(Stroke. 1996;27:210-215.)
© 1996 American Heart Association, Inc.
Articles |
Diabetes Mellitus as a Risk Factor for Death From Stroke
Prospective Study of the Middle-aged Finnish Population
, MDFrom the National Public Health Institute, Department of Epidemiology and Health Promotion, Helsinki, Finland.
Correspondence to Prof Jaakko Tuomilehto, National Public Health Institute, Department of Epidemiology and Health Promotion, Mannerheimintie 166, FIN-00300 Helsinki, Finland.
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Abstract |
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Background and Purpose High blood pressure is the most important risk factor for stroke. It is also known that diabetic patients are at increased risk of both hypertension and stroke. The aim of this study was to assess the independent effect of diabetes as a risk factor for stroke. Results from the previous studies of this question have been somewhat inconclusive.
Methods We performed a prospective study (average follow-up, 16.4 years) of 8077 men and 8572 women who had participated in risk factor surveys in Eastern Finland in 1972 (20 years of follow-up) and 1977 (15 years of follow-up). Risk factors included in the current analyses were smoking, blood pressure, antihypertensive drug treatment, serum total cholesterol, and diabetes either at baseline or developed during the follow-up. Age- and risk factor-adjusted relative risks for death of stroke were determined with the Cox proportional hazards model.
Results Diabetes mellitus was the strongest risk factor for death from stroke among both men and women in univariate and multivariate analyses. In addition, smoking and systolic blood pressure appeared to be independent risk factors among both sexes, as did serum total cholesterol among men. Men with diabetes at baseline appeared to be at a sixfold increased risk of death from stroke, while relative risk for men who developed diabetes during the follow-up was 1.7. In women, those who were diabetic at baseline were at higher risk of stroke than women who developed diabetes later (relative risks, 8.2 and 3.7, respectively). Of stroke deaths, 16% in men and 33% in women were attributed to diabetes.
Conclusions Diabetic subjects have a very high risk of death from stroke, particularly women. Our data also suggest that the duration of diabetes is an important factor contributing to the risk of stroke.
Key Words: diabetes mellitus • Finland • prospective studies • risk factors
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Introduction |
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TopAbstractIntroductionSubjects and Methods Results Discussion References |
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High BP is the most important known risk factor for stroke.1 2 3 4 It is also known that diabetic patients are at an increased risk of hypertension and stroke.5 While many studies have identified diabetes mellitus as an independent and significant risk factor for stroke,3 6 7 8 9 in other studies diabetes did not persist as an independent risk factor for stroke in the multivariate analysis.10 11 Also, in a recent review article on diabetes and the risk of stroke the problem was unresolved.12 Limited information is available on the influence of known cardiovascular risk factors on stroke mortality in diabetic persons, and the results are conflicting.5 9 Earlier studies on diabetes and the risk of stroke performed in Finland13 14 have provided some additional information, but they have not been able to fully answer the question of the role of known cardiovascular risk factors in diabetic subjects. This report deals with the relationship between stroke mortality and diabetes, systolic BP, antihypertensive drug treatment, serum total cholesterol, cigarette smoking, and BMI in a prospective study of the adult population in eastern Finland.
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Subjects and Methods |
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TopAbstractIntroductionSubjects and Methods Results Discussion References |
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Cardiovascular risk factor surveys were performed in the provinces of North Karelia and Kuopio in eastern Finland in 1972 and 1977. Independent random samples of 6.6% of the population aged 30 to 59 years were drawn in both areas in both years. The total sample size was 19 894 persons, with participation rates of 90% among men and 93% among women. Persons who participated in both surveys were only included in the follow-up of the first survey cohort. Of 17 682 participants, 104 were excluded from this study because of a reported history of stroke at the time of the risk factor survey and 929 because of incomplete data on smoking, serum total cholesterol, BP, weight, or height. Thus, 8077 men and 8572 women were included in the present analysis.
