Impact Of Plasma Glucose Levels On Recurrence And Mortality Of Acute Cerebral Infarction

BACKGROUNDDiabetes as an independent risk factor of acute cerebral infarction has long been recognized in medical domain,with the development of economy and the raise of living standard,the hazard of diabetes and its complications in the quality of human life become increasingly conspicuous.Compared with non-diabetic population,the diabetic population have higher prevalence rate of atherosclerosis,the lower age of onset,and the faster progress of pathogenesis.Diabetes can lead to abnormal lipid metabolism,cause hyperlipidemia,increase blood viscosity,step down the blood flow velocity,and make it abnormal of the platelet function and the role of anticoagulation.These factors can be the theoretical basis for diabetic patients with more serious clinical manifestations and worse prognosis after cerebral infarction.Previous research have shown that the incidence rate of cerebrovascular disease in diabetic patients was twice of non-diabetic patients.And there was a relationship of the level of blood glucose with the cerebral infarction area,the severity of symptoms and the recovery of neurological function,the higher the blood glucose level,the worse the prognosis and the higher the mortality.Clinical patients with acute cerebral infarction accompanied with hyperglycemia, foreign researchers found that 28%of the acute cerebral infarction in patients accompanied with hyperglycemia,and these patients had not been diagnosed as diabetes before.The traditional view was that the elevated blood glucose level in acute stoke patient was the result of acute stress,due to hypoxic-ischemic activated the hypothalamus-pituitary-adrenal axis,resulting in hormone cortisol and catecholamines increased,thereby cause increased blood glucose.And further study showed that high blood glucose in acute cerebral infarction patient was not only a simple non-specific physiological stress response.It may also be due to a series of changes in hormones and metabolism in brain caused by tissue damage,the stimulation of the brain glucose-regulated hub caused by ischemia and insulin resistance caused by cytokine as well as the existence of undiscovered recessive diabetes, etc. It was found that for non-diabetic patients,the presence of high blood glucose can also add to the clinical symptoms of cerebral infarction,and increase its hospital mortality,and their prognosis is worse.Research shows that high blood glucose can reduce the blood perfusion of brain ischemia and peripheral tissues,and enlarge the circumscription of infarct;hyperglycemia causes the accumulation of large amount of lactic acid,lead to mitochondrial dysfunction,brain cells acidosis;hyperglycemia breakdown calcium balance and lead to too much calcium into cells,and the impact calcium returning in early reperfusion,thereby cause mitochondrial damage and nerve cell death;hyperglycemia can damage the balance of mechanisms of coagulation and fibrinolysis,damage local micro-circulation;hyperglycemia can also through a variety of mechanisms to promote oxidative stress and local inflammatory response in the brain;hyperglycemia undermine the integrity of the blood-brain barrier,and increase its permeability,lead to cerebral edema. Therefore,the presence of high blood glucose can increase brain damage in patients with acute cerebral infarction,affecting their functional prognosis.In recent years,a number of domestic and international clinical study have been done to determine the relationship between blood glucose levels and clinical prognosis in patients with acute cerebral infarction,results showed that high blood glucose levels in patients with acute cerebral infarction can increase the nervous system injury and the occurrence of complications.Therefore,the acute cerebral infarction patients with high blood glucose is an important issue that should not be overlooked.Positively control the hyperglycaemia is expected to control the development of disease,prevent further expand of infarction circumscription,reduce brain damage,and reduce mortality.OBJECTIVEIn the present study,we retrospectively evaluated the medical records of 974 cases of acute cerebral infarction patients,analysis the influence of fasting blood glucose,blood pressure and blood lipid levels on acute cerebral infarction recidivism,the number of hospitalization days and the mortality to obtain theoretical basis for further hypoglycemic treatment to prevent recurrence,reduce the number of hospitalization days after and reduce mortality.PATIENTS AND METHODS1.Patients:A total of 974 hospitalized patients(646 man and 328 women,ranging in age from 31 to 98 years,with a mean of 67.0±11.6 years,average of hospitalization days 24.0±21.2) who hospitalized in department of neurology of changhai hospital between February 1996 and December 2006.Those patients was diagnosed as having acute cerebral infarction by CT and MRI according to the diagnostic criteria made by the forth national cerebrovascular disease association in 1995.2.Methods:①case collection:The day after hospitalization morning fasting plasma glucose levels(determined by glucose oxidase method,unit mmol/L),plasma total cholesterol(TC) levels,triglycerides(TG) levels,low-density lipoprotein(LDL) levels, high-density lipoprotein(HDL) levels(mmol/L),and blood pressure levels of the hospitalization day(mmHg) were recorded.The age of onset,hospitalization time,the number of hospitalization days were recorded.