International Journal of Medicine and Medical Sciences Vol. 3(8) pp. 247-251, August 2011Available online http://www.acade...
248         Int. J. Med. Med. Sci.       Table 1. Baseline characteristics of all patients (n=357).        Characteristic ...
Shaikh et al.   249       Table 2. Comparision of various categorical variables with ischemic stroke.        Variable     ...
250        Int. J. Med. Med. Sci.contradiction in results may be attributed to differences in              Study: Stroke, ...
Shaikh et al.           251   Manhattan Stroke Study. Cerebrovasc. Dis., 28: 65-71                     and impairs vascula...
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Frequency of metabolic syndrome and its’ various

  1. 1. International Journal of Medicine and Medical Sciences Vol. 3(8) pp. 247-251, August 2011Available online http://www.academicjournals.org/ijmmsISSN 2006-9723 ©2011 Academic JournalsFull Length Research Paper Frequency of metabolic syndrome and its’ various components in patients with ischemic stroke Shaikh Samiullah*, Soomro Hafiz, Qazi Iftikhar and Shaikh Khalid Department of Medicine, Liaquat University of Medical and Health Sciences, Jamshoro, Hyderabad, Pakistan. Accepted 4 August, 2011 The aim of this study was to observe the frequency of metabolic syndrome and its’ various components in patients with ischemic stroke. This descriptive case study was conducted in Liaquat University Medical and Health Sciences hospital Hyderabad, Pakistan from June 2008 to November 2009. The study included 357 consecutive patients of either sex, presenting with ischemic stroke. Stroke was defined as a focal neurological disorder with rapid onset, which persisted at least 24 h or until death and had a brain Computerised tomography (CT) that showed a compatible low-density lesion. Patients were diagnosed as metabolic syndrome on the basis of ATPIII criteria which include the presence of at least three features: 1) blood pressure of at least 130/85 mmHg or treated hypertension, 2) serum triglyceride level of at least 150 mg/dl (1.7 mmol/l), 3) HDL cholesterol of < 40 mg/dl (1.03 mmol/l) in men and < 50 mg/dl (1.29 mmol/l) in women, 4) fasting glucose of >100 mg/dl (5.6 mmol/l) or previously diagnosed with type 2 diabetes and 5) central obesity, waist circumference greater than 90 cm in men and 80 cm in women according to the ethnic criteria for Asians. Continuous variables were expressed as range, and categorical variables as frequency and percentage. The chi-square test was applied to compare categorical variables with ischemic stroke. A p-value of 0.05 was considered as statistically significant. All calculations were done using SPSS version 16 (Chicago, IL, USA). This study included 357 patients of which 131 (36.7%) were male and 226 (63.3%) were female. The age of the patients range was from 35 to 95 years. The three components of metabolic syndrome were present in 165 (46.2%) patients, of which 41 (24.8%) were male and 124 (75.2%) were female. A strong association was found between waist circumference and low HDL. Metabolic syndrome is a frequent occurrence in patients with ischemic stroke. Key words: Ischemic stroke, metabolic syndrome, risk factors.INTRODUCTIONStroke is the ninth leading cause of death with more than (Syed et al., 2003). Over the years, much stress has5.5 million people dying annually, only second after been given to the traditional risk factors such as age,ischemic heart disease. Stroke not only adds to mortality gender, body mass index (BMI), hypertension, smoking,but morbidity as well (WHO, 2008). Stroke is now the diabetes mellitus and dyslipidemia as possible contribu-sixth most common cause of disability adjusted life in ting factors in the development of ischemic stroke.years (DALYs) in the world (Lopez, 2006). As 85% of the Metabolic syndrome, defined as clustering of fastingworld population resides in low-income and middle - glucose, high blood pressure (BP), high levels ofincome countries, the burden of disease is definitely triglyceride (TG), low level of high-density lipoproteingreater in these countries (Strong et al., 2007). In cholesterol (HDL-C), and abdominal obesity, was firstPakistan, prevalence of stroke was found to be 4.5% described by Reaven in 1983 (Reaven, 2001). Since then, metabolic syndrome has been linked to increased risk of ischemic stroke (Ninomiya et al., 2004). It is pre- sumed that various components of metabolic syndrome*Corresponding author. E-mail: shaikhsamiullah@yahoo.com. interacts synergistically thereby accelerating athero-Tel: 0300-3019233, 022-2771711. sclerosis (Park et al., 2007). The aim of this study was to
