Stroke and type 2 diabetes: lessons from a French medico-economic study

Diabeto-Cardio

Published on June 17, 2024Reading 3 mins

This is the whole purpose of the INSIST study, a retrospective study carried out from the EGB sample (General Sample of Beneficiaries, approximately 700,000 individuals) from the national health database SNDS (National Health Data System) bringing together 99% of French social security beneficiaries. Among the 45,331 T2DM patients included in the study, 2,090 (n = 4.6%) were hospitalized for a first stroke between 2012 and 2018 (mean age 75 years; men 55.3%; high blood pressure 83.0 %; dyslipidemia 63.6%; obesity 11.9%; coronary artery disease 15.2%; lower limb arteriopathy 8.5%; .7%). It was an ischemic stroke in 75.7% of cases, a hemorrhagic stroke in 15.6% of cases and a stroke of unspecified etiology in 8.6% of cases. After standardizing for age, the incidence of stroke increased from 10.3 to 7.6 per 1,000 patient-years between 2012 and 2018. The incidence of ischemic stroke was almost 5 times higher than that of hemorrhagic stroke. (6.80 vs 1.38 per 1,000 patient-years). At the end of a follow-up of 2.8 years on average after the initial stroke, and after adjustment for age, sex and the existence of a history of arrhythmia, the prognosis was more unfavorable after a hemorrhagic stroke. than after an ischemic stroke (death 291.5 vs 144.1 per 1,000 patient-years; cardiovascular events 130.9 vs 126.4 per 1,000 patient-years; new stroke 86.5 vs 66.5 per 1,000 patient-year) but only the risk of mortality was significantly increased (HR 1.95 [IC95% 1,66-2,92]). This excess mortality after a hemorrhagic vs. ischemic stroke was found from the first weeks of follow-up (35.4 vs. 12.4% at 30 days; 47.1 vs. 23.9% at 1 year; 60.3% vs. 41. 9% at the end of follow-up). Ultimately, 68.8% of patients were hospitalized at least once after their initial stroke, with a much higher incidence after a hemorrhagic stroke than after an ischemic stroke (3,110 vs. 1,926 hospitalizations per 1,000 patient-years). ). Concerning the evolution of anti-hyperglycemic prescriptions before and after the initial stroke (in a pre-gliflozin era), if the use of metformin remained approximately stable (54.8 vs 56.3%), the use of sulphonylureas decreased (28.2 vs 36.3%) while that of insulin, DPP4 inhibitors and GLP-1 receptor agonists increased (37.5 vs 27.7 %; 20.7 vs. 17.9%; 6.6% vs. 4.2%, respectively). The prescription of several other treatments also increased after the stroke (anti-hypertensives 85.5 vs 78.3%; antiplatelet agents 72.2 vs 50.3%; anticoagulants 40.0 vs 23.0%) while, surprisingly, the frequency of use of statins hardly changed (30.0 vs 31.4%). Finally, annual health costs (hospitalizations, consultations, treatments) were estimated on average at €18,592 (standard deviation €20,558), with a median of €12,199 (interquartile range €6,846-22,378) comparable between Ischemic and hemorrhagic stroke. Despite the limitations inherent to its methodology, including the absence of data on glycemic balance, lipid profile or blood pressure control, this study sponsored by the Novo Nordisk laboratory shows that the incidence of stroke remains high in patients T2D in France (although a gradual decline is evident between 2012 and 2018) and it is ischemic stroke in more than three-quarters of cases. This work also illustrates the medical burden represented by this pathology in this population – very high risk of occurrence of a cardiovascular event (53.2%), a new stroke (16.5%) or death (45 .6%) in the 2.8 years following the initial episode, with a risk of death multiplied by two after a hemorrhagic vs ischemic stroke – as well as its major economic weight (annual direct costs multiplied by three compared to a T2D patient without cardiovascular disease). These results finally underline the work that remains to be accomplished so that these very high-risk T2DM patients benefit from all of the medications currently recommended for cardiovascular protection (in particular statins and cardioprotective anti-hyperglycemic agents) even if we can hope that things have improved a little over the past 5 years. Published by Practical Diabetology