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Prevention and Treatment of Ischaemic and Haemorrhagic Stroke in People With Diabetes
TAKE-HOME MESSAGE
- This review summarises evidence on the associations between type 2 diabetes and cardiovascular disease. The authors review practical recommendations for the management of hyperglycaemia in the context of acute and subacute ischaemic and haemorrhagic stroke, as well as management of diabetes in vulnerable subgroups of people with diabetes and chronic kidney disease, atherosclerotic cardiovascular disease, atrial fibrillation, and heart failure.
- A multidisciplinary approach is needed in the management of hyperglycaemia in the hyperacute setting of a stroke, paired with strategies for long-term prevention in people with diabetes.
abstract
This abstract is available on the publisher's site.
Access this abstract nowDiabetes mellitus is a significant risk factor for both ischaemic and haemorrhagic stroke, affecting up to a third of individuals with cerebrovascular diseases. Beyond being a risk factor for stroke, diabetes and hyperglycaemia have a negative impact on outcomes after ischaemic and haemorrhagic stroke. Hyperglycaemia during the acute ischaemic stroke phase is associated with a higher risk of haemorrhagic transformation and poor functional outcome, with evidence in favour of early intervention to limit and manage severe hyperglycaemia. Similarly, intensive glucose control nested in a broader bundle of care, including blood pressure, coagulation and temperature control, can provide substantial benefit for clinical outcomes after haemorrhagic stroke. As micro- and macrovascular complications are frequent in people with diabetes, cardiovascular prevention strategies also need to consider tailored treatment. In this regard, the broader availability of sodium-glucose cotransporter 2 inhibitors and glucagon-like peptide 1 receptor agonists can allow tailored treatments, particularly for those with heart failure and chronic kidney disease as comorbidities. Here, we review the main concepts of hyperacute stroke management and CVD prevention among people with diabetes, capitalising on results from large studies and RCTs to inform clinicians on preferred treatments.
Additional Info
Prevention and treatment of ischaemic and haemorrhagic stroke in people with diabetes mellitus: a focus on glucose control and comorbidities
Diabetologia 2024 Jul 01;67(7)1192-1205, S Sacco, M Foschi, R Ornello, F De Santis, R Pofi, M RomoliFrom MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.
Diabetes is a major risk factor for both ischemic and hemorrhagic stroke, and hyperglycemia has been linked to increased morbidity and mortality following stroke. In this review, Sacco et al provide an update on the prevention and management of stroke in patients with type 2 diabetes.
The authors begin by highlighting the link between diabetes and stroke, including that 1 in 4 people with acute stroke have underlying diabetes and that the risk of stroke increases with the duration of diabetes. They then explore the mechanisms behind the increased risk of stroke, such as arterial stiffness and cerebral small-vessel disease, as well as its association with common comorbidities, including diabetic cardiomyopathy and kidney disease.
Importantly, the authors then discuss the implications of treatment and prevention of diabetes on stroke. In the acute setting, management of both ischemic and hemorrhagic stroke includes the treatment of severe hyperglycemia while avoiding and promptly treating hypoglycemia; however, overly aggressive glucose-lowering treatment may be avoided in the first 72 hours after an ischemic stroke. In patients with diabetes, the suggested glucose targets are 7.8 to 10.0 mmol/L (140–180 mg/dL).
With respect to prevention, cardiovascular risk-factor modification has been shown to reduce the risk of stroke in people with diabetes. Treatment with GLP-1 receptor agonists and pioglitazone has been associated with a reduced risk of stroke. Furthermore, in people with atherosclerotic cardiovascular disease, SGLT2 inhibitors reduce the risk of major cardiovascular events. Patients with common comorbidities, including chronic kidney disease and heart failure, may also benefit from SGLT2 inhibitors. Finally, the authors discuss the role of a multidisciplinary approach following hospital discharge and the importance of ongoing cardiovascular risk-factor modification.