  2. 2. 248 Int. J. Med. Med. Sci. Table 1. Baseline characteristics of all patients (n=357). Characteristic Value Continuous variable Range Min-maximum Age (years) 63 35-95 Categorical variable Frequency Percentage Male 226 63.3 Female 131 36.7 Components of metabolic syndrome Male Female Male Female Three 41/165 124/165 24.8 75.2 Systolic blood pressure >130 mmHG 65/165 100/165 39.39 60.60 Triglyceride levels >150 mg /dl 62/183 121/183 33.87 66.12 HDL levels < 50 mg/dl female and < 40 mg/dl in male 62/234 172/234 26.49 73.50 waist circumference >90 cm in male and >80 cm in female 123 34.45 FBS >100 mg/dl 126 35.29 FBS = fasting blood sugar; HDL= high density lipoprotein.observe the frequency of metabolic syndrome and its’ HDL and LDL cholesterol levels. Glucose levels were measured byvarious components in patients with ischemic stroke. enzymatic assay using an Eppendorf 5060 auto-analyzer. Patients were diagnosed as metabolic syndrome on the basis of ATPIII (Alberti, 2005) criteria which include presence of at leastMATERIALS AND METHODS three features: 1) blood pressure of at least 130/85 mmHg or trea- ted hypertension, 2) serum triglyceride level of at least 150 mg/dlThis descriptive case study was conducted in Liaquat University (1.7 mmol/l), 3) HDL cholesterol of < 40 mg/dl (1.03 mmol/L) in menMedical and Health Sciences hospital, Hyderabad, Pakistan from and < 50 mg/dl (1.29 mmol/L) in women, 4) fasting glucose of > 100June, 2008 to November, 2009. This is a tertiary care hospital for mg/dl (5.6 mmol/l) or previously diagnosed with type 2 diabetes andabout 20 million urban, rural and multi-ethnic populations. The 5) central obesity, waist circumference greater than 90 cm in menstudy included 357 consecutive patients of either sex presented and 80 cm in female according to Population- and country-specificwith ischemic stroke. The study was started after approval of the definitions (WHO Expert Consultation, 2004).university ethical committee. Informed consent was taken from thepatients or their relatives. During the first visit, records were Statistical procedureobtained on the patient’s medical history. The conventional risk fac-tors such as body weight, body mass index (BMI), blood pressuremeasurement, history of smoking, a past history of stroke, family Continuous variables such as age was expressed as range withhistory of stroke, use of antidiabetic, antihypertensive, and minimum and maximum. Categorical variables such as sex, pres-antihyperlipidemic drugs were enrolled in well designed proforma. A ence or absence of metabolic syndrome, components of metaboliccomplete physical examination was performed. Stroke was defined syndrome HDL levels > or < 50mg/dl in female and > or < 40 mg/dlas a focal neurological disorder with rapid onset which persisted at in male, waist circumference > or < 90 cm in men and > or < 80 cmleast 24 h or until death and had a brain CT that showed a in women, triglyceride levels > or < 150 mg /dl, fasting glucose of >compatible low-density lesion (Shimamoto et al., 1989). or < 100 mg/dl, blood pressure of at least 130/85 mmHg were For each patient, blood pressure was taken after 15 min of rest. It expressed as percentage and frequency. The chi-square test waswas measured by a mercury sphygmomanometer with the subject applied to compare categorical variables such as metabolic syn-seated comfortably with the arm supported and positioned at the drome, HDL levels, waist circumference, systolic blood pressure,level of the heart. The final blood pressure estimate was the triglyceride levels and fasting blood sugar with the ischemic stroke.average of three readings. Neither smoking nor caffeine was per- A p-value of 0.05 was considered as statistically significant. Allmitted before the blood pressure measurement. Individuals on calculations were done using SPSS version 16 (Chicago, IL, USA).antihypertensive medications were considered as hypertensionpatients regardless of blood pressure levels. Waist circumferencewas measured by a trained examiner using a measuring tape RESULTSpositioned midway between the lowest rib and the iliac crest. Allstudy participants were individually interviewed by trained medical This study included 357 patients of which 131 (36.7%)students with a structured questionnaire to obtain information on were male and 226 (63.3%) were female. The age of thesocio-demographic characteristics, physical activity and exercise patients ranged from 35 to 95 years. Table 1 shows thehabits (yes vs. no, defined by less than 20 min exercise per week), baseline characteristics of patients. The three compo-smoking, and alcohol consumption. For baseline examination, nents of metabolic syndrome was present in 165 (46.2%)blood was drawn from patients into a plain, siliconized glass tubeand the serum was separated. Fasting serum samples were stored patients of which 41/165(24.8%) were male and 124/165at -7° prior to the batch assay using standard enzymatic tests for C (75.2%) were female (0.001). Systolic blood pressure gcholesterol and triglyceride levels and precipitation methods for was present in 165 patients of which 65 were male and
