COMMENTARY

A Paradigm Shift for Preventing Stroke in Patients With Diabetes

Hans-Christoph Diener, MD

Disclosures

November 23, 2020

This transcript has been edited for clarity.

Dear colleagues, I'm Christoph Diener from the faculty of medicine at the University of Duisburg-Essen in Germany. Usually I speak with you to report the results from randomized trials published within recent months, but October was an incredibly disappointing period in which no such interesting studies appeared. Therefore, I decided to discuss a topic that I think is important for neurologists, and for stroke neurologists in particular: the relationship between diabetes and stroke.

Worldwide, the prevalence of diabetes is approximately 9.3%, and it is mostly due to obesity and lack of physical activity. We expect that these numbers will increase in the next 10 years. Diabetes has two consequences: small- and large-vessel disease. Small-vessel disease affects the retina, kidney, and brain. Large-vessel disease leads to a higher risk for ischemic stroke, myocardial infarction, and peripheral arterial disease.

The impact of increased glucose levels in patients with acute ischemic stroke is considerable. Patients who have high glucose levels have a decidedly poorer prognosis, which is also true for those who receive thrombolysis or thrombectomy. Unfortunately, randomized trials have failed to show a benefit to aggressively lowering high glucose in patients with acute stroke, with basically no impact on outcomes and a high rate of hypoglycemia. Therefore, the advice at the moment is to slowly lower high glucose levels in patients with acute ischemic stroke.

In previous years, there have been frustrating findings regarding the role of treating diabetes mellitus in both primary and secondary stroke prevention. Three large-scale randomized trials that investigated aggressive therapy of diabetes showed a positive effect on small-vessel disease but had no impact on large-vessel disease or on the incidence of stroke, myocardial infarction, and vascular deaths.

However, this has changed with the arrival of two new classes of drugs. We now have the sodium-glucose cotransporter 2 (SGLT2) inhibitors. In six randomized trials where SGLT2 inhibitors were compared with placebo, they were shown to have a major impact on cardiac failure and associated deaths.

The second group of new drugs are the glucagon-like peptide 1 (GLP-1) receptor agonists. These not only reduce blood glucose and body weight, but they also have a positive impact on the risk for major adverse cardiac events such as myocardial infarction, stroke, and vascular death. Two randomized controlled trials of GLP-1 receptor agonists showed that they had a significant benefit in preventing stroke, with one study indicating that they even have an impact on cognitive impairment in patients with diabetes mellitus.

Together, I think the availability of these new classes of drugs changes the approach to patients with diabetes mellitus who have a high risk for cardiac failure or who have cardiac failure and a high risk for stroke.

The treatment of coexisting hypertension and high cholesterol is another important aspect contributing to secondary stroke prevention. Randomized trials have shown that if you treat hypertension in people with diabetes mellitus who had a stroke, you can decrease the risk for a recurrent stroke by about 40%. If patients with diabetes and high cholesterol get a statin, the risk for a recurrent stroke is reduced by 21%.

In summary, I think we are experiencing a paradigm shift in the treatment of patients with diabetes mellitus when it comes to the prevention of cardiac failure and stroke.

Ladies and gentlemen, I'm Christoph Diener from the medical faculty at the University of Duisburg-Essen. Thank you very much for listening and watching.

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