Stroke in type 2 diabetes mellitus patients admitted to emergency unit in Central African country (Congo): Preliminary findings

doi:10.4236/jdm.2013.34032

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Vol.3, No.4, 208-213 (2013) Journal of Diabetes Mellitus

http://dx.doi.org/10.4236/jdm.2013.34032

S troke in type 2 diabetes mellitus p atient s admitted to

emergency unit in Central African country (Congo):

Preliminary findings*

Bertrand Fikahem Ellenga-Mbolla1,2#, Henri Germain Monabeka2, Paul Macaire Ossou-Nguiet2,

Gilbert Fabrice Otiobanda3, Kryste Chancel Mahoungou Guimbi3, Thierry Raoul Gombet2,4,

Suzy-Gisèle Kimbally-Kaky1,2, Benjamin Longo Mbenza5

1Department of Cardiology, University Hospital of Brazzaville, Brazzaville, Congo;

#Corresponding Author: [email protected]

2Department of Medicine, Faculty of Health Sciences, Marien Ngouabi University, Brazzaville, Congo

3Intensive Care Unit, University Hospital of Brazzaville, Brazzaville, Congo

4Emergengy Unit, University Hospital of Brazzaville, Brazzaville, Congo

5Faculty of Health Sciences, Walter Sisulu University, Mthatha, South Africa

Received 5 October 2013; revised 2 November 2013; accepted 9 November 2013

Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is

properly cited.

ABSTRACT

Background: The cardiovascular risk factors

including type 2 diabetes mellitus (T2DM) are a

public health problem in sub-Saharan Africa.

The aim of this study is to determine the preva-

lence and factors associated with stroke in

T2DM p atients admitted to the emergency Unit in

Brazzaville. Patients and Methods: This is the

preliminary findings of a cross-sectional study

including patients with T2DM, admitted in Emer-

gency Unit of University Hospital of Brazzaville

from January to April 2011. One hundred and

seven patients were included. Sex ratio was 1.5.

Results: The mean age was 60.3 ± 10.2 years

(range 40 - 80 years). S troke story was noted in 5

cases (4.6%). The main pathologies were meta-

bolic complications (n = 51; 47.6%) and cardio-

vascular diseases (n = 36; 33.6%), dominated by

stroke (17 cases). Epidemiological factors asso-

ciated with stroke were high standard living (OR

= 3, 95% CI: 1.02 - 8.9, p = 0.03), polypharmacy

(OR = 3.7, 95% CI: 1.27 - 10.8, p = 0.01), previous

hospitalization (OR = 3.1, 95% CI: 1.07 - 8.9, p =

0.03), and the absence of antiplatelet therapy

(OR = 4.2, 95% CI 1.2 to 15, p = 0.03). Clinical

associated factors were coma (OR = 3.3, 95% CI

1.14 to 9.6, p = 0.02) and the presence of severe

hypertension (OR = 4, 95% CI: 1.2 - 12, p = 0.02).

Finally, prognostic factors were the transfer in

intensive care unit (O R = 9.8, 95% CI: 2.7 - 34, p <

0.001). Conclusion: The f irst card iovascular co m-

plication in p atient s with T2DM admitted in emer-

gency at University Hospital of Brazzaville is

stroke. Primary prevention in high-risk patients

is still inadequate.

Keywords: Type 2 Diabetes Mellitus; Stroke;

Emergency; Brazzaville

1. INTRODUCTION

The type 2 diabetes mellitus (T2DM) is a public health

problem in sub-Saharan Africa (SSA) where its preva-

lence constantly increases and the complications of this

disease become concerned [1]. The stroke represents a

serious and frequent complication of T2DM because of

its lethality, disability and relapse [2]. T2DM patient of-

ten has multiple risk factors, which lead to frequent oc-

currence of cardiovascular complications [1]. Thus, a

comprehensive and efficient management of T2DM pa-

tients, includes the management of all risk factors. Sev-

eral predictors of stroke have been described in black

patient with T2DM. Among them, there is an increase in

blood pressure, presence of infection, poor medical care,

the addictions and occurrence of microvascular compli-

cations [3]. In SSA, the management of T2DM is diffi-

cult because of poverty, poor access to medical care, lack

of equipment and qualified healthcare professionals [4,

*Competing interests: None.

