Although the optimal HbA1c range in the study was below 6.8% to 7.0%, "this may be different according to the ischemic stroke subtype," Dr. Jun Young Chang of Asan Medical Center in Seoul told Reuters Health in an email on behalf of the authors
Further, he said, "the target threshold level was higher for large artery atherosclerosis and lowest for small vessel occlusion. This result is in line with the current notion that patients with established or advanced atherosclerosis may have less benefit from strict glycemic control."
As reported in Neurology, the team analyzed data on 18,567 patients with diabetes (median age, 70; 60% men) who had a transient ischemic attack or acute ischemic stroke within 7 days of symptom onset. At one-year follow-up, 1,437, or about 8%, had a heart attack or died from vascular disease and 954, or 5%, had another stroke.
In multivariable analysis, as Dr. Chang indicated, the risk significantly increased at an HbA1c threshold of 6.8%-7.0% compared with an HbA1c below 6.0.
After adjustment, participants' risk for a heart attack or other vascular diseases was 27% greater when they were admitted to the hospital with HbA1c levels above 7.0%, compared to those admitted with levels below 6.5%.
The risk for having another stroke was 28% greater when admitted to the hospital with HbA1c levels above 7.0%, compared to those below 6.5%.
The influence of admission HbA1c level on the risk of composite vascular events was particularly pronounced among those with a fasting glucose at admission of 130 mg/dL or less. The authors noted, "Discordance of HbA1c and fasting glucose was found in almost 25% of patients with type 2 DM. Old age, elevated body mass index, male sex, fatty liver, and prolonged DM history were associated with high fasting glucose and normal HbA1c values. Increased cardiovascular risk among the patients with this discordance may be attributed to these characteristics."
The optimal ranges of HbA1c associated with minimal risks for composite vascular events was lowest for the small vessel occlusion subtype (6.6) compared to the large artery atherosclerosis (7.3) or the cardioembolic subtype (7.4).
Dr. Chang noted, "I'd like to emphasize that as the glycemic target may be different according to the ischemic stroke subtype, consideration of ischemic stroke subtype and a specialized approach may be needed for making a plan for glycemic control in these patients."
Dr. Daniel Labovitz, medical director, Montefiore Comprehensive Center for Stroke Care and associate professor, Albert Einstein College of Medicine in New York City, commented on the study in an email to Reuters Health. "Although diabetes (carries) significant risk of stroke, we do not have specific guidelines for preventing recurrent stroke. The American Heart Association and American Diabetes Association recommend a goal HbA1c <7, regardless of whether a patient has had a prior stroke."
"This study is the first large registry to specifically evaluate what level of HbA1c carries increased risk and found risk is higher at a level of 6.8 - close to, but slightly lower than current guidelines - and that potential goal HbA1c levels vary between different initial ischemic stroke subtypes," he said.
"The study is exploratory and does not show that intensifying diabetes control to achieve a goal HbA1c <6.8 will actually reduce the risk of recurrent stroke," he noted. "There are many features of patients who are already at that goal that might be driving the finding, so just adding more medication to reach a lower goal might not actually reduce risk. The findings serve to reinforce current practice, where the current target is very close to the HbA1c level identified in the study."
"A large, pragmatic, randomized clinical trial of patients with diabetes assigned to different HbA1c targets would tell us whether intensifying treatment reduces recurrent stroke without adding other risks," Dr. Labovitz said. "This study will help justify spending the money to conduct such a study."
SOURCE: https://bit.ly/3mtzD5W Neurology, online September 29, 2021.
By Marilynn Larkin
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