Research paper about the prevalence of metabolic syndrome in patients with stroke

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Journal of the Arab Board of Health Specializations Vol.11, No 4, 2010
Original Article ‫أصيل‬ ‫مقال‬
ABStRACt
Objective:Theobjectiveofthestudyweretodetermine
theprevalenceandidentifytheassociatedandprognostic
factors that influence the risk of metabolic syndrome
among patients with acute stroke admitted to medical
department in AL-kuwait University Hospital(KUH) in
Sanaa city, Yemen.
Methods: The study population of this cross sectional
survey consisted of 331 patients recently diagnosed
with acute stroke in the period between (2009-2010).
Metabolic syndrome was defined according to the
National Cholesterol Education Program–Adult
Treatment Panel III (NCEP –ATP III) criteria
Results: The prevalence of metabolic syndrome in
our study was 39.5% males was more frequently affected
than females. Hypertension was the most metabolic
comorbiditiesinstrokepatientswithmetabolicsyndrome
while central obesity is the least.
Conclusions: We conclude that metabolic syndrome
was common in stroke patients which could be explained
by metabolic syndrome perse or due to different
metabolic co morbidities that are associated with it.
IntRoDuCtIon
Several studies showed high prevalence of the
metabolic syndrome in different high risk populations,1,2
but the magnitude of the metabolic syndrome MS
becomes apparent when in an apparently healthy
population prevalence of nearly 24% is found.3
In our
country there is no study dealing with the prevalence of
metabolic syndrome in acute stroke patients, therefore
we decided to start this study in Al-Kuwait University
Hospital (KUH) in Sanaa City aiming to provide more
information about the prevalence of MS and other
associated risk factors in patients with acute stroke.
THE PREVALENCE OF METABOLIC SYNDROME IN PATIENTS WITH STROKE
‫الدماغية‬ ‫السكتة‬ ‫مرضى‬ ‫لدى‬ ‫األيضية‬ ‫المتالزمة‬ ‫انتشار‬
Mohammed Bamashmoos, MD; Kalid Alagbary, MD; Faizaa Asker, MD
‫عسكر‬ ‫فايزة‬ .‫د‬ ،‫األغبري‬ ‫خالد‬ .‫د‬ ،‫بامشموس‬ ‫محمد‬ .‫د‬
‫البحث‬ ‫ملخص‬
‫المقبولين‬ ‫الحادة‬ ‫الدماغية‬ ‫السكتة‬ ‫مرضى‬ ‫عند‬ ‫لها‬ ‫افقة‬
‫ر‬‫الم‬ ‫ية‬‫ر‬‫اإلنذا‬ ‫امل‬‫و‬‫الع‬‫و‬ ‫األيضية‬ ‫المتالزمة‬ ‫انتشار‬ ‫تحديد‬ ‫إلى‬ ‫اسة‬
‫ر‬‫الد‬ ‫هذه‬ ‫تهدف‬ :‫البحث‬ ‫هدف‬
.‫اليمن‬ ‫في‬ ‫صنعاء‬ ‫مدينة‬ ‫في‬ ‫الجامعي‬ ‫الكويت‬ ‫مشفى‬ ‫في‬
‫تم‬ .)2010-2009( ‫عامي‬ ‫بين‬ ‫ة‬
‫ر‬‫الفت‬ ‫خالل‬ ‫الحادة‬ ‫الدماغية‬ ‫بالسكتة‬ ً‫ا‬‫حديث‬ ‫المشخصين‬ ‫من‬ ً‫ا‬‫يض‬‫ر‬‫م‬ 331 ‫المقطعية‬ ‫اسة‬
‫ر‬‫الد‬ ‫هذه‬ ‫شملت‬ :‫البحث‬ ‫طرق‬
.)NCEP-ATPIII( ‫الثالث‬ ‫البالغين‬ ‫معالجة‬ ‫سلم‬ ‫معايير‬ -‫التثقيفي‬ ‫الوطني‬ ‫الكولسترول‬ ‫نامج‬‫ر‬‫لب‬ ً‫ا‬‫تبع‬ ‫األيضية‬ ‫المتالزمة‬ ‫يف‬‫ر‬‫تع‬ ‫اعتماد‬
‫تفاع‬‫ر‬‫ا‬ ‫شكل‬ .‫باإلناث‬ ً
‫ة‬‫ن‬‫ر‬‫مقا‬ ‫المتالزمة‬ ‫بهذه‬ ‫للذكور‬ ‫أكبر‬ ‫تأثر‬ ‫لوحظ‬ ‫كما‬ ،%39.5 ‫اسة‬
‫ر‬‫الد‬ ‫هذه‬ ‫في‬ ‫األيضية‬ ‫المتالزمة‬ ‫انتشار‬ ‫نسبة‬ ‫بلغت‬ :‫النتائج‬
‫ة‬
‫ر‬‫األخي‬ ‫تبة‬‫ر‬‫الم‬ ‫ية‬‫ز‬‫المرك‬ ‫البدانة‬ ‫احتلت‬ ‫بينما‬ ،‫األيضية‬ ‫بالمتالزمة‬ ‫المصابين‬ ‫الدماغية‬ ‫السكتة‬ ‫مرضى‬ ‫عند‬ ‫افقة‬