B. F. Ellenga-Mbolla et al. / Journal of Diabetes Mellitus 3 (2013) 208-213 209

5].

The aim of this study is to determine the prevalence

and factors associated with stroke in T2DM patients ad-

mitted to the emergency Unit in Brazzaville.

2. PATIENTS AND METHODS

It is a cross-sectional study, conducted from January to

April 2011 (4 months) in the emergency Unit of Univer-

sity Hospital of Brazzaville.

We included all patients admitted with a diagnosis of

T2DM, with records including at least of standard boil-

ogy, an electrocardiogram and chest X-ray. A CT scan

performed within 48 hours was required for the diagnosis

of stroke.

2.1. Variables Anal yzed

They were epidemiological (age, sex, anthropometry,

diabetes follow up, duration of diabetes, clinical history,

outpatient treatment, adherence and reference), clinical

(signs and diagnosis) and prognostic (transfer in inten-

sive care unit and death).

2.2. Definitions

Obesity was defined as a body mass index greater than

30 kg/m2. Polypharmacy was seen when taking more

than three medications in outpatient treatment. Poor

compliance was indicated by irregular intake of treat-

ment. Reference represented patients addressed by a sec-

ondary health center. The high standard of living was

based on occupation and monthly salary. Major hyper-

glycemia was defined when glycemia ≥5 g/L. Severe

hypertension was defined when blood pressure ≥180/110

mm Hg.

2.3. Statistical Analysis

Data were treated with EPI INFO 3.3.2 software (CDC

Atlanta, USA) and SPSS 10.0 for Windows (Chocago, IL,

USA). Quantitative variables were expressed as mean

and standard deviation, and qualitative staffing percent-

age. The chi-square test was used to compare qualitative

variable and ANOVA for quantitative variable. The uni-

variate risk of stroke was assessed in calculating Odds

ratio (OR) with 95% confidence intervals (95% CI).

Multivariates analyses such as logistic regression models

were used to assess the independent determinants of

stroke. The receiving operating characteristic (ROC) curve

to predict stroke was plotted. The significance level was

0.05.

3. RESULTS

One hundred and seven patients were included. They

were 65 women (60.7%), the sex ratio was 1.5. The mean

age was 60.3 ± 10.2 years (range 40 and 80 years). The

mean age by sex was 60.4 ± 9.8 years (range: 40 - 78

years) for women and 60.3 ± 11 years (range: 40 - 80

years) for men (p = 0.98). In ROC curve (Figure 1), age

>62.5 ans to predict stroke (sensitivity 64.7%, specificity

57.8%) was no significant.

3.1. Epidemiological Status

High standard living was noted in 45 cases (42%), in-

cluding 22 women (33.8%) and 23 men (54.8%). Patients

were referred from a secondary health center in 26 cases

(24.3%). The mean duration of T2DM was 7.6 ± 5.4

years (range 0 - 22 years), respectively 5 ± 7.7 years

(range 0 - 2 years) for women and 7.6 ± 6 years (range 0

- 22 years) for men (p = 0.6). Duration of diabetes >10.5

years in ROC curve (Figure 1) was predicted stroke with

sensibility 35.3% and specificity 74.4% (p = 0.048). The

history of diabetes was known in 96 cases (90%), respec-

tively 59 cases (90.8%) for women and 37 (88%) for

men. Previous hospitalization was noted in 33 cases

(30.8%). The distribution of patients by sex, duration of

diabetes, poor adherence, polypharmacy and the number

of medications is reported in Table 1.

