetes, and more studies are needed to define the risk of cerebrovascular disease in diabetic patients.     

Cardiovascular risk in diabetes: a brief review

Cardiovascular disease (CVD) is the major cause of the morbidity and mortality associated with diabetes in the US. A 2- to 3-fold incidence of CVD occurs in both type 1 and type 2 diabetic individuals over that in age- and gender-matched non-diabetic persons. Recent encouraging data demonstrating a decline in CVD mortality in the general US population do not reflect such a decline in the diabetic population, particularly in women.Increased risk for CVD is related to duration of diabetes and hyperglycemia, as well as hypertension, dyslipidemia, insulin resistance, gender, coagulation abnormalities, and other factors. Health care providers need to advocate for an uncompromising, multi-component attack on all modifiable risk factors for CVD, including glucose control, in the person with diabetes mellitus. This review focuses on known modifiable risk factors for CVD associated with diabetes, potential targets for primary and secondary prevention.     

Considerations for treating dyslipidemia in special diabetic populations

This is a review of the problem of dyslipidemia and cardiovascular disease (CVD) in special diabetic populations. Clearly all patients with diabetes are at increased risk for CVD compared to non-diabetic populations. But within the subset that is patients with diabetes there are individuals who are particularly vulnerable. These groups include women, who are often overlooked and undertreated for their cardiovascular risk. Additionally, it includes those with fewer resources, many from minority populations, who are at very high risk for poor preventive care and serious cardiovascular morbidity. This review details the risk for CVD in a variety of different diabetic high-risk groups. It then discusses treatment options and approaches that should be employed in these populations.     

Measurement of subclinical carotid atherosclerosis may help in predicting risk for stroke in patients with diabetes

Diabetes is one of the most important risk factor for stroke and cardiovascular disease (CVD), especially in young patients. The control of classical vascular risk factors failed in terms of prevention of stroke in patients with diabetes. In addiction, in these patients the glycemic control showed a benefit on microvascular disease but lacked an established benefit in macrovascular disease. Therefore, implementations of effective stroke prevention strategies appear necessary in patients with diabetes. Ultrasound surrogate or intermediate markers of carotid atherosclerosis include carotid intima-media thickness (cIMT), carotid plaque (CP), and carotid stiffness (STIFF) have been demonstrated to increase in patients with diabetes and to be able to predict risk for stroke. In this editorial we discuss the opportunity to prevent the onset of vascular disease in their “preclinical or subclinical” stage in patients with higher risk for stroke such as diabetic patients.     

Proteinuria and metabolic syndrome as predictors of cardiovascular death in non-diabetic and type 2 diabetic men and women

Aims/hypothesis Proteinuria predicts cardiovascular disease (CVD), but it is unclear whether this is explained by the association of the metabolic syndrome with proteinuria. Therefore, we investigated proteinuria and the metabolic syndrome as independent predictors of CVD death in men and women. Methods The cohort comprised 574 non-diabetic men, 707 non-diabetic women, 371 diabetic men and 349 diabetic women, all free of CVD at baseline. Modified World Health Organization criteria were used to define the metabolic syndrome, and a urinary protein concentration of ≥0.1 g/l (or ≥0.2 g/l) to define proteinuria. The endpoint was CVD mortality during the 18-year follow-up. Results Among non-diabetic men, CVD mortality per 1,000 person-years was as follows: no metabolic syndrome, no urinary protein group: 5.3; no metabolic syndrome, positive for urinary protein: 8.9; positive for metabolic syndrome, no urinary protein: 13.3; and positive for metabolic syndrome and urinary protein: 14.9. For non-diabetic women the corresponding values were: 0.9, 2.3, 4.9 and 7.9, respectively. Among diabetic men, CVD mortality per 1,000 person-years was 15.2, 32.5, 23.6 and 42.0 for the respective groups. Among diabetic women it was 25.3, 38.0, 26.3 and 40.3 (urinary protein in all cases defined as ≥0.1 g/l). In multivariate Cox models including both urinary protein and metabolic syndrome, the hazard ratios (HRs, 95% CI) of proteinuria for CVD mortality were 1.5 (0.9–2.4) in non-diabetic men, 1.8 (0.8–4.2) in non-diabetic women, 1.6 (1.0–2.6) in diabetic men and 1.6 (1.1–2.3) in diabetic women. Urinary protein as a continuous variable was associated with CVD mortality in all groups. The corresponding HRs for metabolic syndrome were: 1.6 (0.9–2.7), 4.0 (1.7–9.7), 1.5 (1.1–2.0) and 1.1 (0.8–1.5). Conclusions/interpretation Proteinuria predicted CVD mortality independently of the presence of metabolic syndrome in non-diabetic and diabetic subjects. Metabolic syndrome predicted CVD mortality in non-diabetic women and in diabetic men, independently of the presence of proteinuria.     