‫ر‬‫الم‬ ‫اضية‬
‫ر‬‫اإلم‬ ‫امل‬‫و‬‫الع‬ ‫أكثر‬ ‫ياني‬‫ر‬‫الش‬ ‫التوتر‬
.‫افق‬
‫ر‬‫م‬ ‫كعامل‬
‫إلى‬ ‫أو‬ ،‫ذاتها‬ ‫بحد‬ ‫األيضية‬ ‫المتالزمة‬ ‫دور‬ ‫إلى‬ ‫ى‬
‫يعز‬ ‫ما‬ ‫وهو‬ ‫الدماغية‬ ‫السكتة‬ ‫مرضى‬ ‫عند‬ ‫األيضية‬ ‫المتالزمة‬ ‫ع‬
‫شيو‬ ‫اسة‬
‫ر‬‫الد‬ ‫هذه‬ ‫تظهر‬ :‫االستنتاجات‬
.‫لها‬ ‫افقة‬
‫ر‬‫الم‬ ‫ى‬
‫األخر‬ ‫اضية‬
‫ر‬‫اإلم‬ ‫امل‬‫و‬‫الع‬
*Mohammed Bamashmoos, MD, Assistant Professor of Internal Medicine, Sana'a University, Sana'a, Yemen. E-mail: mabamashmoos@yahoo.com.
*Kalid Alagbary, MD, Assistant Professor of Internal Medicine, Sana'a University, Sana'a, Yemen.
*Faizaa Asker, MD, Arab Board.

2. 29
Journal of the Arab Board of Health Specializations Vol.11, No 4, 2010
The presence of metabolic syndrome has been asso-
ciated with an increased risk of prevalent stroke in the
existing literature. In the National Health and Nutrition
Examination survey among 10357 subjects,4
the preva-
lence of metabolic syndrome was significantly higher
in persons with self reported history of stroke (43.5%)
than in subjects with no history of vascular disease
(22.8%).
Metabolic syndrome was independently associated
with stroke history in all ethnic groups and in both sexes
(OR, 2.16 ;95% CI, 1.48 to 3.160).5
The association
between metabolic syndrome and stroke has been
confirmed in other populations integrated by elderly
subjects, and the frequency of metabolic syndrome has
been reported to be significantly higher in patients with
a history of atherothrombotic or non embolic ischemic
stroke.5-6
MEtHoDS
Thesamplingframeofthisstudyincludedallnationals
and non-national patients who were admitted with acute
stroke toAl-Kuwait University Hospital (KUH) medical
departments in Sana'a city. The diagnosis of acute
stroke was defined as rapidly developing clinical signs
of focal or global disturbance of cerebral function of
presumed vascular origin lasting more than 24 hours.
In total, 400 patients were approached by the authors
out of which 331 (82.7%) patients agreed to enroll. The
study was approved by the Joint Ethics Committee of
the Faculty of Medicine and Health Sciences of Sanaa
University. The data were collected between May 2009
and May 2010.
Data collection
After receiving a prior informed consent (a written
one from literate patients and a verbally informed one
from illiterate patients), a standardised data sheet was
used to record the demographic variables including age,
sex and presence of DM. DM was defined as a fasting
plasma glucose level of > 7.8 mmol/l, random plasma
glucose of > 11.1 mmol/l, or the requirement of regular
hypoglycaemic drug(s). History of hypertension,
hyperlipedemia (high TG, low HDL, high LDL),
smoking and ischaemic heart disease was also recorded.
Hypertension was defined as a previous record of at
least two blood pressure reading of ≥130/85mmHg.
Hyperlipedemia was defined as serum TG ≥150 mg/
dl, Low HDL ≤40 mg/dl in males and ≤50 mg/dl in
females.
Waistcircumferencewasmeasuredwithatapmeasure
mid way between lower rib margin and the iliac crest.