Diabetes treatment included an oral antidiabetic alone

in 63 cases (58.9%), insulin alone in 16 cases (15%) and

both associated in 10 cases (9.3%). There wasn’t diabetes

treatment in 18 cases (16.8%).

A history of stroke was noted in 5 cases (4.6%). The

antiplatelet therapy was ongoing in 13 patients (12.1%).

3.2. Clinical Features

The clinical signs presented by patients on admission

are reported in Table 2.

Seventeen cases of cerebral ischemia divided in 16

constituted strokes and one transient ischemic attack

Figure 1. ROC curve of age and duration of diabetes to predict

stroke. For age, area under curve (AUC) = 0.622 (95% CI:

0.497 - 0.747; p = 0.112). For duration of diabetes AUC =

0.652 (95% CI: 0.538 - 0.774).

B. F. Ellenga-Mbolla et al. / Journal of Diabetes Mellitus 3 (2013) 208-213

210

Tabl e 1. Sex distribution, monitoring of diabetes, poor adher-

ence, polypharmacy, and the number of drugs being.

Females (n = 65) Males (n = 42) All (n = 107)

Diabetes monitoring

Although monitoring 26 (40) 12 (28.6) 38 (35.5)

Poorly monitored 33 (50.8) 24 (57.1) 57 (53.3)

Not followed 6 (9.2) 6 (14.3) 12 (11.2)

Poor compliance 26 (40) 15 (35.7) 41 (38.3)

Drug

None 4 (6.2) 7 (16.7) 11 (10.3)

1 24 (36.9) 14 (33.3) 38 (35.5)

2 15 (23.1) 9 (21.4) 24 (22.4)

Polypharmacy 23 (35.4) 12 (28.6) 35 (32.7)

Table 2. Clinical signs listed in the admission of patients.

n %

Major hyperglycemia

Coma

Polyuri polydipsia signs

Fever

Dyspnea

Severe hypertension

Dehydration

Hemiplegia

Cough

Psychomotor agitation

State of shock

Convulsions

Hypoglycemia

Vomiting

Abdominal pain

Brief loss of consciousness

Heart rhythm disorders

Aphasia

42.1

34.6

24.3

21.5

15.8

12.1

11.2

9.3

6.5

5.6

4.6

2.8

were registered. It represents the first condition beyond

those attributable to glycemic control (major hypergly-

cemia and hypoglycemia). All patients with cerebral

ischemia were hypertensive (p < 0.0001) and were know

diabetics (p = 0.06). The mean age of patients with stroke

was 64.2 ± 7.8 years vs 59.6 ± 10.5 for other patients (p

= 0.09). The mean duration of diabetes in patients with

stroke was 9.7 ± 4.8 years vs 7.2 ± 5.4 years for other (p

= 0.04). Diabetes follow up was regular in patients with

stroke in 12 cases (70.6%) vs. 26 cases (28.9%) for oth-

ers (p < 0.01).

The distribution of the main diseases is reported in

Table 3.

Tab le 4 shows univariates Odds of stroke. Any vari-

Table 3. Synopsis of pathologies.

n %

Metabolic Complications

Decompensation of diabetes

Diabetic coma

Hypoglycemia

Cardiovascular disease

Stroke and transcient ischemic attack

Hypertensive encephalopathy

Heart failure

Arteriopathy

Infectious diseases

Bronchopulmonary infection

Diabetic foot

Gastrointestinal infection

Urinary tractus infection

Septicemia

Myositis

Erysipelas

Other

Uremic syndrome

47.6

26.2

6.5

33.6

15.8

10.3

5.6

0.9

7.5

6.5

4.7

1.9

0.9

able was independent determinant of stroke in logistic

regression (Ta bl e 5 ). In ROC curve, only polypharmacy

(Figure 2) was significant to predict stroke: sensitivity

58.8%, specificity 72.2% (p = 0.043).