Prevention of Cardiovascular Complications of Diabetes Mellitus by Aspirin

Eighteen million Americans have type 2 Diabetes Mellitus (DM) while another 40 million have impaired glucose tolerance. Atherosclerotic heart disease is the leading cause of death in patients with diabetes mellitus. In addition to the increased risk for Cardio Vascular Disease (CVD), patients with diabetes have a worse prognosis than nondiabetics when they suffer an ischemic event. Insulin resistance is increasingly recognized as a chronic, low‐level, inflammatory state. Hyperinsulinemia has been proposed as the forerunner of hypertension, low high‐density lipoprotein cholesterolemia, hypertriglyceridemia, abdominal obesity, and altered glucose tolerance, linking all these abnormalities to the development of coronary vascular disease. Atherosclerosis and insulin resistance share similar pathophysiological mechanisms, due to the actions of proinflammatory cytokines. The dynamic inflammatory milieu found in diabetes explains the susceptibility of diabetics to CVD and the potential mechanism by which aspirin may prevent CVD in diabetics. Aspirin decreases the risk for CVD in diabetic patients by a variety of established and novel mechanisms. Therapeutic strategies that lesson the CVD risk in diabetic patients, including the use of aspirin for primary and secondary prevention, are potentially very important. This review article addresses the antiatherosclerotic effects of aspirin, the potential anti‐diabetic effects of aspirin, and the clinical trial evidence for CVD prevention by aspirin in diabetics. We also present recommendations for the use of aspirin in the diabetic population and the current guidelines put forth by the American Heart Association and by the American Diabetes Association.     

Prevention and treatment of ischemic heart disease in patients with diabetes mellitus

The incidence of cardiovascular diseases among diabetic patients is so high that diabetes mellitus is currently defined as a cardiovascular disease equivalent. Furthermore, diabetic patients who develop acute coronary syndromes have a poorer short-term and long-term prognosis, so primary and secondary preventive measures are critically important in this population subgroup.There is substantial evidence that pharmacological therapy for primary and secondary cardiovascular prevention is more effective in diabetic patients than in non-diabetics. This article reviews the evidence of the efficacy of pharmacological prevention therapies in diabetic patients in favor of an aggressive pharmacological preventive strategy. Every diabetic patient without known cardiovascular disease should be treated with angiotensin-converting enzyme inhibitors and statins. High-risk patients should also receive low-dose aspirin.Compared with non-diabetics, diabetic patients who develop acute coronary events benefit more from the addition of intensive antithrombotic therapy to aspirin treatment. Diabetic patients presenting with non-ST segment elevation syndromes have better outcomes when treated with clopidogrel or glycoprotein IIb/IIIa inhibitors, and diabetics presenting with ST-segment elevation or left bundle-branch block have a greater survival benefit when given thrombolytic therapy compared with non-diabetic patients.Unless formal contraindications are present, diabetic patients with ischemic heart disease, particularly those with previous myocardial infarction, should always be treated with aspirin, betablockers, angiotensin converting enzyme inhibitors, and statins, regardless of lipid levels, left ventricular systolic function or the presence of congestive heart failure.     