The methodology used in the risk factor surveys has been described in detail earlier.15 The same methodology was used in both areas and during both years. The survey included a self-administered questionnaire, which was sent to the participants in advance. The questionnaire contained questions regarding medical history, use of antihypertensive drugs, and health behavior. At the study site, specially trained nurses measured height, weight, and BP using a standardized protocol. BP was measured from the right arm of the subject after 5 minutes' rest in a sitting position. The fifth phase of Korotkoff sound was recorded as diastolic BP. Weight was measured with a balance scale with the subject in light clothing and without shoes; height was measured to the nearest centimeter with the subject without shoes. BMI (weight [kilograms] divided by height [square meters]) was used as a measure of relative body weight. After the BP measurement, a venous blood specimen was taken. Serum cholesterol was determined from the frozen samples by the Lieberman-Burchard method. All serum samples were analyzed in the same laboratory.
Information regarding smoking habits was obtained with a set of standardized questions in a self-administered questionnaire. Based on their responses, the participants were classified as current smokers (persons who had smoked regularly for at least 1 year and had smoked during the preceding month more than once a day on average) and nonsmokers. In the present study, ex-smokers who had not smoked during the previous 6 months were considered nonsmokers, and ex-smokers who had not smoked for less than 6 months were considered smokers.
Information regarding the presence of diabetes and antihypertensive drug treatment was also obtained on the questionnaire, which revealed that 143 men and 137 women reported that they had diabetes diagnosed by a physician. In addition, we had a unique opportunity to obtain data on diagnosed cases of diabetes during the follow-up. The questionnaire data were complemented with data from the National Social Insurance Institutions' register for those who had received free medication. In Finland, free medication can be granted to people after the diagnosis of certain chronic diseases, including diabetes mellitus. In the case of diabetes, at least 6 months of continuous drug treatment is required before an approval for free medication can be obtained. To apply for free medication, the patients must receive a certificate from the treating physician attesting that drug treatment needs to be continued. All subjects who had received an approval for free medication for diabetes from 1972 to 1990 in our cohort were identified through record linkage by a unique national identification number (229 men and 293 women). Thus, the total number of diabetic subjects in our cohort at the end of the follow-up was 372 men and 430 women.
Stroke mortality data were obtained from the Central Statistical Office of Finland. The 8th revision of the International Classification of Diseases, Injuries and Causes of Death was used in Finland from 1969 to 1986, and the 9th revision was adopted from the beginning of 1987. All cases with codes 430 through 438 as the underlying cause of death were considered stroke in the present analyses. The follow-up time of each subject in our present study was 20 years for the 1972 cohort and 15 years for the 1977 cohort. The number of stroke deaths was 95 among men and 71 among women during the follow-up.
Statistical Methods
ANCOVA was used to compare age-adjusted
means of total serum
cholesterol, BP, and BMI among nondiabetic and diabetic
subjects. To calculate the CIs for mortality from stroke during the
follow-up, we assumed the Poisson distribution among stroke deaths.
RRs were calculated with the Cox proportional hazards
model.16 The estimates of RRs and their 95% CIs were
based on this model. The end point of the follow-up was the time of
stroke death. All analyses were adjusted for age and study
year. Smoking, serum cholesterol, systolic BP,
antihypertensive drug treatment, and BMI were included in the model to
assess their effect on diabetes-associated stroke mortality.
Furthermore, first-level interactions were tested for all
explanatory variables. The associations of smoking, serum
cholesterol, BP, antihypertensive drug treatment, and BMI
with death from stroke among nondiabetic and diabetic subjects were
first analyzed separately for men and women and then among the
entire cohort, with adjustments for sex. The population attributable
risk (PAR) was calculated according to the formula17
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where E is the ratio of the exposed population to the entire study population.
Statistical analyses were performed with the use of SAS statistical software.