Blood pressure was measured in the right arm of
seated subjects using mercury sphygmomanometer
after 10-15 minutes of rest. Each subject had two
measurements of blood pressure at 5-minutes. interval.
Venous blood sampling was performed in the morning
afteranovernightfastfordeterminationoffastingplasma
glucose, triglyceride, and high density lipoprotein.
Metabolic syndrome was diagnosed according to the
NCEP-ATP 111(4) as the presence of three or more of
the following five criteria:
- Waist circumference ≥103 cm in males, or ≥88 in
females.
- Blood pressure ≥130/85 mmHg.
- Triglycerides ≥150 mg/dl.
- High density lipoprotein ≤40 mg/dl in males or ≤50
mg/dl in females.
- Fasting blood sugar ≥110 mg/dl.
The results were expressed a s mean±SD. Statistical
analysis were performed using the statistical package
for the social sciences (window version 11.0; SPSS inc,
Chicago IL USA). Differences between groups were
tested statistically using the Chi square test. Data were
considered statistically significant when the p-value
was ≤0.05.
RESultS
We studied 331 consecutive acute stroke patients, 211
(63.7%) were males and 120 (36.2%) were females.
There age ranges were between 35-78 years, mean
(55±32), males being older than females. Of all studied

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Journal of the Arab Board of Health Specializations Vol.11, No 4, 2010
patients, 266 (80.3%) had ischemic stroke and 64
(19.6%) had hemorrhagic stroke.
Total (331)
Female (120)
Male (211)
Factors
35-70
40-78
Age, (years)
120 (36%)
35 (10%)
85 (25%)
Smoking habit
266 (80.3%)
95 (28.7%)
171 (51.6%)
ischemic
Stroke
type 65 (19.6%)
25 (7.5%)
40 (12%)
hemorrhagic
108 (32.6%)
43 (12.9%)
65 (19.6%)
Type-2 DM
25 (7.5%)
10 (3%)
15 (4.5%)
IFG
70 (21.1%)
39 (11.7%)
31 (9.%)
Waist circumference
184 (55.5%)
59 (17.8%)
125 (37.7%)
HTN
103 (31.1%)
37 (11%)
66 (19.9%)
TG mg/dI
88 (26.5%)
45 (13.5%)
43 (12.9%)
HDL mg/dI
131 (39.5%)
59 (17.8%)
72 (21.7%)
Metabolic syndrom
Table 1. Baseline characteristics of patients
with stroke.
The base line characteristics of patients with stroke is
shown in Table 1.
It shows that the most important risks factor in most
patients was hypertension (55.5%) and metabolic
syndrome (39.5%).
Other traditional risk factors like smoking, type-2
diabetes, obesity and dyslipidaemia (high TG, low
HDL) was seen in a less proportion of patients.
The overall prevalence of the metabolic syndrome
was 39.5%, with prevalence of 54.9% in males and 45%
in females. However, there is no significant difference
in the prevalence of metabolic syndrome between males
and females.
The physical and metabolic characteristics of stroke
patients with and without metabolic syndrome are
shown in Table 2.
The main age for patients with metabolic syndrome
was (58.5±43) versus (55.3±21) for patients without
metabolic syndrome p=0.001,Also metabolic syndrome
with stroke was more prevalent in males.
64.8% of patients with metabolic syndrome are
smokers versus 17.5% without metabolic syndrome
(p=0.0001).
There is no significant difference regarding the
prevalence of metabolic syndrome in patients with
either ischemic or hemorrhagic stroke (p=0.44).
Seventy seven percent (77%) of the stroke patients
with metabolic syndrome had raised blood pressure
versus 41.5% of patients without metabolic syndrome
(p-value=0.00001), while 74% of them had high
FBS or type 2 DM versus 18% had normal FBS
(p-value=0.00001), 53.4% had high serum TG versus
p-value
Without MS (200)
With MS (131)
All patients (331)
Factors
0.001
55.3±21
58.5±43
54±31
Age (years)
0.0071
139 (69.5%)
72 (54.9%)
211 (63.7%)
Male sex
35 (17.5%)
58 (64.8%)
120 (36.2)
Smoking
0.44
158 (79%)
108 (82.4%)
266 (80.3%)
ischemic
Type of
stroke 0.44
42 (21%)
23 (17.5%)
65 (19.6)
hemorrhagic
0.00001
36 (18%)
82 (62.5%)
108 (32.6%)
Type-2 DM
0.02
17 (8.5%)
8 (6%)
25 (7.5%)
IFG
0.0001
18 (9%)
52 (39.6%)
70 (21%)
Obesity
0.00001
83 (41.5%)
101 (77%)
184 (55.5%)
HTN
0.0001
33 (16.5%)
70 (53.4%)
103 (31.1%)
TG mg/dl
0.0001
22 (11%)
66 (50.3%)
88 (26.5%)
HDL mg/dl
Table 2. Physical and metabolic characteristics of stroke patients with and without metabolic syndrome.