Cardiovascular trials in diabetes: past and present. Invited lecture of the XXXVth National Congress of the Spanish Society of Cardiology

The risk of coronary heart disease in subjects with Type2 diabetes is 2-4 times higher than in non-diabetic subjects of the same age. About 20% of patients with clinically established coronary heart disease have diabetes and the prognosis is much worse in diabetic than in non-diabetic patients. Trial evidence suggests that good blood glucose control reduces the risk of myocardial infarction in diabetic patients and improves prognosis after it. Trial evidence indicates that the benefit from antihypertensive treatment is at least as good in diabetic than in non-diabetic patients, and that diabetic patients with coronary heart disease or other form of atherosclerotic vascular disease should be treated with lipid-lowering drugs (usually with statins), if their LDL cholesterol levels on diet remain> 3.0 mmol/l (115 mg/dl). Trial evidence supports the use of aspirin in middle-aged or elderly diabetic patients. All diabetic patients should be advised to stop smoking.     

Increased prevalence of cardiovascular disease in Type 2 diabetic patients with non-alcoholic fatty liver disease.

AIMS: To estimate the prevalence of cardiovascular disease (CVD) in Type 2 diabetic patients with and without non-alcoholic fatty liver disease (NAFLD), and to assess whether NAFLD is independently related to prevalent CVD. METHODS: We studied 400 Type 2 diabetic patients with NAFLD and 400 diabetic patients without NAFLD who were matched for age and sex. Main outcome measures were prevalent CVD (as ascertained by medical history, physical examination, electrocardiogram and echo-Doppler scanning of carotid and lower limb arteries), NAFLD (by ultrasonography) and presence of the metabolic syndrome (MetS) as defined by the World Health Organization or Adult Treatment Panel III criteria. RESULTS: The prevalences of coronary (23.0 vs. 15.5%), cerebrovascular (17.2 vs. 10.2%) and peripheral (12.8 vs. 7.0%) vascular disease were significantly increased in those with NAFLD as compared with those without NAFLD (P < 0.001), with no differences between sexes. The MetS (by any criteria) and all its individual components were more frequent in NAFLD patients (P < 0.001). In logistic regression analysis, male sex, age, smoking history and MetS were independently related to prevalent CVD, whereas NAFLD was not. CONCLUSIONS: The prevalence of CVD is increased in patients with Type 2 diabetes and NAFLD in association with an increased prevalence of MetS as compared with diabetic patients without NAFLD. Follow-up studies are necessary to determine whether this higher prevalence of CVD among diabetic patients with NAFLD affects long-term mortality.     

Echocardiography and sonography of the carotid arteries in diabetics with cerebrovascular stroke

The incidence of cerebrovascular attacks (CVA) in diabetics is 2-3 times higher as compared with the non-diabetic population. The objective of the present work was to evaluate etiological factors by means of echocardiography and sonography of the carotid arteries. The authors evaluated retrospectively findings of these examinations in 253 patients with CVA in a group of diabetic and non-diabetic patients as well as in a group of patients with atrial fibrillations or sinus rhythm. In patients with a sinus rhythm the presence of diabetes was associated with a more frequent finding of atherosclerotic changes, significant stenoses of the carotid vessels (2% as compared with 8%, p < 0.05) as well as thickness of the intima in the carotid bulbus (0.78 as compared with 0.96 mm, p < 0.05). Conversely when evaluating signs of thromboembolic risk, i.e. the size of the left ventricle (42 vs. 40 mm, n.s.) and ejection fraction of the left ventricle (55% vs. 50%, n.s.) no statistical significance in the difference of parameters was found. In the sub-group of patients with atrial fibrillation, who accounted for 28% of the group, the authors did not find when comparing diabetic and non-diabetic patients, any difference as regards the presence of significant stenoses in the carotid arteries nor in the thickness of the intima. There was no statistically significant difference in the size of the left atrium and left ventricular function. The findings suggest the possibility that the increased risk of ischaemic CVA in diabetic patients is caused by the atherosclerotic process in the carotid vessels and not a higher risk of embolism of cardiac origin.     

