Huaguang Zheng

Diabetes and Poor Outcomes Within 6 Months After Acute Ischemic Stroke The China National Stroke Registry

Background and Purpose— Diabetes mellitus (DM) is an independent risk factor for ischemic stroke. However, controversy exists with regard to the impact of DM on prognosis after ischemic stroke in the Chinese population. We investigated the associations between DM and death, dependency, and stroke recurrence in patients after ischemic stroke onset in a nationwide, prospective registry, the China National Stroke Registry. Methods— The China National Stroke Registry consecutively recruited patients hospitalized for acute ischemic stroke in 2007 to 2008 and who were prospectively followed up for clinical and functional outcomes (death, dependency, and stroke recurrence) at 3 and 6 months after disease onset. Multivariable logistic regression was performed to analyze the association between DM and stroke outcomes after adjusting for potential confounding including age, sex, National Institutes of Health Stroke Scale score, glucose level at admission, hypertension, coronary heart disease, smoking, urinary tract infection, and other factors. Results— DM was identified in 3483 (27.0%) of stroke patients. Compared with stroke patients without DM, patients with DM had a significantly higher incidence of death or dependency and of recurrent stroke at 3 and 6 months after stroke onset. DM was an independent risk factor for death or dependency (adjusted odds ratio=1.23; 95% confidence interval, 1.10 to 1.37) in patients with ischemic stroke at 6 months after onset. Conclusions— DM independently predicted poor outcomes in Chinese patients after acute ischemic stroke.

Abnormal Glucose Regulation in Patients With Acute Stroke Across China: Prevalence and Baseline Patient Characteristics

Background and Purpose— The prevalence of diabetes is high among patients with ischemic stroke. However, the prevalence of abnormal glucose regulation and clinical characteristics among patients with stroke in the Chinese population is uncertain. We investigated the prevalence of prediabetes and diabetes in Chinese patients after stroke onset in a nationwide cohort study and investigated abnormal glucose regulation in patients with acute stroke across China (ACROSS-China). Methods— The ACROSS-China study consecutively recruited patients hospitalized for acute stroke in 2008 to 2009 and investigated the prevalence of impaired glucose tolerance and diabetes among the patients on day 14 after stroke onset. Oral glucose tolerance test was performed in the diagnosis of abnormal glucose regulation. Results— The prevalence of abnormal glucose regulation was 68.7% among all the patients with stroke. Diabetes was identified in 42.3% of all the patients (45.8% for patients with ischemic stroke, 31.2% for patients with intracerebral hemorrhage, and 26.4% for patients with subarachnoid hemorrhage, respectively). Prediabetes (impaired fasting glucose and impaired glucose tolerance) was identified in 26.4% of all the patients with stroke. The prevalence of diabetes and impaired glucose tolerance was the highest in the patients with atherothrombotic infarction (73.4%). Conclusions— The prevalence of abnormal glucose regulation was high in Chinese patients with acute stroke, especially in patients with atherothrombotic infarction. Oral glucose tolerance test identified a large percentage of patients with newly diagnosed diabetes or impaired glucose tolerance after stroke onset.

External Validation of the ASTRAL Score to Predict 3- and 12-Month Functional Outcome in the China National Stroke Registry

Background and Purpose— The ASTRAL score was recently introduced as a prognostic tool for acute ischemic stroke. It predicts 3-month outcome reliably in both the derivation and the validation European cohorts. We aimed to validate the ASTRAL score in a Chinese stroke population and moreover to explore its prognostic value to predict 12-month outcome. Methods— We applied the ASTRAL score to acute ischemic stroke patients admitted to 132 study sites of the China National Stroke Registry. Unfavorable outcome was assessed as a modified Rankin Scale score >2 at 3 and 12 months. Areas under the curve were calculated to quantify the prognostic value. Calibration was assessed by comparing predicted and observed probability of unfavorable outcome using Pearson correlation coefficient. Results— Among 3755 patients, 1473 (39.7%) had 3-month unfavorable outcome. Areas under the curve for 3 and 12 months were 0.82 and 0.81, respectively. There was high correlation between observed and expected probability of unfavorable 3- and 12-month outcome (Pearson correlation coefficient: 0.964 and 0.963, respectively). Conclusions— ASTRAL score is a reliable tool to predict unfavorable outcome at 3 and 12 months after acute ischemic stroke in the Chinese population. It is a useful tool that can be readily applied in clinical practice to risk-stratify acute stroke patients.

