[Health]WebMD醫學新聞-CHD、糖尿病與惡化缺血性中風女性的功能性結果有關

CHD、糖尿病與惡化缺血性中風女性的功能性結果有關

作者：Caroline Cassels
出處：WebMD醫學新聞

October 9, 2007 (華盛頓特區) — 新研究顯示，中風前共病症增加，特別是糖尿病和冠心症(CHD)，與缺血性中風婦女的中風後不佳功能有獨立相關。
　　
　　來自杜克大學醫學中心的研究者，於美國神經學會第132屆年會中發表一項前溯研究，指出中風前糖尿病和CHD是婦女中風後90天或之後失能的獨立相關因素。
　　
　　研究人員Cheryl Bushnell醫師向Medscape Neurology & Neurosurgery表示，其他共病症對中風後失能看似有些許影響，但是CHD和糖尿病這兩個狀況最能解釋。
　　
　　Bushnell醫師表示，已經相當清楚地知道，缺血性中風女性的功能性結果比男性差，收容在病院(或養老院等)的比率較高，也有較多的失能；不過，她指出，此現象背後的原因迄今尚未被研究。
　　
　　【眼光放遠】
　　Bushnell醫師表示，我們之前發現中風前CHD是婦女嚴重中風的獨立因子，這讓我們假設中風前心臟病或許也會惡化中風後的功能性結果，但是我們需將眼光放遠，並且檢視其他共病症是否會影響婦女的中風後結果。
　　
　　為了辨識特定的預測因子，研究者前溯評估133位18歲以上婦女，在2001年9月到2005年2月之間發生急性缺血性中風24小時內的基本共病狀，初級結果是90天以上的中風後失能，以改良式Rankin中風等級(mRS)評估；研究者也檢視中風嚴重度的潛在預測因子，住院後24到48小時、以及住院後7天或出院時使用美國國家衛生研究院腦中風評估量表(NIHSS)評估。
　　
　　藉由醫療紀錄或者自我報告提供高血壓、高膽固醇血症、之前的中風或者暫時性腦缺血、CHD、鬱血性心臟衰竭、心房纖維顫動、週邊血管疾病、以及靜脈栓塞等資訊。
　　
　　此外，參與者的健康習慣，例如抽菸和喝酒以及濫用藥物等也加以評估，並且計算身體質量指數。
　　
　　【CHD只預測中風嚴重度】
　　使用修正版察爾森共病症嚴重度指標(Charlson comorbidity index)來測量共病症，且假設可以作為結果的預測因子，此效度良好的共病症指標藉由16個狀況（包括CHD和糖尿病）算出一個分數預測1年死亡率。
　　
　　以多變項模式調整一開始的NIHSS，失能的獨立預測因子是CHD和糖尿病；只有排除糖尿病和CHD時，察爾森共病症嚴重度指標才變成唯一的中風後失能預測因子，佔約14%的變異性。
　　
　　該研究也指出，中風前CHD是唯一與初始中風嚴重度有關的臨床因素。
　　
　　根據Bushnell醫師所述，該研究結果指出，需要妥善處理有糖尿病和CHD的婦女，證據顯示有改善空間。
　　
　　她表示，舉例來說，女性若沒有妥善控制她們的脂質，代表藥物順從性和血清膽固醇治療目標不佳；她指出，根據這些結果，中風結果研究需要校正開始時的共病狀態。
　　
　　該研究接受國家健康研究中心和國家中風協會研究獎金贊助。
　　
　　美國神經學會第132屆年會：摘要S-5。發表於2007年10月7日。

CHD, Diabetes Linked to Worse Functional Outcomes in Women With Ischemic Stroke

By Caroline Cassels
Medscape Medical News

October 9, 2007 (Washington, DC) — New research shows increased prestroke comorbidity, particularly diabetes and coronary heart disease (CHD), is independently associated with poorer poststroke functional status among women with ischemic stroke.

Presented here at the 132nd Annual Meeting of the American Neurological Association by researchers from Duke University Medical Center. in Durham, North Carolina, the prospective study showed prestroke diabetes and CHD were independently associated with poststroke disability in women at 90 days or more.

"It appears there is a slight influence of other comorbidities on poststroke disability, but the vast majority of it is explained by these 2 premorbid conditions [CHD and diabetes]," study investigator Cheryl Bushnell, MD, told Medscape Neurology & Neurosurgery.

It is well-known, said Dr. Bushnell, that women with ischemic stroke have poorer functional outcomes than their male counterparts, with higher rates of institutionalization and greater disability. However, she added, until now the reasons behind this phenomenon have not been investigated.

"Big Picture"

"We previously found the presence of prestroke CHD was independently associated with more severe strokes in women. This led us to hypothesize that prestroke heart disease might also be associated with worse poststroke functional outcomes. But we also wanted to look at the 'big picture' and examine whether other comorbidities might influence poststroke outcomes [in women]," said Dr. Bushnell.

To identify specific outcome predictors, the researchers prospectively assessed baseline comorbid conditions in 133 consecutive women older than 18 years who presented within 24 hours of onset of acute ischemic stroke between September 2001 and February 2005.

The primary outcome was poststroke disability at 90 days or more evaluated with the modified Rankin Scale (mRS). The researchers also examined potential predictors of stroke severity, which was assessed using the National Institutes of Health Stroke Scale (NIHSS) 24 to 48 hours after admission and at 7 days or discharge, whichever came first.

Information on hypertension, hypercholesterolemia, prior stroke or transient ischemic attack, CHD, congestive heart failure, atrial fibrillation, peripheral vascular disease, and venous thrombosis were determined by medical records or self-report.

In addition, participants' health habits, including cigarette smoking and alcohol and illicit drug use, were also assessed, and body-mass index calculated.

CHD Only Predictor of Stroke Severity

The modified Charlson Index was used to measure comorbidities and was hypothesized to be a predictor of outcome. This well-validated comorbidity index predicts 1-year mortality by weighting 16 conditions, including CHD and diabetes, and assigning a single score.

In multivariable modeling adjusted for initial NIHSS, independent predictors of disability were CHD and diabetes. It was only when diabetes and CHD were excluded that the Charlson Index became the sole predictor of poststroke disability, accounting for about 14% of the variance.

The study also revealed prestroke CHD was the only clinical factor associated with initial stroke severity.

According to Dr. Bushnell, the study results indicate a need for optimal management of women with diabetes and CHD, where evidence indicates there is room for improvement.

"We know, for example, that women are not well managed with respect to their lipids, both with respect to medication adherence and achieving target [serum cholesterol] levels," she said.

She added that, based on these results, stroke outcome studies need to be adjusted for the presence of baseline comorbid conditions.

The study was supported by a grant from the National Institutes of Health and National Stroke Association Research Fellowship.

132nd Annual Meeting of the American Neurological Association: Abstract S-5. Presented October 7, 2007