The average duration in emergency unit was 32.5 ± 20

hours (range 12 to 96 hours). This duration was 47.4 ±

23.5 hours for patient with stroke vs 29.6 ± 18.5 hours

for others (p < 0.001). A treatment in Intensive care Unit

of University Hospital of Brazzaville was required in 13

cases (12.1%). Three cases of deaths were recorded

(2.8%), including 2 cases of stroke (OR 11.8, 95% CI

1.01 to 139, p = 0.03).

4. DISCUSSION

4.1. Study Limitations

The study we conducted in an emergency unit, we

were able to raise the profile of T2DM and other risk

factors. It’s a preliminary finding. The best would be to

conduct a cohort study to determine the long-term prog-

nosis. Indeed, glucose and blood pressure levels, recur-

rent stroke, readmissions and mortality are important to

assess the real risk of morbidity and mortality. In addi-

tion, we had included the outcome of patients after ori-

entation in intensive care unit or department of diabetol-

ogy.

4.2. Epidemiological Aspects

The profile of our patients reflects the socio-demo-

graphic and epidemiological realities in SSA. Indeed, the

low standard of living (58%), poor reference (24.3%),

B. F. Ellenga-Mbolla et al. / Journal of Diabetes Mellitus 3 (2013) 208-213

211

Table 4. Univariates factors associated with stroke.

Stroke (n = 17)Without stroke (n = 90)OR 95% IC p-value

Epidemiological aspects

Female

Age >75 years

High standard of living

Polypharmacy

History of stroke

Anterior hospitalization

Without antiplatelet

Poor compliance

12 (70.6)

3 (17.6)

11 (64.7)

10 (58.8)

2 (11.8)

9 (52.9)

5 (29.4)

53 (58.9)

9 (10)

34 (37.8)

25 (27.8)

3 (3.3)

24 (26.7)

8 (8.9)

36 (40)

1.67

1.92

3.01

3.7

3.86

3.09

4.2

0.6

0.54 - 5.1

0.46 - 8

1.02 - 8.9

1.27 - 10.8

0.59 - 25

1.07 - 8.9

1.2 - 15

0.2 - 1.9

0.26

0.19

0.03

0.01

0.1

0.03

0.29

Clinical aspects

Obesity

Severe hypertension

Coma

Major hyperglycemia

16 (94.1)

6 (35.3)

10 (58.8)

3 (17.6)

70 (77.8)

11 (12.2)

27 (30)

42 (46.7)

4.5

3.3

0.24

0.5 - 36

1.2 - 12

1.14 - 9.6

0.06 - 0.91

0.06

0.02

0.01

Prognosis

Transfer in intensive care unit 7 (41.2) 6 (6.7) 9.8 2.7 - 34 <0.001

Table 5. Independents determinants of stroke by logistic regression.

Independant variables β coefficient Standard errorWald Χ2 OR (95% CI) p-value

Age (years)

Age >75 years (yes vs no)

Duration of diabetes

Anterior hospitalization (yes/no)

Coma (yes vs no)

Major glycemia (yes vs no)

Severe hypertension (yes vs no)

HSL (yes vs no)

Obesity (yes vs no)

Polypharmacy (yes vs no)

Transfert intensive care (yes/no)

Sex (male vs female)

0.026

–0.274

0.042

1.138

2.069

–14.59

1.001

1.247

1.27

0.734

14.23

–1.464

0.047

1.418

0.081

0.92

1.159

253.8

0.842

0.777

1.229

0.855

253.8

0.875

0.559

–0.382

0.519

1.237

1.784

–0.05

1.188

1.605

1.033

0.858

0.056

–1.672

1.02 (0.93 - 1.12)

0.58 (0.03 - 9)

1.04 (0.88 - 1.22)

3.12 (0.51 - 19)

7.92 (0.81 - 76)

<0.01 (0 - >105)

2.72 (0.52 - 14)

3.48 (0.75 - 15)

3.56 (0.32 - 39)

2.08 (0.38 - 11)

>105 (<105 - >105)

0.23 (0.04 - 1.28)

0.575

0.701

0.603

0.216

0.074

0.954

0.234

0.108

0.301

0.39

0.955

0.094

HSL: High standard of living.

poor adherence (64.5%), demonstrate the realities of ma-

nagement of cardiovascular disease in our environment

[6].

