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Persistent long-term increased risk for stroke in people with diabetes mellitus

Jiten Vora

Numerous studies have examined the risk factors for stroke, but mostly in study durations of less than 10 years’ follow-up. It must be recognised, however, that estimates of risk may differ according to cohorts evaluated over longer periods of follow-up. Thus, when studied consecutively over time, some risk factors may be contributory either during differing periods or throughout the duration of a patient’s lifetime. Others may have reducing effect with time. For example, it has been suggested that hypertension, the single most important risk factor for stroke, has a diminishing impact with increasing age (Whisnant et al, 2002). Similar long-term data was not available, until recently, for diabetes.

A recent study has evaluated the predicted value of risk factors for stroke measured in mid-life or a follow-up extending through 28 years (Harmsen et al, 2006). In a cohort of 7457 men aged 47–55 years, risk of stroke was analysed in periods for 0–15, 16–21 and 22–28 years of follow-up using an age-adjusted and multiple regression analysis. This analysis demonstrated that age, diabetes and high blood pressure were independently associated with increased risk of stroke for the entire 28-years of follow-up. Previous transient ischaemic attacks, atrial fibrillation, ischaemic heart disease, smoking and psychological stress were independently related to stroke for the entire follow-up, though the greatest effect was seen in the first two follow-up periods. Elevated body mass index seemed to predict stroke during the later part of follow-up.

With our increasing elderly population, particularly with diabetes mellitus, prophylaxis for stroke prevention will have to be continued long-term. Consequently, in the presence of multiple medications and the associated issues with adherence, regular use of anti-thrombotic agents, statins and angiotensin converting enzmye inhibitors will need to be commenced early and continued over a prolonged period.

Numerous studies have examined the risk factors for stroke, but mostly in study durations of less than 10 years’ follow-up. It must be recognised, however, that estimates of risk may differ according to cohorts evaluated over longer periods of follow-up. Thus, when studied consecutively over time, some risk factors may be contributory either during differing periods or throughout the duration of a patient’s lifetime. Others may have reducing effect with time. For example, it has been suggested that hypertension, the single most important risk factor for stroke, has a diminishing impact with increasing age (Whisnant et al, 2002). Similar long-term data was not available, until recently, for diabetes.

A recent study has evaluated the predicted value of risk factors for stroke measured in mid-life or a follow-up extending through 28 years (Harmsen et al, 2006). In a cohort of 7457 men aged 47–55 years, risk of stroke was analysed in periods for 0–15, 16–21 and 22–28 years of follow-up using an age-adjusted and multiple regression analysis. This analysis demonstrated that age, diabetes and high blood pressure were independently associated with increased risk of stroke for the entire 28-years of follow-up. Previous transient ischaemic attacks, atrial fibrillation, ischaemic heart disease, smoking and psychological stress were independently related to stroke for the entire follow-up, though the greatest effect was seen in the first two follow-up periods. Elevated body mass index seemed to predict stroke during the later part of follow-up.

With our increasing elderly population, particularly with diabetes mellitus, prophylaxis for stroke prevention will have to be continued long-term. Consequently, in the presence of multiple medications and the associated issues with adherence, regular use of anti-thrombotic agents, statins and angiotensin converting enzmye inhibitors will need to be commenced early and continued over a prolonged period.

REFERENCES:

Harmsen P, Lappas G, Rosengren A et al (2006) Long-term risk factors for stroke. Twenty-eight years of follow-up of 7457 middle-aged men in Goteborg, Sweden. Stroke 37: 1663–7
Whisnant JP, Wiebers DO, O’Fallon WM et al (2002) Effects of time since onset of risk factors on the occurrence of ischaemic stroke. Neurology 58: 787–94

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