Rates and predictors of risk of stroke and its subtypes in diabetes: a prospective observational study.

BACKGROUND: Small vessel disease is reported to be a more common cause of ischaemic stroke in people with diabetes than in others. However, population based studies have shown no difference between those with and those without diabetes in the subtypes of stroke. We determined the rates and predictors of risk of stroke and its subtypes in the Fenofibrate Intervention and Event Lowering in Diabetes (FIELD) trial. METHODS: 9795 patients aged 50-75 years with type 2 diabetes were followed up for a median of 5 years. Annual rates were derived by the Kaplan-Meier method and independent predictors of risk by Cox proportional hazards regression analyses. RESULTS: The annual rate of stroke was 6.7 per 1000 person years; 82% were ischaemic and caused by small artery disease (36%), large artery disease (17%) and embolism from the heart (13%); 10% were haemorrhagic. Among the strongest baseline predictors of ischaemic or unknown stroke were age (60-65 years, HR 1.98; >65 years, HR 2.35) and a history of stroke or transient ischaemic attack (TIA) (HR 2.06). Other independent baseline predictors were male sex, smoking, history of hypertension, ischaemic heart disease, nephropathy, systolic blood pressure and blood low density lipoprotein (LDL) cholesterol, HbA(1c) and fibrinogen. A history of peripheral vascular disease, low high density lipoprotein, age and history of hypertension were associated with large artery ischaemic stroke. A history of diabetic retinopathy, LDL cholesterol, male sex, systolic blood pressure, smoking, diabetes duration and a history of stroke or TIA were associated with small artery ischaemic stroke. CONCLUSIONS: Older people with a history of stroke were at highest risk of stroke, but the prognosis and prognostic factors of subtypes were heterogeneous. The results will help clinicians quantify the absolute risk of stroke and its subtypes for typical diabetes patients.

Recurrent infarction causes the most deaths following myocardial infarction with left ventricular dysfunction.

PURPOSE: The development of left ventricular systolic dysfunction or heart failure following an acute myocardial infarction (MI) is a powerful marker of an adverse prognosis. Recurrent MI could be an important cause of death, either directly or by provoking arrhythmias. METHODS: The OPTIMAAL trial randomized 5477 patients with heart failure or evidence of left ventricular dysfunction following acute MI to losartan or captopril. Over a follow-up of 2.7 years, there were 946 deaths. Of the 180 (19%) of these deaths for which autopsy reports were available, acute MI was found in 57% (102 of 180) of the autopsies. By comparison, an endpoints adjudication committee using clinical data attributed death to acute MI in only 29 cases. An acute MI was found at autopsy in 55% (37 of 67) of the deaths that had been classified as due to an arrhythmia and in 81% (21 of 26) of the deaths classified as due to progressive heart failure. Including autopsy diagnoses, the rate of acute MI in patients who died suddenly was independent of the time elapsed since the index MI, but in patients not classified as dying suddenly, there was a time-related decrease in recurrent MI from 78% in the first 30 days to 30% by the end of follow-up. However, only 19% of patients who died underwent autopsy, so recurrent MI may have been substantially more common and perhaps had a different relation to time since the index MI if more patients had undergone autopsy. CONCLUSIONS: In patients with evidence of major cardiac dysfunction after MI, recurrent MI found at autopsy is common and has often not been clinically detected.