Impaired Glucose Regulation Predicted 1-Year Mortality of Chinese Patients With Ischemic Stroke: Data From Abnormal Glucose Regulation in Patients With Acute Stroke Across China

Background and Purpose— It remains uncertain if impaired glucose regulation (IGR) as a predictor for stroke outcomes. This study aimed at observing the effect of IGR on the 1-year outcomes in Chinese patients with ischemic stroke. Methods— Patients with acute ischemic stroke were recruited consecutively in multihospitals across China. Oral glucose tolerance test was performed to identify IGR. Cox proportion hazard model was performed to investigate the effect of IGR on 1-year mortality or stroke recurrence in patients with ischemic stroke. Results— The study recruited 2639 patients with ischemic stroke. IGR was shown as an independent risk factor for the mortality of patients with ischemic stroke (hazard ratio [95% confidence interval], 3.088 [1.386–6.884]; P=0.006). However, IGR showed no significant effects on the dependency or stroke recurrence of patients (P=0.540 and 0.618, respectively). Conclusions— IGR was an independent predictor for the mortality of patients with ischemic stroke. IGR should be highlighted and intervened actively in the patients with ischemic stroke.

Metabolic syndrome and stroke recurrence in Chinese ischemic stroke patients--the ACROSS-China study.

Objective Metabolic syndrome has emerged as a novel risk factor in cardiovascular disease due to its potential for predicting stroke in population-based studies. We investigated the relationship of metabolic syndrome with stroke recurrence. Methods This was a retrospective analysis of Chinese patients enrolled in the prospective Abnormal gluCose Regulation in patients with acute strOke acroSS China (ACROSS-China) study after their first ischemic stroke. Metabolic syndrome was defined using the International Diabetes Federation (IDF) criteria. Vascular risk factors were assessed. Outcome was defined as recurrence of stroke within one year after the index ischemic stroke. Cox proportional hazards regression was performed to identify potential predictors of stroke recurrence. Results The prevalence of metabolic syndrome among 2639 ischemic stroke patients was 51.35%. During the one-year follow-up, 195 strokes (7.4%) recurred. The multivariate hazard ratio (95% CI) of stroke recurrence was 1.94 (1.39–2.73) for metabolic syndrome. After adjustment for components, metabolic syndrome lost its association with stroke recurrence; in this model, high fasting plasma glucose (IDF definition) was a predictor for stroke recurrence. Conclusion Metabolic syndrome may not be predictive for stroke recurrence beyond its component individual factors for Chinese ischemic stroke patients.

Persistence and predictors of abnormal glucose metabolisms in patients after acute stroke

Abstract Objectives: To determine the persistence of newly recognized abnormal glucose metabolism in patients following acute ischemic stroke and delineate the possible predictive factors for this persistence. Methods: A prospective observational study was performed. One hundred and twenty-three patients with acute first-ever ischemic stroke and no previous diagnosis of diabetes mellitus were enrolled consecutively. Information from baseline and laboratory tests was recorded. A standard oral glucose tolerance test was performed on the fourteenth day after onset and 3 months later, respectively. Results: One hundred and seven patients completed the study. Thirty-nine patients (36·3%) were diagnosed as having newly recognized diabetes on the 14th day and 28 patients (26·1%) after 3 months. Among the patients diagnosed as having diabetes or impaired glucose tolerance during hospitalization, 68·6% remained to present with abnormal glucose metabolism 3 months later. Lower post-load plasma glucose on the fourteenth day was detected as a predictor for aggravated glucose metabolism after 3 months of onset. Conclusion: Majority of newly recognized abnormal glucose metabolism during hospitalization persisted 3 months later. Patients with lower post-load glucose level on the fourteenth day had higher risk for aggravated glucose metabolism 3 months later. Those with higher fasting glucose concentration on admission or higher 2 hour post-load plasma glucose on the fourteenth day had significantly high risk for diabetes after 3 months.

Insulin Resistance and Prognosis of Nondiabetic Patients With Ischemic Stroke: The ACROSS-China Study (Abnormal Glucose Regulation in Patients With Acute Stroke Across China)

Background and Purpose— Insulin resistance was common in patients with stroke. This study investigated the association between insulin resistance and outcomes in nondiabetic patients with first-ever acute ischemic stroke. Methods— Patients with ischemic stroke without history of diabetes mellitus in the ACROSS-China registry (Abnormal Glucose Regulation in Patients With Acute Stroke Across China) were included. Insulin resistance was defined as a homeostatis model assessment–insulin resistance (HOMA-IR) index in the top quartile (Q4). HOMA-IR was calculated as fasting insulin (&mgr;U/mL)×fasting glucose (mmol/L)/22.5. Multivariable logistic regression or Cox regression was performed to estimate the association between HOMA-IR and 1-year prognosis (mortality, stroke recurrence, poor functional outcome [modified Rankin scale score 3–6], and dependence [modified Rankin scale score 3–5]). Results— Among the 1245 patients with acute ischemic stroke enrolled in this study, the median HOMA-IR was 1.9 (interquartile range, 1.1–3.1). Patients with insulin resistance were associated with a higher mortality risk than those without (adjusted hazard ratio, 1.68; 95% confidence interval, 1.12–2.53; P=0.01), stroke recurrence (adjusted hazard ratio, 1.57, 95% confidence interval, 1.12–2.19; P=0.008), and poor outcome (adjusted odds ratio, 1.42; 95% confidence interval, 1.03–1.95; P=0.03) but not dependence after adjustment for potential confounders. Higher HOMA-IR quartile categories were associated with a higher risk of 1-year death, stroke recurrence, and poor outcome (P for trend =0.005, 0.005, and 0.001, respectively). Conclusions— Insulin resistance was associated with an increased risk of death, stroke recurrence, and poor outcome but not dependence in nondiabetic patients with acute ischemic stroke.