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Results |
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TopAbstractIntroductionSubjects and Methods Results Discussion References |
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The main characteristics of both men and women at the initial screening visit are presented in Table 1
. Men
and women were of similar age and had similar levels of serum
cholesterol and systolic BP. The prevalence of
diabetes and hypertension was similar among both men and women, while
more women (11.4%) than men (7.0%) were under antihypertensive drug
treatment. Women had a somewhat higher BMI than men. The proportion of
smokers was much higher among men than women.
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Men with diabetes were 4 years older and women 6 years older than the nondiabetic cohort. After we adjusted for age, in both men and women the mean values of systolic BP, diastolic BP, and BMI were significantly higher in diabetic than in nondiabetic subjects, while the differences in serum total cholesterol and the proportion of cigarette smokers were not significant. The prevalence of hypertension in diabetic subjects was almost twice as high as in nondiabetic subjects. Antihypertensive drug treatment was twice as common in diabetic women (37.2%) as in diabetic men (19.1%).
Both men and women who died from stroke had higher systolic and
diastolic BPs and were more obese than those who died from
other causes or were alive at the end of follow-up (Table 2).
The prevalence of diabetes was twice as high in men
who died from stroke as in men who were alive at the end of
follow-up. Among women who died from stroke, the prevalence of
diabetes was almost three times higher than among those who died from
other causes and more than eight times higher than among those who were
alive at the end of follow-up. Smoking and antihypertensive drug
treatment were more prevalent among both men and women and the serum
cholesterol level was higher among men who died from stroke
than those who were alive at the end of follow-up.
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After adjustment for age and survey year, diabetes mellitus was the
strongest risk factor for death from stroke among both men and women:
the RR estimates were 3.8 and 6.0 (P<.001), respectively
(Table 3). Among both men and women, systolic BP
(P<.001; RR estimates, 1.03 and 1.02, respectively),
diastolic BP (P<.001; RR estimates, 1.04 for
both men and women), and antihypertensive drug treatment
(P<.01; RR estimates, 2.05 and 2.26, respectively) were
strongly associated with the risk of death from stroke. Serum
cholesterol was associated with an increased risk of death
from stroke among men (RR, 1.24; P=.006), and BMI was
associated with an increased risk of death among women (RR, 1.06;
P=.02). Female smokers were at a 1.8-fold increased risk of
death from stroke. In the overall analysis after adjustment for
sex, smokers appeared to be at a 1.5-fold increased risk of death from
stroke (P=.03). Overweight was also positively associated
with the risk of stroke (RR, 1.05; P=.003).
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In the multivariate analysis, diabetes remained
strongly associated with the risk of stroke. RR estimates were 3.4 and
4.9 in men and women, respectively (Table 3
). The risk of death
from
stroke was twice as high in men as in women. Age, smoking, and
systolic BP also appeared to be independent risk factors for
death from stroke among both men and women. In addition, serum total
cholesterol was an independent risk factor for death from
stroke among men. Serum total cholesterol level among women
and BMI and antihypertensive drug treatment among both men and women
failed to be associated with the risk of stroke in the
multivariate analysis.
Since our diabetic cohort comprised both persons who had diabetes mellitus at the time of the initial survey and those who developed diabetes during the follow-up, we also included data on diagnosis of diabetes (before or after the surveys) in the model. In this model men with diabetes at baseline appeared to be at a sixfold increased risk of death from stroke (95% CI, 3.2 to 11.4; P<.001), while for men who developed diabetes later the RR was clearly lower, 1.7 (95% CI, 0.76 to 3.82; P=.2). Also, women who were diabetic at baseline were at a slightly higher risk of stroke (RR, 8.24; 95% CI, 4.02 to 16.87; P<.001) than women who developed diabetes later (RR, 3.68; 95% CI, 1.91 to 7.07; P<.001).