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Journal of the Arab Board of Health Specializations Vol.11, No 4, 2010
16.5% had normal TG level (p-value=0.00001) 50.3%
had low HDL cholesterol versus 11% had normal HDL
cholesterol (p-value=0.0001).
The lowest prevalence of comorbidity in patients
with metabolic syndrome was obesity (39.6% VS 9%)
(p-value=0.0001).
DISCuSSIon
This study analyzes the prevalence of the metabolic
syndrome in stroke patients who attended the medical
department in (KUH) using the NCPE panel III criteria
for definition of the metabolic syndrome.
The result of this study provide valuable information
about the metabolic syndrome in patients with stroke.
The overall prevalence of the metabolic syndrome
among patients with stroke in the present study is 39.5%
which is equal to that in other comparable studies in
stroke patients conducted in Italy 40% and 40% in
Netherland.7,8
The similarity in the prevalence might
be due to the same definition used for the criteria of
metabolic syndrome in the different study population.
The increased prevalence of the metabolic syndrome
in patients with stroke may be explained by individual
risk factors of the metabolic syndrome in association
with other not routinely measured aspects of the
metabolic syndrome as impaired fibrinolysis oxidative
stress, increased small dense LDL, hypercoagulability,
inflammation and hyperinsulinemia.9
Patients with stroke and metabolic syndrome were
older than those without metabolic syndrome (mean
58.5±43 years).
The prevalence of individual metabolic comorbidities
of the metabolic syndrome in our study was high.
Hypertension (77%) was the most common finding in
our study. this was followed by the prevalence of type-2
diabetes and IFG (74%), high TG (53.4), low HDL
50.3% and obesity 39.6%.
Similar finding was observed in the study by Chen
et al in Taiwan,9
and by Arenilly et al in Spain10
where
elevated blood pressure or previously diagnosed
hypertension has high prevalence in patients with stroke
(68.9% and 68%) respectively.
Rodriguez, et al11
found that all metabolic syndrome
components contributed to stroke risk, they found that
groups with elevated blood pressure or elevated blood
sugar were at greatest risk for stroke.
Hypertension remain the most common modifiable
risk factors for stroke in population including the
elderly.12,13,14
Presence of hypertension as apart of metabolic
syndrome was associated with increased risk of acute
stroke. This association was high statistically significant
in our study between stroke patients with and without
metabolic syndrome (p-value=0.00001).
Many researchers believe that insulin resistance is the
patho physiological process underlining the clustering
of vascular risk factors in the metabolic syndrome.15
Indices of insulin resistance predict atherosclerosis
and vascular events independently of other risk factors
including fasting glucose and lipid levels.16
Current NCEP/ATP III guidelines used impaired
fasting glucose (>110 mg/dl or previously diagnosed
type-2 diabetes as one of criterion for identifying
subjects with metabolic syndrome, insulin resistance
with normal, impaired glucose tolerance or diabetes
may play a role as risk factors for stroke.
Dyslipidaemia is the hall mark of the metabolic
syndrome. Its characterized by elevated TG and low
HDL cholesterol levels.17,18
In our analysis there is a
significant correlation between high TG and low HDL
in stroke patients with and without metabolic syndrome.
There is controversy regarding the association between
serum TG levels and stroke.19
It has been shown that
postprandial hypertriglyceridemia is associated with
carotid artery atherosclerosis.20
Nonetheless, in the Copenhagen city heart study, a
long linear association between serumTG levels and non

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Journal of the Arab Board of Health Specializations Vol.11, No 4, 2010
hemorrhagic stroke was found, which was independent
of age and sex.21
Inthemajorityofstudies,therewasinverseassociation
between HDL–C and stroke.22,23
There is evidence that excess body weight is a
predictor of stroke (total, ischemic, hemorrhagic) in
men.23
Even though obesity is regarded as modifiable
risk factor for vascular disease, high value of waist
circumference increases the risk for stroke in 20 years
old men but not in women.
ConCluSIonS
We conclude that metabolic syndrome was common
in stroke patients which could be explained by the
metabolic syndrome perse or due to different metabolic
co morbidities that are associated with it.
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