Prognosis of Ischemic Stroke With Newly Diagnosed Diabetes Mellitus According to Hemoglobin A1c Criteria in Chinese Population

Background and Purpose— Hemoglobin A1c (HbA1c) was recommended to diagnose diabetes mellitus, but whether newly diagnosed diabetes mellitus (NDDM) according to the new criteria was associated with stroke prognosis was unclear. We aimed to investigate the prognosis of ischemic stroke with NDDM according to the new criteria. Methods— Ischemic stroke without a diabetes mellitus history in the survey on Abnormal Glucose Regulation in Patients With Acute Stroke Across China were included in the analysis. NDDM was defined as fasting plasma glucose ≥7.0 mmol/L, 2-hour oral glucose tolerance test ≥11.1 mmol/L, or HbA1c ≥6.5%, and NDDM was divided into group 1, diagnosed by glucose criteria (fasting plasma glucose ≥7.0 mmol/L or 2-hour oral glucose tolerance test ≥11.1 mmol/L with/without HbA1c ≥6.5%), or group 2, diagnosed by single high HbA1c (fasting plasma glucose <7.0 mmol/L, 2-hour oral glucose tolerance test <11.1 mmol/L, and HbA1c ≥6.5%). The association between NDDM and 1-year prognosis (mortality, stroke recurrence, and poor functional outcome [modified Rankin scale score 3–6]) was estimated. Results— Among 1251 ischemic stroke patients, 539 were NDDM and 141 of NDDM with single high HbA1c. NDDM was an independent risk factor for 1-year mortality (hazard ratio, 1.12; 95% confidence interval, 1.001–1.26), stroke recurrence (hazard ratio, 1.14; 95% confidence interval, 1.01–1.28), and poor functional outcome (odds ratio, 2.58; 95% confidence interval, 1.95–3.43) compared with non–diabetes mellitus. Nevertheless, NDDM with single high HbA1c was not significantly associated with 1-year prognosis for all end points (P>0.05 for all). Conclusions— NDDM by new criteria was associated with poor prognosis at 1 year after ischemic stroke; however, NDDM with single high HbA1c did not predict a poor prognosis.

Risk Assessment of Deep‐Vein Thrombosis After Acute Stroke: a Prospective Study Using Clinical Factors

Deep‐vein thrombosis (DVT) represents a serious complication in acute stroke patients with pulmonary embolus (PE) as a potential outcome. Prediction of DVT may help with formulating a proper prevention strategy. To assess of the risk of deep venous thrombosis (DVT) in acute stroke patients, we developed and validated a clinical score in a cohort study.

Post–Glucose Load Measures of Insulin Resistance and Prognosis of Nondiabetic Patients With Ischemic Stroke

Background Insulin resistance is associated with an increased risk of cardiovascular events in the general population. This study aimed to estimate the association between post–glucose load measures of insulin resistance and prognosis of nondiabetic patients with ischemic stroke. Methods and Results Data were derived from the ACROSS‐China (Abnormal Glucose Regulation in Patients with Acute Stroke across China) registry. Patients with ischemic stroke without a history of diabetes mellitus were included. Two post–glucose load measures of insulin sensitivity, the insulin sensitivity indices ISI(composite) and the ISI 0,120, were calculated. Outcomes included stroke recurrence, all‐cause death, and poor functional outcome at 12 months. Among 1203 patients, 63.3% were male with an average age of 62.1 years. At 12 months, 168 (14.4%) patients had recurrent stroke, 111 (9.2%) had died, and 288 (24.4%) had poor outcome. After adjustment for potential covariates, the first quartile of the ISI(composite) was associated with increased 12‐month stroke recurrence (adjusted hazard ratio 2.02, 95% CI 1.28–3.18, P=0.003), death (adjusted hazard ratio 2.78, 95% CI 1.59–4.86, P<0.001), and poor outcome (adjusted odds ratio 2.67, 95% CI 1.69–4.21, P<0.001) compared with the fourth quartile. Similar results were observed for the ISI 0,120 but with a larger magnitude of association. Using a multivariable regression model with restricted cubic spline, we found an L‐shaped association between the insulin sensitivity indices and the risk of each end point. Conclusions In this large‐scale registry, post–glucose load measures of insulin resistance with the ISI(composite) and the ISI 0,120 were associated with 12‐month poor outcomes of nondiabetic patients with ischemic stroke.