Among diabetic men, 19 deaths from stroke were found during the average 16.4-year follow-up period. The risk of stroke death was 29.6/10 000 person-years (95% CI, 12.4 to 65.6) compared with 76 deaths or the risk of 7.4/10 000 person-years (95% CI, 5.1 to 10.6) among men without diabetes. The number of deaths from stroke among diabetic women was 26, corresponding to 30.9/10 000 person-years (95% CI, 13.0 to 69.9), compared with 45 stroke deaths or 3.6/10 000 person-years (95% CI, 2.4 to 5.6) in nondiabetic women.
To investigate which factors were independently associated with the
risk of death from stroke among diabetic and nondiabetic subjects
separately, multivariate analyses were
performed stratified for diabetes (Table 4). In diabetic
men only age remained as an independent predictor of stroke death, and
in diabetic women none of the other risk factors in the model predicted
stroke death. In nondiabetic subjects, age, smoking, and
systolic BP were independently and significantly associated
with an increased risk of death from stroke. Nevertheless, differences
between RR estimates in diabetic and nondiabetic subjects were not
statistically significant. There was no evidence for an interaction
between diabetes and smoking, between diabetes and serum total
cholesterol, between diabetes and BMI, or between diabetes
and systolic BP. The population attributable risk of stroke
related to diabetes was 23.4%. We found that 16.1% of stroke deaths
among men and 33.3% of stroke deaths among women could be attributed
to diabetes.
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Discussion |
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TopAbstractIntroductionSubjects and Methods Results Discussion References |
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Our results show that diabetes is a strong and independent risk factor for death from stroke among both men and women. The RR associated with diabetes was higher than that of systolic BP, serum total cholesterol, and cigarette smoking. Our findings also suggest that hypertension and smoking are important predictors of stroke mortality in persons with and without diabetes.
In earlier prospective studies, investigators determined the risk of stroke using different ways to determine diabetes status in their study subjects (eg, history, drug therapy, fasting blood glucose). Furthermore, the baseline assessments were usually performed a long time before the stroke event occurred. Since the prevalence of diabetes steeply increases with age and since the study cohort of middle-aged subjects is aging during the follow-up, it is likely that many diabetic subjects are diagnosed during the follow-up rather than at baseline. That leads to a misclassification problem, ie, false-negatives that will dilute the possible effect of the risk factor in the analyses. In our study, in contrast to most other studies, we were able to use two sources of ascertainment of diabetic subjects. In addition to self-reported diabetes at the time of the screening, data from the National Social Insurance Institution regarding approval for diabetic drug treatment were used. Thus, a subject starting drug therapy for diabetes was considered diabetic at the time of the screening survey.
There is good evidence showing that the onset of non-insulin-dependent diabetes may actually occur 9 to 12 years before its clinical diagnosis.18 Our method of ascertainment of diabetic subjects allowed us to compose the diabetic cohort more accurately than in most other studies. The prevalence of diabetes in our study cohort, 4.8% of the study population, is well in agreement with the prevalence of diabetes mellitus in the Finnish population reported earlier.19
On the other hand, the main known risk factors for cardiovascular disease were screened before the clinical diagnosis of diabetes was made in 35% of the diabetic cohort. It has been shown that the risk of cardiovascular disease is already increased before the onset of non-insulin-dependent diabetes.20 21 The Honolulu Heart Program showed that impaired glucose tolerance was strongly associated with an increased risk of thromboembolic stroke.22 In our study, subjects who developed diabetes after the survey appeared to be at an increased risk of death from stroke, although the risk was less than in subjects who were diabetic at baseline. This difference may be partly explained by a relatively small number of deaths from stroke that occurred among the group of diabetic persons diagnosed during the follow-up. The main reason, however, may be the difference in the duration of diabetes. Previous studies have clearly shown that the risk of cerebrovascular complications increases linearly with the duration of clinical diabetes.23 Our data also suggest that the duration of diabetes is an important factor contributing to the risk of stroke.