  3. 3. Shaikh et al. 249 Table 2. Comparision of various categorical variables with ischemic stroke. Variable Frequency Percentage P value Three components of metabolic syndrome 165 46.2 0.001* Gender 0.001* Male 41 24.8 Female 124 75.2 HDL levels < 50mg/dl female and < 40 mg/dl in male 234 65.5 0.001* Triglyceride levels >150 mg /dl 183 51.26 0.153 Systolic blood pressure >130mm Hg 165 46.21 0.001* FBS > 100mg/dl 126 35.29 0.421 Waist circumference >90 cms in male and >80cms in female 123 34.45 0.001* *P value < 0.05 is statistically significant . FBS = fasting blood sugar; HDL= high density lipoprotein.100 were female (0.137). FBS > 100 mg/dl was present 23 times greater in female than male persons within 126 patients of which 57 had metabolic Syndrome metabolic syndrome. The Northern Manhattan study(0.421).Triglyceride levels >150 mg/dl was present in183 which included Hispanic, African-American, andcases of which 62 were male and 121 female (0.153). Caucasian subjects, reported an increased risk of strokeWaist circumference greater than 90 cm in men and 80 among women with metabolic syndrome [hazard ratiocm in female was present in 123 patients of which 90 had (HR=2.1)] compared to men (HR=0.9) (Rincon et al.,other components of metabolic syndrome (0.001) HDL 2009). Koren and Morag (2005) similarly reported thatlevels < 50mg/dl was present in172 female and >40 metabolic syndrome without diabetes mellitus was amg/dl in 62 male (0.001). Table 2 shows comparison of significant risk factor for ischemic stroke in both sexes,different categorical variables with the ischemic stroke. but the effect was more pronounced in women [odds ratio (OR=2. 10)] than in men (OR=1. 39). On the other hand, Kurl et al. (2006) reported that the risk of ischemic strokeDISCUSSION is significantly increased in men with metabolic syndrome in Finland. The result of theirs might be due to the longIn this case study, metabolic syndrome was found in follow-up period (average follow-up of 14.3 years).46.3% of patients, with ischemic stroke making a signifi- Dyslipidemia which is characterized by highcant association. Our observation was supported by triglycerides and low HDL has always been consideredGorter et al. (2004) who found metabolic syndrome in 40 as a hallmark of the MetSyn. Our data has shown strongto 50% of patients with various cardiovascular diseases. association between dyslipidemia and ischemic stroke asMetabolic syndrome was present in 56% of patients with triglyceride levels >150 mg /dl was present in183 casesischemic stroke in a study conducted by Koren and and HDL levels <50mg/dl was present in 172 female andMorag (2005). De Silva (2007) recorded metabolic syn- >40 mg/dl in 62 male. According to Copenhagen Citydrome in 61% of South Asian patients. In Third National Heart Study, a 47% reduction in ischemic stroke wasHealth and Nutrition Examination survey of 15922 sub- found for 1.0 mmol/l (39 mg/dl) rise in HDL (Lindenstrom,jects, metabolic syndrome was significantly associated 1994). Our study is also in consistence with Milionis et al.with self reported stroke (odds ratio 2.2; 95% CI, 1.5 to (2005) which stated that high TG levels and low HDL-C3.2) (National Institutes of Health , 2001). In Framingham levels had a relationship with ischemic stroke. The Britishoffspring study, metabolic syndrome was found more regional heart study, a prospective study consisting 7735important risk factor for ischemic stroke as compared to men followed up for 16.8 years, also revealed a signifi-diabetes mellitus (19 vs. 7%) (Najarian et al., 2006) .The cant association between HDL levels and stroke with aAtherosclerosis Risk in Communities (ARIC) study also relative risk (RR) for nonfatal stroke was 0.59 (95% confi-noted that patients with metabolic syndrome have higher dence interval, CI, 50.39 to 0.90; P50.03) (Wannametheerisk of incident stroke (hazard ratio, 2.74 to 4.16 com- et al., 2000).pared to the reference group) provided the metabolic In the Finnmark study, a 51.29% increase in stroke insyndrome contains either high blood pressure or elevated women was seen for each 1.0 mm/l (88.5 mg/dl) increasefasting blood sugar (Sol et al., 2009). In our study, meta- in TG levels (Njolstad et al., 1996). The Framinghambolic syndrome was found in 75.2% female as compared study (Gordon et al., 1981) contradicts these results byto 24.8% male. Takahashi et al. (2007) in their study observing that HDL had a non-significant effect on thenoted that the chances of developing ischemic stroke are development of ischemic stroke in either sex. The