Among metabolic complications, glycemic imbalance

was found in 51.4% of cases and 42.1% of major hyper-

glycemia. It is recognized that the major hyperglycemia

is pejorative in the acute stage of cardiovascular compli-

cations of T2DM [7]. It plays also a role in the early de-

velopment of complications [8]. The specificity of this

major hyperglycemia in the black people is the presence

of ketosis, thus defining the ketosis prone T2DM [1,9].

The others complications is represented by hypoglyce-

mia (9.3%). It is often secondary to poor adherence to

treatment, but also the low status and illiteracy [6].

Associated pathologies, we identified cardiovascular

disease with stroke in the foreground and infectious dis-

eases. There were mainly represented by the broncho-

pulmonary infections and diabetic foot. The diabetic foot

is often mixed in our context with a tricky treatment,

sometimes leading to amputation in 20% of cases ac-

cording to Longo-Mbenza et al. [10] and 43% reported

by Monabeka et al. [11].

4.3. Stroke

Cardiovascular complications were mainly represented

by stroke (15.8%) and hypertensive encephalopathy

(10.3%). Any studied factor was independent determi-

nant of stroke in our study. Many factors were commonly

independently associated with ischemic stroke in T2DM

patients [12]. Arboix et al., identified hypertension, atrial

B. F. Ellenga-Mbolla et al. / Journal of Diabetes Mellitus 3 (2013) 208-213

212

Figure 2. ROC curve to predict stroke for polypharmacy (AUC

= 0.655; 95% CI: 0.508 - 0.803) Coma (AUC = 0.644; 95% CI:

0.497 - 0.791; p = 0.06) severe hypertension (AUC = 0.615;

95% CI: 0.457 - 0.774; p = 0.133) anterior hospitalization

(AUC = 0.631; 95% CI: 0.481 - 0.782; p = 0.07).

fibrillation, congestive heart failure, and valvumopathy

was causes of stroke [12]. The female sex was signifi-

cantly associated with stroke and mortality [12]. This

aspect was not significant in our study. According to

Mbanya et al., the prevalence of cardiovascular compli-

cations varies from 4 to 28 in diabetes, and 15% of pa-

tients with stroke have diabetes, and 5% of diabetes de-

velop stroke [1]. In our series, the number of stroke ap-

pears to be limited, because we included only patients

who had realized the CT brain scan. However, in Braz-

zaville, 50% of hypertensive emergencies are represented

by stroke [13]. The diagnosis of stroke remains difficult

in SSA. Indeed, the lack of equipment and qualified

healthcare professionals limit the diagnosis and man-

agement [5]. It is certain that the achievement of CT scan

improves the initial emergency treatment and prognosis

[14]. The poor glycemic control in patients contributes to

the early onset of complications including stroke [8], and

alters the prognosis [7] what motivated the transfer re-

suscitation in a large number in our series. In addition,

the social level of patients limit access to care [6]. In our

series, stroke is univariate factor of mortality in T2DM

patients. In addition, stroke is the leading cause of car-

diovascular emergencies at University Hospital of Braz-

zaville [15]. Given these aspects, primary prevention

using the lifestyle measures involving diet and physical

activity reduces the risk of occurrence of complications

especially stroke [16,17]. In primary prevention, the oc-

currence of diabetes is significantly lower in subjects

with regular physical activity in addition to appropriate

diet [16].

5. CONCLUSION

The risk of stroke is higher in T2DM. Given the diffi-

culties of management of cardiovascular risk factors in

sub-Saharan Africa, an active primary prevention would

not only lessen the cost of treatment, but also reduce the

occurrence of complications.

6. ACKNOWLEDGEMENTS

We thank Dr Charley Elenga Bongo for his contribution in the

manuscript translation.

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