The number of diabetic subjects in our cohort was not small if compared with most of other known studies6 7 8 24 except the Multiple Risk Factor Intervention Trial, in which more than 300 000 men were screened at the initial screening and more than 5000 of them reported themselves as diabetic.9 Our finding that diabetes is a strong and independent predictor of death from stroke is in agreement with the findings from the Multiple Risk Factor Intervention Trial and other studies.7 8 9 There were no significant differences between RR estimates for different risk factors in diabetic and nondiabetic subjects. This is in agreement with results from the Multiple Risk Factor Intervention Trial, which found serum cholesterol, systolic BP, and cigarette smoking to be significant, strong, and independent predictors of stroke mortality in men with and without diabetes.9
In our study we did not find evidence for an interaction between BMI, diabetes, and systolic BP. There were neither additive nor multiplicative effects between diabetes and other cardiovascular disease risk factors. This was somewhat surprising since the average BP level in diabetic subjects was much higher than in nondiabetic subjects. It is possible that some of the increased risk of stroke in hypertensive subjects is not related to BP itself but to a glucose abnormality, which is a relatively common correlate of hypertension.25 26 This issue has not received much attention previously. On the contrary, it has been commonly believed that the increased risk of stroke in diabetic patients is mainly due to high BP.27 28 29 Unfortunately, we have no data on glucose intolerance in our surveys performed in the 1970s since it was not customary to perform an oral glucose tolerance test in cardiovascular risk factors surveys at that time. Therefore, milder cases of diabetes and glucose intolerance could not be detected in the subgroup we classified as nondiabetic in our cohort.
It is possible that some of the effect of hypertension on the risk of stroke also can be attributed to glucose intolerance rather than BP. It has been shown that diabetes results in an increased permeability of vessel walls, particularly in patients with proteinuria or microalbuminuria.30 Microalbuminuria is an independent determinant of coronary heart disease in diabetic subjects.31 32 With the same mechanism, diabetes may cause cerebrovascular disease as well.
Antihypertensive drug treatment was not found to be independently associated with increased risk of death from stroke in either the diabetic or the nondiabetic cohort. Several antihypertensive drugs have been shown to have adverse effects on glucose control and lipid levels.33 34 35 Whether these metabolic abnormalities associated with antihypertensive drug treatment increase the risk of cardiovascular diseases is under debate. In this study we were unable to evaluate the effects of different treatments for hypertension on the risk of stroke because the type of drug was not recorded during the risk factor surveys. Nevertheless, a recent study demonstrated that there may not be any possible advantage of a particular antihypertensive drug over other such drugs in terms of worsening glucose control.36 Effective antihypertensive drug treatment seems to reduce the risk of stroke similarly in both diabetic and nondiabetic subjects.37
In addition, our present findings confirmed that cigarette smoking is an independent risk factor for stroke, as shown in earlier studies.38 39 40 41 The effect of smoking on risk of death from stroke was more pronounced in nondiabetic than diabetic subjects and in the entire cohort. This may be the reason why some earlier studies failed to detect an association between smoking and stroke.3 42
The association between risk factors and stroke mortality, especially in diabetic subjects, may be underestimated because of other causes of death, particularly deaths from coronary heart disease, which generally occur earlier in life and with a greater frequency than deaths from stroke43 44 45 46 and also share some common risk factors with stroke.47 Finnish Stroke Register data show that approximately 20% of stroke patients suffered an acute myocardial infarction before an acute stroke (unpublished data).
In conclusion, diabetic subjects have a very high risk of death from stroke. More than one fifth of stroke deaths in the population can be attributed to diabetes, more in women than in men. Diabetes should be taken into account when the stroke risk profile of a population is analyzed. Among both diabetic and nondiabetic subjects, all the known risk factors for cardiovascular disease should be the target of primary prevention of stroke.
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Selected Abbreviations and Acronyms |
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Received May 2, 1995; revision received August 25, 1995; accepted October 27, 1995.