  4. 4. 250 Int. J. Med. Med. Sci.contradiction in results may be attributed to differences in Study: Stroke, 39:30-35. De Silva DA, Fung PW, Xiao YX, Christopher LHC, Hui MC, Meng CWsample size as in the Copenhagen study the number of (2007). Metabolic Syndrome Among Ethnic South Asian Patientssubjects studied were 11,342 vs. 2723 in the With Ischemic Stroke and Comparison With Ethnic Chinese Patients:Framingham study. The Singapore General Hospital Experience: J. Stroke Cerebrovasc. High blood pressure has emerged as an important Dis., 16(3): 119-121.component in our patients as 165 patients had systolic Gorter PM, Olijhoek JK, van der GY (2004) Prevalence of the metabolic syndrome in patients with coronary heart disease, cerebrovascularblood pressure >130 mm of HG. In NOMAS study, a disease, peripheral arterial disease or abdominal aortic aneurysm.linear relationship between blood pressure and risk of Atherosclerosis, 173: 363-369.ischemic stroke and other vascular events such as fatal Gordon T, Kannel WB, Castelli WP, Dawber TR (1981) Lipoproteins, cardiovascular disease and death: the Framingham study. Arch. Int.or nonfatal hospitalized myocardial infarction, fatal CHD, Med., 141: 1128-1131.silent myocardial infarction was found with an increase in Howard BV. (1999). Insulin resistance and lipid metabolism. Am. J.either event by 35% (Boden-Albala et al., 2008). McNeill Cardiol., 84: 28-32.and Rosamond (2006) have found high blood pressure Isomma B, Almgren P, Tuomi T, Forsen B, Lahti K, Nissen M, Groop L (2001). Cardiovascular morbidity and mortality associated with theas an important component of metabolic syndrome which metabolic syndrome. Diabetes Care, 24: 683-689.increased the risk of ischemic stroke by 1.5 and 2 times Kazuo T, Hirokazu B, Shotai K, Kenichi I, Atsushi N, Shuhei Y (2007)after adjustment for established risk factors. Metabolic Syndrome Increases the Risk of Ischemic Stroke in Increased waist circumference which represents abdo- Women: internal medicine Tokyo Japan, 46(10): 643-648.minal obesity has a strong association with stroke in our Kurl S, Laukkanen JA, Niskanen L (2006).Metabolic syndromeand the risk of stroke in middle-aged men. Stroke, 37: 806-811study as a waist circumference greater than 90 cm in Lindenstrom E, Boysen G, Nyboe J (1994) Influence of total cholesterol,men and 80 cm in female was present in 123 patients. high-density lipoprotein cholesterol, and triglycerides on risk ofIsomma (2001) in study of 6,645 persons noticed obesity cerebrovascular disease: the Copenhagen City Heart Study. BMJ, 309: 11–15.in 76% of men with normal glucose tolerance (NGT) and Liu J, Grundy SM, Wang W, Smith SC Jr, Vega GL, Wu Z, Zeng Z,92% of diabetic men with ischemic stroke.Helsinki Police- Wang W, Zhao D (2007) Ten-year risk of cardiovascular incidencemen Study has also shown a moderate association with related to diabetes, prediabetes, and the metabolic syndrome. Am.HR (hazard ratios) 2.12 (1.28 to 3.49) between metabolic Heart J., 153: 552-558.syndrome and stroke with special emphasis on obesity as Lopez AD, Mathers CD, Ezzati M, Jamison DT, Murray CJ (2006) Global and regional burden of disease and risk factors: systematica risk factor (Marja Pyörälä, 1998). Visceral fat which analysis of population health data. 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Milionis HJ, Rizos E, Goudevenos J, Seferiadis K, Mikhailidis DP, Elisaf There was a lack of association between glucose MS (2005) Components of the metabolic syndrome and risk forabnormality and the risk of stroke in our study. This could firstever acute ischemic nonembolic stroke in elderly subjects. Strokebe due to inclusion of patients with mild to moderate 36:1372–6.glucose abnormality in our study. Liu et al. (2007) has Koren-Morag N, Goldbourt U, Tanne D (2005) Relation between thealso shown in their study that glucose abnormality can Metabolic Syndrome and Ischemic Stroke or Transient Ischemic AttackA Prospective Cohort Study in Patients with Atheroscleroticonly increase the risk of ischemic stroke by 14%. This Cardiovascular Disease. Stroke, 36: 1366-1371.study has its limitations. The results of this study cannot National Institutes of Health (2001). Third Report of the Nationalbe generalized to the population as this is not a case Cholesterol Education Program Expert Panel on Detection, Evaluation and Treatment of High Blood Cholesterol in Adults (Adultcontrol study which requires the prevalence of metabolic Treatment Panel III). Washington DC: US Government Printingsyndrome in the normal population in Pakistan. Office. NIH Publication No. 01-3670. Metabolic syndrome is a frequent occurrence in Najarian RM, Lisa MS, William BK, Peter WFW, Ralph BDA, Philip AWpatients with ischemic stroke. It is not only metabolic syn- (2006). Metabolic Syndrome Compared With Type 2Diabetes Mellitus as a Risk Factor for Stroke; The Framingham Offspring Study. Arch.drome, but its individual components have emerged as Int. Med., 166: 106-111an important risk factor for ischemic stroke. 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