Secondary prevention of stroke with antiplatelet agents in patients with diabetes mellitus.

The prevalence of diabetes mellitus (DM) varies from 1.2 to 13.3% in the general population. The most frequent is type 2 (non-insulin-dependent) DM, which constitutes 90-95% of all cases. DM increases the risk of cardiac disease, stroke, retinopathy, nephropathy, neuropathy and gangrene, and the disease is associated with an increased prevalence of other cardiovascular risk factors such as hypertension, hypercholesterolaemia, asymptomatic carotid artery disease, and obesity. The risk of stroke may be directly and indirectly increased by the presence of DM. Epidemiological data show that DM independently amplifies the risk of ischaemic stroke from 1.8- up to 6-fold, so that prevention of cardiovascular risk in diabetics is of utmost importance. The main goal is to control glycaemia, although it has never been shown to be beneficial in stroke patients. Other preventive strategies include antiplatelet treatment. The open-label Primary Prevention Project trial tested the efficacy of low-dose acetylsalicylic acid (ASA) in prevention of ischaemic events in high-risk patients, but failed to demonstrate a significant benefit of ASA in diabetic patients. However, in the CAPRIE trial, the benefit of clopidogrel was amplified in patients with DM versus those without DM in preventing ischaemic events. This difference was even more striking when comparing patients treated with insulin versus non-diabetics. Another trial -- MATCH -- tested the benefit of adding ASA to clopidogrel versus clopidogrel alone in the prevention of ischaemic events in high-risk cerebrovascular patients, two-thirds of whom had DM. Further research is needed to clarify the effects of different antiplatelet regimens in stroke prevention in diabetic patients, who should be considered as high vascular-risk patients

Stroke patterns, etiology, and prognosis in patients with diabetes mellitus

Background: Although diabetes mellitus (DM) is a risk factor for stroke, it is unclear whether stroke features are different in diabetic vs nondiabetic individuals.Objective: To assess the role of DM in stroke patients.Methods: Risk factors, etiology, lesion topography, clinical features, and outcome were assessed in 611 diabetic individuals (history of DM or fasting plasma glucose level of ≥7.0 mmol/L) among 4,064 consecutive patients of the Lausanne Stroke Registry.Results: Patients with DM were 5.3 years older than non-DM patients. After multivariate analysis, DM was associated with lower relative prevalence of intracerebral hemorrhage (ICH; odds ratio [95% CI]: 0.63 (0.45 to 0.9); p = 0.022), higher relative prevalence of subcortical infarction (SCI; 1.34 [1.11 to 1.62]; p = 0.009), and higher relative frequency of small-vessel (SVD; 1.78 [1.31 to 3.82]; p = 0.012) and large-artery (LAD; 2.02 [1.31 to 2.02]; p = 0.002) disease. In the cohort of diabetic stroke patients, there was no interaction of DM with either hypertension or age for the outcomes of ICH, SCI, SVD, and LAD. Moderate to severe deficit on admission (31.1 vs 31.6%; p = 0.4) and poor functional outcome at 1 month (14.1 vs 15.3%; p = 0.24) did not differ in patients with DM compared with non-DM patients. In multivariate analysis, neither DM (0.86 [0.63 to 1.11]; p = 0.15) nor hypertension (1.09 [0.91 to 1.39]; p = 0.32) was associated with poor functional outcome.Conclusions: Diabetic stroke patients are associated with specific patterns of stroke type, etiology, and topography but not with poor functional outcome. There was no interaction between DM and hypertension or age.</jats:p

P6542Early Prolonged Ambulatory Cardiac monitoring in Stroke (EPACS): an open-label randomised controlled trial and economic evaluation

Abstract Background Cardioembolism in paroxysmal atrial fibrillation (PAF) is a preventable cause of transient ischaemic attack (TIA) or ischaemic stroke, however, due its transient nature, a short-duration Holter monitor may miss a significant proportion of events. Methods We conducted an open-label randomised controlled trial of cardiac monitoring after a TIA or ischaemic stroke comparing a 14-day ECG monitoring patch with short-duration Holter monitoring for the detection of PAF. The primary outcome was the detection of one or more episodes of ECG-documented PAF lasting at least 30 seconds within 90 days in each of the study arms. A budget impact analysis from the healthcare perspective was performed to assess the theoretical economic implications of the patch-based service versus Holter monitoring. Based on the AF detection rates found in this study, Hospital Episode Statistics data for the incidence of stroke and TIA (October 2016-September 2017) and National Health Service reference costs, the cost-effectiveness of the patch-based service versus Holter monitoring was calculated. The Sentinel Stroke National Audit Programme estimate of £13,452 was used as the mean year one direct medical cost of a stroke. Results From February 2016 through February 2017, 43 (76.8%) of the 56 patients assigned to the patch-based monitoring group and 47 (78.3%) of the 60 patients assigned to the short-duration Holter monitoring group had successful monitor placement with 90 days of follow-up (Figure 1). Of the 26 protocol failures between the two groups, 23 (88.5%) were due to patient refusal for outpatient short-duration Holter monitor placement, whilst only 1 (3.8%) was due to unsuccessful patch placement. The rate of detection of PAF at 90 days was 16.3% in the patch-based monitoring group (7 patients) compared to 2.1% in the short-duration Holter monitoring group (1 patient), with an odds ratio of 8.9 (95% CI 1.1–76.0; P=0.026). Implementation of the patch-based service at our hospital would result in 10.8 more strokes avoided per year compared to current practice with short-duration Holter monitoring. This would equate to a yearly saving in direct medical costs of £57,481, increasing to £106,342 over 5 years. When social care costs are included, incremental savings of £154,716 can be achieved in the first year and £410,449 at 5 years. In addition, an analysis of the potential reduction in outpatient follow-up appointment costs resulted in a further saving of £56,149, giving a total potential saving of £113,630 over the first year with the use of the patch-based service compared to short-duration Holter monitoring, increasing to £162,491 over 5 years. Figure 1. Study participant flowchart Conclusions Early, prolonged, patch-based monitoring after an index stroke or TIA is superior to short-duration Holter monitoring in the detection of PAF and likely cost-effective for preventing recurrent strokes. Acknowledgement/Funding Bristol-Myers Squibb-Pfizer alliance (Grant Number CV185-475) </jats:sec