Introduction

The “umbrella” of cardiovascular diseases has expanded to include other conditions like diabetes and strokes, due to their effects on the heart. Generally, any issue that affects or could affect the heart and blood vessels, will be categorised as a cardiovascular disease. Cardiovascular diseases are the leading cause of death in the UK and globally.^1,2 

Many factors could contribute to the development of heart issues including: 

• A stressful lifestyle 
• Unhealthy habits 
• Absence of exercise 
• High blood pressure 
• High cholesterol 
• Elevated sugar blood levels 
• Obesity
• Family history
• Ethnicity 
• Advanced age¹ 

Although national authorities and health agencies have released global strategies and guidelines to limit cardiovascular death incidents, only some of the major risk factors have been reduced..² 

Diabetes is more than a chronic metabolic disease. Type 2 diabetes is a well-known global disease due to its massive impact on communities all around the world, it has been recognised as a major cause of death during the last couple of decades.³ Nevertheless, most people are unaware of the interconnected nature of the disease, affecting the heart, the kidneys, and the pancreas. 

Poor management of Type 2 diabetes can lead to serious and complex events, such as the increased risk of developing ischaemic strokes. It has been estimated that 65% of diabetic patients die from strokes.⁴ 

How can diabetes lead to ischemic strokes?

Ischemic stroke

Overview

In a general sense, strokes are considered to be severely dangerous as they are a result of a lack of oxygen reaching the brain. The symptoms of a stroke are easily recognised as they affect the face, arms, and speech, and are also related to survival time. This can be remembered as the acronym FAST.⁵

Ischemic strokes contribute 85% of strokes, due to the formation of a thrombus which suspends the oxygen and blood supply to the brain, thus causing brain injury or brain death. Other types of strokes include Transient Ischemic Attack (TIA) and Hemorrhage, caused when a frail blood vessel connected to the brain explodes.⁵

Common risk factors

• Hyperlipidemia⁵
• Hypertension⁵
• Diabetes⁵
• Atrial Fibrillation⁵

Recovery and treatment

If patients overcome strokes and have a second chance to live, they may be left with brain issues and will need continuous rehabilitation. Sadly, many patients don’t fully recover and require further assistance. The treatment regimen includes surgeries, anticoagulant medicines that remove blood clots, drugs that lower blood pressure and cholesterol levels, and certain groups of diabetic medications, which have recently been discovered to save patients from ischemic strokes.⁵

Few preventative measures could aid in avoiding stroke events. For example: adopting a healthier lifestyle, including lots of exercise and eating well, as well as cutting the consumption of alcohol and ceasing smoking in all of its forms.⁵

Diabetes

Overview

Diabetes is defined as elevated sugar levels in the bloodstream due to insulin resistance, causing disturbances to the body’s physiology.⁶ Several factors contribute to this disease, such as a stressful and unhealthy lifestyle. Diabetes is often linked to inactivity, obesity, and having a family history of the disease.⁷ Some people may not know they have diabetes, as they don’t have any symptoms, while others might feel exhausted and may struggle with their eyesight.⁸

Type 2 diabetes can be managed and controlled, yet not fully cured. Metformin, the most commonly used medication for diabetes, is not always sufficient in lowering and stabilising blood sugar levels. The best thing to do is to follow a regular healthy routine and speak to your nearest GP or diabetes specialist as they will recommend the most suitable additional medication if required.⁹

Diabetic patients are more prone to developing health problems compared to healthy individuals. Type 2 diabetes can disturb the function of vital organs of the body such as the heart and kidneys, resulting in a vicious cycle between diabetic symptoms and negative consequences to the heart and kidneys. For this reason, pharmaceutical companies that produce anti-diabetic agents, focus on ensuring their products go beyond controlling blood sugar levels, like protecting against the increased risk of developing heart and kidney diseases.

Also, these types of medication are beneficial as they cause weight loss, so reduce mental health issues of diabetics who have experienced excessive weight gain.¹⁰ Several clinical trials have shown that some anti-diabetic agents possess the whole package of management and protection like Empagliflozin and Liraglutide.^11,12

Treatment options

There are a variety of treatment options for Type 2 diabetes, either as a monotherapy or combination therapy, where more than one type of medication is used to control blood sugar levels. These medications are taken as tablets or injections, depending on their formulation. Some examples include Metformin, sulfonylurea agents, DPP4-inhibitors, SGLT2-inhibitors, incretin mimetics, and insulin.

Relationship between ischemic stroke and diabetes

Unmanaged cases of diabetes will potentially put patients at a dangerous risk of developing ischemic strokes. One study mentions the pathophysiological reasons for getting an ischemic stroke coexisting with diabetes including:

• Vascular endothelial dysfunction
• Increased early-age arterial stiffness
• Systemic inflammation
• Thickening of the capillary basal membrane
• Abnormalities in early left ventricular diastolic filling are commonly seen in type 2 diabetes⁴ 

All these factors could lead to a condition known as atherosclerosis, where the arteries get narrower due to the buildup of fat, reducing blood flow to vital organs. This could result in the development of many types of cardiovascular diseases, but the most common is ischemic stroke.¹³ 

Prevention and management strategies

Medications

Blood thinning agents

The majority of patients will receive blood-thinning drugs taken daily and for a lifetime either as antiplatelets or anticoagulants like Aspirin, Clopidogrel, Dabigatran, and Warfarin. The purpose of these types of medicines is to limit the formation of blood clots.¹⁴

High cholesterol drugs

To avoid the formation of blood clots and an increased risk of developing ischemic strokes, anti-cholesterol medications may be prescribed, such as:

• Statins like Atorvastatin, are the most commonly prescribed for high cholesterol. They can be taken as tablets once daily and for a lifetime¹⁵
• Fibrates
• Special injections

Glycemic management

Type 2 diabetes is regarded as the number one factor in the development of ischemic strokes, which is why it is of high importance to control blood sugar levels using anti-diabetic medicines. Currently, new groups of medications have been found in the market that can protect patients from future strokes, regardless of their history with ischaemic strokes. These magical agents are known as SGLT2-inhibitors like Empagliflozin.¹¹ Another injectable form of cardiovascular protective agent are GLP-1 agonist, like Liraglutide.¹²

Blood pressure control

Hypertensive patients are also at a higher risk of developing different types of strokes. Antihypertensive agents play a crucial role in protecting patients with high blood pressure:

• Angiotensin-converting Enzyme (ACE) inhibitors
• Angiotensin Receptor Blockers (ARBs)
• Diuretics
• Beta-blockers
• Calcium channel blockers

Lifestyle modifications

Ischemic strokes have a massive impact on people’s lives, so those who have suffered from an ischaemic stroke must be given the support and guidance that they deserve. The most important things after an ischaemic stroke are rehabilitation, continuous monitoring, follow-up visits to a specialised doctor, and taking prescribed medications.

Alongside medications, lifestyle changes are essential to decrease the likelihood of developing further cardiovascular incidents. Going for daily 30-minute strolls, eating a healthy and balanced diet, smoking cessation, and cutting alcohol consumption are simple things that will protect patients in the long term.

Summary

Type 2 diabetes is an essential alterable risk factor for ischemic stroke, meaning that good control of cholesterol, blood pressure, and sugar levels, is associated with ischemic stroke prevention.⁴

A healthy heart is the key to leading a happy life, learning more about diabetes and its consequences on the heart and arteries, understanding your risk, and seeking professional guidance as necessary can be very helpful in saving your life or the life of those who matter to you the most. It is important to realise the consequences of the gradual progression of diabetes on human health. Always remember the choices you make today can pave the way to a happier tomorrow.