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G. Hu, P. Jousilahti, S. Bidel, R. Antikainen, and J. Tuomilehto Type 2 Diabetes and the Risk of Parkinson's Disease Diabetes Care, April 1, 2007; 30(4): 842 - 847. [Abstract] [Full Text] [PDF]
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 N. Cheung, S. Rogers, D. J. Couper, R. Klein, A. R. Sharrett, and T. Y. Wong Is Diabetic Retinopathy an Independent Risk Factor For Ischemic Stroke? Stroke, February 1, 2007; 38(2): 398 - 401. [Abstract] [Full Text] [PDF]
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 Authors/Task Force Members, L. Ryden, E. Standl, M. Bartnik, G. Van den Berghe, J. Betteridge, M.-J. de Boer, F. Cosentino, B. Jonsson, M. Laakso, et al. Guidelines on diabetes, pre-diabetes, and cardiovascular diseases: executive summary: The Task Force on Diabetes and Cardiovascular Diseases of the European Society of Cardiology (ESC) and of the European Association for the Study of Diabetes (EASD) Eur. Heart J., January 1, 2007; 28(1): 88 - 136. [Full Text] [PDF]
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P. Harmsen, G. Lappas, A. Rosengren, and L. Wilhelmsen Long-Term Risk Factors for Stroke: Twenty-Eight Years of Follow-Up of 7457 Middle-Aged Men in Goteborg, Sweden Stroke, July 1, 2006; 37(7): 1663 - 1667. [Abstract] [Full Text] [PDF]
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K. Matz, K. Keresztes, C. Tatschl, M. Nowotny, A. Dachenhausen, M. Brainin, and J. Tuomilehto Disorders of Glucose Metabolism in Acute Stroke Patients: An underrecognized problem Diabetes Care, April 1, 2006; 29(4): 792 - 797. [Abstract] [Full Text] [PDF]
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G. Hu, C. Sarti, P. Jousilahti, M. Peltonen, Q. Qiao, R. Antikainen, and J. Tuomilehto The Impact of History of Hypertension and Type 2 Diabetes at Baseline on the Incidence of Stroke and Stroke Mortality Stroke, December 1, 2005; 36(12): 2538 - 2543. [Abstract] [Full Text] [PDF]
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 E. J. Diamantopoulos, V. G. Athyros, G. K. Yfanti, E. N. Migdalis, M. Elisaf, P. E. Vardas, A. S. Manolis, D. T. Karamitsos, E. S. Ganotakis, D. Hatseras, et al. The contrOL of dYslipideMia in outPatIent clinics in GreeCe (Olympic) Study Angiology, November 1, 2005; 56(6): 731 - 741. [Abstract] [PDF]
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 A. M. Kanaya, D. Herrington, E. Vittinghoff, F. Lin, V. Bittner, J. A. Cauley, S. Hulley, and E. Barrett-Connor Impaired Fasting Glucose and Cardiovascular Outcomes in Postmenopausal Women with Coronary Artery Disease Ann Intern Med, May 17, 2005; 142(10): 813 - 820. [Abstract] [Full Text] [PDF]
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B. M. Kissela, J. Khoury, D. Kleindorfer, D. Woo, A. Schneider, K. Alwell, R. Miller, I. Ewing, C. J. Moomaw, J. P. Szaflarski, et al. Epidemiology of Ischemic Stroke in Patients With Diabetes: The Greater Cincinnati/Northern Kentucky Stroke Study Diabetes Care, February 1, 2005; 28(2): 355 - 359. [Abstract] [Full Text] [PDF]
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D. Tanne, N. Koren-Morag, and U. Goldbourt Fasting Plasma Glucose and Risk of Incident Ischemic Stroke or Transient Ischemic Attacks: A Prospective Cohort Study Stroke, October 1, 2004; 35(10): 2351 - 2355. [Abstract] [Full Text] [PDF]
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T. Almdal, H. Scharling, J. S. Jensen, and H. Vestergaard The Independent Effect of Type 2 Diabetes Mellitus on Ischemic Heart Disease, Stroke, and Death: A Population-Based Study of 13 000 Men and Women With 20 Years of Follow-up Arch Intern Med, July 12, 2004; 164(13): 1422 - 1426. [Abstract] [Full Text] [PDF]