脑血管病再发相关危险因素

目的探讨高血压病、糖尿病、血脂异常与脑血管病再发的关系。方法对686例60岁以上脑血管病患者的临床资料进行回顾性分析,其中再发病例221例(再发组),初次发病者465例(初次发病组)。收集患者的血压、糖化血红蛋白水平、是否患有血脂异常等因素,与同期因脑血管病入院的初次发病者进行比较。结果脑血管病再发患者存在明显的高血压病(OR=5.37)和血糖控制不良(OR=7.96),但血脂异常在脑血管病再发中差异无显著性意义。结论高血压病和糖尿病控制不良是脑血管病再发的主要危险因素,应在脑血管病二级预防中充分重视,同时血脂异常亦是不能忽视的因素。     

Diabetic foot disease in the elderly

Elderly diabetic patients are particularly burdened by foot disease. The main causes for foot disease are peripheral neuropathy, foot deformities and peripheral arterial disease (PAD). Other risk factors include poor vision, gait abnormalities, reduced mobility an medical co-morbidities. The risk of major amputations increases with age, along with the increased prevalence of these risk factors. Th true risk of amputation and other burdens of foot disease in the elderly are likely underestimated by current epidemiological data. Th prevalence of neuropathy, foot deformities and PAD as well as the risk of amputation all increase with age even in non-diabetic patients. The principles of prevention and management of diabetic foot disease may also apply to large segments of the elderly non-diabetic population. Foot ulcer prevention relies on the identification of high risk patients and avoidance of triggering events, such as ill-fitting shoes, walking barefoot or poor self-care. PAD is a major cause of amputation and should be prevented by lifelong attention to glycaemic control, treatment of hypertension and dyslipidemia, and avoidance of smoking. The treatment of foot ulcers relies on pressure relief (off-loading), wound debridement, and treatment of infection and ischemia. It requires an individualized approach considering the patient's co-morbidities and functional status. Off-loading remains essential, but devices such as total contact casts or crutches can only rarely be implemented. However, providing adapted standard foot-wear and insisting on its consistent use even at home is often effective. The benefits of aggressive vascular or orthopaedic surgery should be weighed against the risks of prolonged hospitalisation and resulting functional decline. Greater attention to prevention and individualized care are needed to reduce the burden of diabetic foot disease in the elderly.     

Comparison of secondary prevention measures after myocardial infarction in subjects with and without diabetes mellitus

OBJECTIVES: To survey and compare secondary prevention measures in diabetic and non-diabetic patients following myocardial infarction (MI). DESIGN: Follow-up of a cohort of patients who suffered their first MI 1 year previously. SETTING: Three district general hospitals. MAIN OUTCOME MEASURES: Review 1 year post-MI for signs of left ventricular failure (LVF), serum cholesterol, smoking status, weight, blood pressure and glycaemic control. Assessment of appropriate treatment with aspirin, beta-blockers, angiotensin-converting enzyme (ACE) inhibitors and lipid-lowering therapy before discharge and at least 1 year post-MI. RESULTS: A total of 189 non-diabetic and 86 diabetic patients were studied. Most patients received beta-blockers and aspirin appropriately, and most gave up smoking. In non-diabetic subjects, cholesterol fell significantly (P < 0.05), as did the proportion of patients with cholesterol > 5.5 mmol L(-1) (P < 0.05), whereas cholesterol did not fall significantly in diabetic subjects, due to a lower proportion of patients being on lipid-lowering therapy (27.5 vs. 37.9%). A higher proportion of non-diabetic patients with LVF were treated with ACE inhibitors compared with diabetic subjects (73.6 vs. 61.%). Glycaemic control did not improve in the diabetic subjects. CONCLUSIONS: Patients with diabetes do not receive optimal secondary prevention measures compared with their non-diabetic counterparts. This issue needs to be addressed by all units dealing with patients with diabetes in order to reduce the mortality and morbidity of MI in such patients.     

