Key result
Diabetes in women is linked to ~2-fold higher risk of ischemic stroke.
Why the study?
Classic risk factors for stroke have different effects on the 3 main pathologic types of stroke, but their comparative associations were not well characterized in a large cohort.
Cohort (n=712,433)
Yes
Relative Risk: 2.01 (95% CI 1.84–2.2)
Diabetes mellitus links to divergent stroke subtype risks in women; extends inverse SAH association but leaves causality and practice implications open.
Objective To compare associations of behavioral and related factors for incident subarachnoid hemorrhage and intracerebral hemorrhage and ischemic stroke. Methods A total of 712,433 Million Women Study participants without prior stroke, heart disease, or cancer reported behavioral and related factors at baseline (1999–2007) and were followed up by record linkage to national hospital admission and death databases. Cox regression yielded adjusted relative risks (RRs) by type of stroke. Heterogeneity was assessed with χ2 tests. When appropriate, meta-analyses were done of published prospective studies. Results After 12.9 (SD 2.6) years of follow-up, 8,128 women had an incident ischemic stroke, 2,032 had intracerebral hemorrhage, and 1,536 had subarachnoid hemorrhage. In women with diabetes mellitus, the risk of ischemic stroke was substantially increased (RR 2.01, 95% confidence interval [CI] 1.84–2.20), risk of intracerebral hemorrhage was increased slightly (RR 1.31, 95% CI 1.04–1.65), but risk of subarachnoid hemorrhage was reduced (RR 0.43, 95% CI 0.26–0.69) (heterogeneity by stroke type, p < 0.0001). Stroke incidence was greater in women who rated their health as poor/fair compared to those who rated their health as excellent/good (RR 1.36, 95% CI 1.30–1.42). Among 565,850 women who rated their heath as excellent/good, current smokers were at an increased risk of all 3 stroke types, (although greater for subarachnoid hemorrhage [≥15 cigarettes/d vs never smoker, RR 4.75, 95% CI 4.12–5.47] than for intracerebral hemorrhage [RR 2.30, 95% CI 1.94–2.72] or ischemic stroke [RR 2.50, 95% CI 2.29–2.72]; heterogeneity p < 0.0001). Obesity was associated with an increased risk of ischemic stroke and a decreased risk of hemorrhagic stroke (heterogeneity p < 0.0001). Meta-analyses confirmed the associations and the heterogeneity across the 3 types of stroke. Conclusion Classic risk factors for stroke have considerably different effects on the 3 main pathologic types of stroke.
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Price et al. (2018) conducted a cohort in Incident stroke (n=712,433). Diabetes mellitus vs. Women without diabetes mellitus was evaluated on Incident ischemic stroke (RR 2.01, 95% CI 1.84-2.20). In women with diabetes mellitus, the risk of ischemic stroke was substantially increased (RR 2.01) whereas the risk of subarachnoid hemorrhage was reduced (RR 0.43).
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