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 L. I. Solberg, J. R. Desai, P. J. O'Connor, D. B. Bishop, and H. M. Devlin Diabetic Patients Who Smoke: Are They Different? Ann. Fam. Med, January 1, 2004; 2(1): 26 - 32. [Abstract] [Full Text] [PDF]
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J. E. Ho, F. Paultre, and L. Mosca Is Diabetes Mellitus a Cardiovascular Disease Risk Equivalent for Fatal Stroke in Women?: Data From the Women's Pooling Project Stroke, December 1, 2003; 34(12): 2812 - 2816. [Abstract] [Full Text] [PDF]
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 T. F. Luscher, M. A. Creager, J. A. Beckman, and F. Cosentino Diabetes and Vascular Disease: Pathophysiology, Clinical Consequences, and Medical Therapy: Part II Circulation, September 30, 2003; 108(13): 1655 - 1661. [Full Text] [PDF]
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C. R.L. Cardoso, G. F. Salles, and W. Deccache QTc Interval Prolongation Is a Predictor of Future Strokes in Patients With Type 2 Diabetes Mellitus Stroke, September 1, 2003; 34(9): 2187 - 2194. [Abstract] [Full Text] [PDF]
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E.-L. Glader, B. Stegmayr, B. Norrving, A. Terent, K. Hulter-Asberg, P.-O. Wester, and K. Asplund Sex Differences in Management and Outcome After Stroke: A Swedish National Perspective Stroke, August 1, 2003; 34(8): 1970 - 1975. [Abstract] [Full Text] [PDF]
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S.-E. Megherbi, C. Milan, D. Minier, G. Couvreur, G.-V. Osseby, K. Tilling, A. Di Carlo, D. Inzitari, C. D.A. Wolfe, T. Moreau, et al. Association Between Diabetes and Stroke Subtype on Survival and Functional Outcome 3 Months After Stroke: Data From the European BIOMED Stroke Project Stroke, March 1, 2003; 34(3): 688 - 694. [Abstract] [Full Text] [PDF]
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Asia Pacific Cohort Studies Collaboration The Effects of Diabetes on the Risks of Major Cardiovascular Diseases and Death in the Asia-Pacific Region Diabetes Care, February 1, 2003; 26(2): 360 - 366. [Abstract] [Full Text] [PDF]
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 A. H. FRIEDLANDER, N. R. GARRETT, and D. C. NORMAN The prevalence of calcified carotid artery atheromas on the panoramic radiographs of patients with type 2 diabetes mellitus J Am Dent Assoc, November 1, 2002; 133(11): 1516 - 1523. [Abstract] [Full Text] [PDF]
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V. Kothari, R. J. Stevens, A. I. Adler, I. M. Stratton, S. E. Manley, H. A. Neil, and R. R. Holman UKPDS 60: Risk of Stroke in Type 2 Diabetes Estimated by the UK Prospective Diabetes Study Risk Engine Stroke, July 1, 2002; 33(7): 1776 - 1781. [Abstract] [Full Text] [PDF]
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 J. A. Beckman, M. A. Creager, and P. Libby Diabetes and Atherosclerosis: Epidemiology, Pathophysiology, and Management JAMA, May 15, 2002; 287(19): 2570 - 2581. [Abstract] [Full Text] [PDF]
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B. B. Worrall, K. C. Johnston, G. Kongable, E. Hung, D. Richardson, and P. B. Gorelick Stroke Risk Factor Profiles in African American Women: An Interim Report From the African-American Antiplatelet Stroke Prevention Study Stroke, April 1, 2002; 33(4): 913 - 919. [Abstract] [Full Text] [PDF]
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