Comprehensive geriatric assessment and treatment of elderly diabetic patients

Because of diversities of physical, mental, and psychological functions as well as clinical and social backgrounds, comprehensive geriatric assessment (CGA) is of great importance in treating elderly diabetic patients. We addressed three issues as to functions important for the CGA. First, we assessed several domains of cognitive function in 213 elderly diabetic patients. Attention and visual memory in diabetic patients without vascular disease were impaired compared with non-diabetic controls after adjusting for age and sex using analysis of covariance. Multivariate analysis revealed that age, hyperglycemia, and the presence of cerebral infarction were independent determinants for the impairment of attention in the diabetic patients. The results suggest that glucose control is important for the maintenance of cognitive function in elderly diabetic patients. Secondly, we assessed positive well-being as a measure of psychological function using a PGC morale scale in 197 elderly diabetic patients without cerebrovascular disease at baseline and examined whether the low well-being affect the development of cerebrovascular disease in a 3-year longitudinal study. The results indicate that low well-being was an independent risk factor for cerebrovascular disease after adjusting conventional risk factors in elderly diabetic patients. Thirdly, as a physical function, we assessed 5-m walking speed for both usual and maximum walking in 64 diabetic patients. The walking speed decreased with age and correlated significantly with the knee extension power and functional reach. The result suggests that muscle-strength exercise and balance training as well as endurance exercises are necessary to improve age-related decreases in walking speed and for effective exercise in elderly patients. From a gerontological point of view, new strategies of elderly diabetes treatment including muscle strength exercise and psychological approaches should be established to improve physical, mental, psychological, and social functions as assessed by the CGA.     

Schlaganfall-Prim?rpr?vention bei Diabetespatienten

Stroke is the second most frequent cause of death worldwide and the most frequent cause of permanent disability. Patients with diabetes are at 1.5 to 3 times the risk of stroke compared to the general population. Cerebrovascular disease causes 20% of deaths in diabetic patients. Interestingly, there are some striking differences in stroke patterns between diabetic and non-diabetic subjects. Even more important is the fact that diabetes dramatically increases the risk of stroke in younger subjects as well as women. These data highlight the need for optimized primary prevention in diabetic patients. This review summarizes the clinical data available on pharmacological and non-pharmacological primary stroke prevention in diabetic patients.     

Clinical characteristics in diabetic stroke patients

The impact of diabetes was prospectively studied during a 5-year period in 428 unselected and consecutive patients with acute cerebrovascular disease of whom 18% were diabetic. Cerebral infarction was more frequent in diabetics (81 vs 70%, p less than 0.02) whereas transient cerebral ischaemia was less frequent (4 vs 14%, p less than 0.01). Case fatality rate during hospitalization was higher in the diabetic than in the non-diabetic patients (28 vs 15%, p less than 0.02). Patients who died during hospitalization, diabetic as well as non-diabetic, had significantly higher blood glucose concentrations on admission compared with patients who survived. Hematocrit values were higher in the diabetic than in the non-diabetic patients (p less than 0.02). Diabetics had higher systolic blood pressure levels than the non-diabetics in the acute phase (p less than 0.005). The diabetic stroke patients more often had a history of hypertension, atrial fibrillation, heart failure and angina pectoris than non-diabetics stroke patients and diabetic control patients without stroke. Stroke patients, not known to be diabetic, had larger mean oral glucose tolerance test curve areas when compared with healthy controls but not when compared with hospitalized controls. We propose that diabetes increases the risk for stroke through other concurrent risk factors, cardiac disorders in particular.