SAN FRANCISCO — Stroke and diabetes need to be treated as comorbidities, and physicians treating stroke patients should ensure that their patients receive aggressive lipid management, Dr. Lee H. Schwamm reported at the 32nd International Stroke Conference.
Significant numbers of people with diabetes—both the newly diagnosed and the patients previously treated—leave the hospital after a stroke without treatment plans that met evidence-based guidelines, according to Dr. Schwamm.
“We need to educate people who take care of stroke patients about the comorbidity of diabetes and coronary disease to make sure patients get treatment that is best for their combination of conditions and not just the treatment they present with,” he said.
A review of 159,338 acute stroke and transient ischemic attack patients revealed that 49,066 patients—about 31%–-had diabetes. The diabetic population comprised 46,436 patients whose diabetes was known before admission and 2,630 patients who were diagnosed with diabetes after being admitted for stroke.
Although the proportion of diabetic stroke patients was in line with earlier studies, the actual number of stroke patients who have comorbid diabetes may be higher, said Dr. Schwamm, vice chairman of neurology and director of acute stroke services at Massachusetts General Hospital in Boston. The diagnosis of diabetes is dependent on measurement of HbA1c levels, he said, and many hospitals do not routinely screen stroke patients.
“What is really startling is that [66%] of the patients who were known to be diabetic had no measure of [HbA1c] while in the hospital, which tells you that diabetes was not being addressed in the inpatient setting,” he said during an interview at the conference, which was sponsored by the American Stroke Association.
LDL cholesterol levels, he added, were not found in charts for 42% of the stroke patients who were known to have diabetes.
Despite making up a much smaller proportion of the study population, patients who were newly diagnosed with diabetes had significantly worse control of risk factors than did those who had been treated previously, Dr. Schwamm and his colleagues reported.
The researchers said the average age of participants was 70.5 for 46,436 patients known to have diabetes when admitted and 68.67 for 2,630 patients who were newly diagnosed. The difference was statistically significant with a P value of less than .0001.
The mean LDL cholesterol for newly diagnosed patients was 117.6 mg/dL, compared with 106.1 mg/dL in known diabetics; their average total cholesterol was 192.5 mg/dL, compared with 178.2 mg/dL in the stroke patients previously treated for diabetes. The average HbA1c was 7.87% in the previously diagnosed diabetics and 8.18% in patients who were diagnosed while they were hospitalized for stroke.
Compared with the known diabetics, the newly diagnosed were less likely to be obese (27.2% vs. 31.2%) or have high blood pressure (65.5% vs. 82.5%) but more likely to smoke (19.9% vs. 13.7%). They also had fewer vascular risk factors documented in their records before hospitalization.
Ischemic stroke was more common in the patients who had not previously been diagnosed with diabetes (89% vs. 78%).
Dr. Schwamm said the investigators had no way of knowing why diabetes had not been spotted before hospitalization for stroke in the newly diagnosed group. “If you are recognized as a diabetic, lipid control becomes a very important intervention. So the failure to detect diabetes means you are less likely to have lipid control introduced.”
The patients were drawn from a database of 659 hospitals participating in the American Stroke Association's “Get With the Guidelines” stroke initiative, a quality improvement program aimed at increasing adherence to evidence-based guidelines for treatment of acute stroke and prevention of ischemic stroke.
'The failure to detect diabetes means you are less likely to have lipid control introduced.' DR. SCHWAMM