Diabetes and Stroke. Wayne Feng MD MS FANA FAHA

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1 Diabetes and Stroke Wayne Feng MD MS FANA FAHA Associate Professor of Neurology, Health Science & Research Director, ACGME Vascular Neurology Fellowship Director, International Stroke Fellowship Program Director, Post-stroke Spasticity Clinic South Carolina Stroke Recovery Center MUSC Stroke Center Medical University of South Carolina Presentation at the 2015 Annual Diabetes Symposium

2 Disclosure SCTR Discovery Grant Award/NIH/NCRR CTSA (UL1RR029882) American Heart Association Scientist Development Grant (14SDG ) "Optimizing Transcranial Direct Current Stimulation Current and Electrode Montage for Stroke Patients", (Project III in NIH 1P20 GM "South Carolina Research Center for Recovery from Stroke") Halo Neuroscience Inc. (Research grant support) Allergan Inc. ( Site PI for Botox Registry Study) Patent Technology of Transcranial Direct Current Stimulation for Post-Stroke Motor Recovery (pending) 2

3 Feng Stroke Recovery Lab

4 The epidemiology of diabetes and stroke Pathophysiology of diabetes lead to stroke Stroke patterns and treatment of stroke in patients with diabetes Impact of hyperglycemia on post-stroke outcomes Management of hyperglycemia in the acute stroke Diabetic management and stroke prevention

5 Diabetes Global Crisis 285 million patients with diabetes in 2010 all over the world, predict 439 million people with diabetes in % % % % 65.1% Shaw, Sicree, Zimmet. Diabetes research and clinical practice. 2010;87:4-14

6 Diabetes in South Carolina S.C. ranks 10th highest in the nation in the percent of population with diabetes; Approximately 1 in 8 African-Americans in South Carolina has diabetes; Diabetes is the seventh leading cause of death in South Carolina after heart disease, cancer,accidents, stroke, chronic lower respiratory disease and Alzheimer s; In 2006, the total amount for hospital charges related to diabetes diagnosis in South Carolina was $200 million. Medicare and Medicaid paid for more than two-thirds of this cost. 6

7 The Buckle of Stroke Belt The National Heart, Lung, and Blood Institute (NHLBI) examined the 1980 age-adjusted stroke mortality rates by State. There are eleven states had ageadjusted stroke mortality rate more than 10% above the national average. The stroke belt is typically defined to include the states of Alabama, Arkansas, Georgia, Indiana, Kentucky, Louisiana, Mississippi, North Carolina, South Carolina, Tennessee, and Virginia South Carolina has the highest ageadjusted stroke mortality rate in the United States. In 1994, the stroke mortality rate in South Carolina was 32 per 100,000 for Caucasians and 65 per 100,000 for African Americans SC is the the buckle of stroke belt Perry, et al. Hypertension, 1998, NHLBI: data fact sheet. 1989

8 Risk Factors for Stroke Non-modifiable Age Race Gender Genetics Modifiable Hypertension Smoking Diabetes Dyslipidemia Hyperhomocysteinemia Atrial fibrillation 8

9 Collaboration TERF. Lancet, 2010;375:

10 Excessive Risk In the Young Khoury JC, et al. Stroke. 2013;44:

11 Hypertension Microvascular Disease Lipid Abnormalities Metabolic Derangements Autonomic Dysfunction Diabetes Mellitus Arterial Stiffness Systemic Inflammation Endothelial Dysfunction Atherosclerosis Congestive Heart Failure STROKE

12 Risk of Stroke In Patients with Atrial Fibrillation 12

13 13

14 Lees, K. R. et al. Cerebrovasc Dis. 2005;20(1): 9-14

15 Stroke Types in Diabetic Patients

16 16

17 17

18 Acute Stroke Treatment Only one FDA approved drug for acute ischemic stroke rtpa. (NJEM, 1997)

19 19

20

21 Endovascular Strategies

22

23 23 REACH Telestroke

24

25 25

26 Higher Fasting Glucose Next Day after tpa is Associated with Poor Outcomes Wenjie Cao M. et al. Journal of Stroke and Cerebrovascular Diseases. 2015;24:

27 In-hospital or 30-day Mortality after Stroke in Patients with Stress Hyperglycemia Sarah E. Capes et al. Stroke. 2001;32:

28 Long Term Post-ischemic stroke mortality is higher in Diabetic Veterans Kamalesh, et al. stroke, 2008;39:

29 29

30 30

31 31

32 Stroke Hyperglycemia Insulin Network Effort (SHINE) Trial The study hypotheses are that treatment of hyperglycemic acute ischemic stroke patients with targeted glucose concentration (80mg/dL mg/dl) will be safe and result in improved 3 month outcomes after stroke. A multicenter, randomized, controlled clinical trial of 1400 patients that will include approximately 60 enrolling sites in the US. SHINE is expected to be completed in 2016

33 Diabetes Control & Stroke Prevention No major trials for secondary prevention of stroke have specifically examined interventions for pre-dm or DM. Management of stroke patients with these conditions, therefore, is based on trials in non-stroke or mixed populations. 33

34 34

35 N Engl J Med.2008 Feb 7;358(6):580-91

36 The Diabetic Control and Complication Trials (DCCT) The Epidemiology of Diabetes Interventions and Complications (EDIC)

37 Major CVD reduced 40% P= Fatal or Nonfatal MI or Stroke reduced 57%. P=

38 UK Prospective Diabetes Study Group

39 Average age of participants are 56.5 years old

40 National High Blood Pressure Education Program recommended Patients with diabetes or chronic kidney disease, blood pressure goal should be 130/80mmHg.

41 41

42 42

43 Is one hypoglycemic drug more effective than others in preventing vascular events With Prior Stroke Without Prior Stroke 43

44

45 45

46

47 Study Subjects are welcome Study Coordinator - Davis Fay

48 Questions? 48

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