②telephone follow-up:including cerebral infarction palindromia frequency(palindromia was confirmed by symptoms+CT scan),and whether the complicated with diabetes or hypertension.③data unscrambling and analysis: analysis the relationship of age,sex,blood sugar,TC,TG,LDL,HDL,systolic blood pressure,diastolic blood pressure level,and other factors with palindromia frequency and the number of hospitalization days and mortality.Patients was divided into 5 groups according to blood glucose level:＜5.5mmol/L,5.6 to 6.0mmol/L,6.1 to 6.9mmol/L,7.0 to 11.1mmol/L and＞11.1mmol/L,Comparison palindromia frequency,the number of hospitalization days and mortality differences among those groups.3.Statistical analysis:SAS 8.2 software applications of the data for statistical analysis.The multiple linear regression is used for analysis the relationship between the factors and the number of hospital days and palindromia frequency,Logistic regression analysis is used for the relationship between the use of the death,OR＞1 thought the factors for the risk factors. According to the level of blood glucose and lipids after each group division mortality compared with the chi-square test,the Kruskal-Wallis test used to compare the number of hospital days and palindromia frequency.P＜0.05 believe that the results were statistically significant.RESULTS1.The results showed that 120 cases(12.3%) with past history of cerebral infarction,854 was at the first onset;241 with type 2 diabetes(24.7%),733 without diabetic;632 with a history of hypertension(64.9%) and 342 without a history of hypertension.2.The relationship between palindromia frequency and various factors:Logistic regression showed that the number of re-infarction were positively correlated with the fasting blood glucose levels of hospitalization(P＜0.0001).But the number of re-infarction had no significant correlation with the patient gender,age,blood pressure of hospitalization,lipid levels,and whether or not the initial incidence,history of hypertension and diabetes.3.The relationship between the number of hospitalization days and the various factors: Multiple linear regression showed that patients with acute cerebral infarction hospitalization days was positively correlated with age(P=0.0002) and fasting plasma glucose level(P＜0.0001),but had no significant correlations with other factors.4.The relationship between mortality and the various factors:Logistic regression showed that patients with acute cerebral infarction mortality was positively correlated with age [OR=1.044,95%CI(1.012,1.076),P=0.0063]and fasting plasma glucose level [OR=1.954,95%CI(1.522,2.510),P＜0.0001],but had no significant correlations with other factors.5.The comparison of palindromia frequency,hospital days and mortality among groups divided according to the plasma glucose level:The patients were divided into blood glucose levels≤5.5 mmol/L(548 cases 56.3%),5.6 to 6.0 mmol/L(115 cases 11.8%),6.1 to 6.9 mmol/L(122 cases 12.5%),7.0 to 11.1 mmol/L(156 cases 16.0%),＞11.1 mmol/L(33 cases 3.4%),the results showed that the number of re-infarction and mortality ware significantly different between statistical different among groups(P＜0.0001),with the increase of blood glucose levels,the re-infarction frequency and mortality increased.FPG level＞11.1 mmol/L extended the number of hospitalization days.6.The relationship between FPG levels in non-diabetic patients with cerebral infarction and palindromia frequency and various factors:The number of re-infarction were positively correlated with the fasting blood glucose levels of hospitalization(P＜0.0001)in the non-diabetic patients.7.The comparison of palindromia frequency,hospital days and mortality among groups divided according to the plasma lipid level:according to serum lipid levels in each group after group mortality rate and comparison:The palindromia frequency,hospital days and mortality had no significant correlations with plasma TC,TG,LDL,HDL level.High TC, TG,HDL and low LDL levels can not predict the recurrence of patients with acute cerebral infarction.CONCLUSION1.Nearly half of the patients with acute cerebral infarction complicated with hyperglycaemia,a quarter with type 2 diabetes.As the raising of blood glucose,the hospitalization days are prolonged and mortality is raised.2.The hospitalization days and mortality of patients with acute cerebral infarction are positively correlated with the age of onset,suggest that the older of the age of onset,the serious of the pathogenetic condition and worse of the prognosis.And the gender, admission blood pressure,plasma lipid levels,whether or not the initial incidence,history of hypertension and diabetes may have no significant correlation with the number of hospitalization days and death.3.Positively control the hyperglycaemia of the patient accompanied by elevated fasting blood glucose associated with diabetes,the incidence of early intervention treatment whether he or she had a history of diabetes or not may reduce the risk of cerebral re-infarction,shorten the length the number of hospitalization days and reduce the mortality.