Analysis of the Risk Factors for the Recurrence of Ischemic Stroke with Diabetes Mellitus and Establishment of Cox’s Regression Model and the Personal Prognosis Index in Two Years of Follow-Up


Ischemic Stroke
Recurrence Rate
Risk Factors
Type 2 Diabetes Mellitus
Cox Proportional Hazard Regression Model

How to Cite

An, Y.-C. . ., Wang , Y.-X. ., Jiang , Y.-R., Li , Y.-Z. ., Feng , J.-Y. ., Shi , S.-X. ., & Chen, J.-J. . (2020). Analysis of the Risk Factors for the Recurrence of Ischemic Stroke with Diabetes Mellitus and Establishment of Cox’s Regression Model and the Personal Prognosis Index in Two Years of Follow-Up. Iranian Red Crescent Medical Journal, 22(7). Retrieved from


Background: Ischemic stroke is a major cause of disability and mortality in patients with type 2 diabetes mellitus (T2DM), and diabetic stroke has a high recurrence rate.

Objectives: This prospective cohort study aimed at investigating the risk factors and establishing Cox’s regression model and per- sonal prognosis index for the recurrence of ischemic stroke at a two-year follow-up in T2DM patients.

Methods: T2DM patients with ischemic stroke, who were consecutively admitted to the Neurology Department of North China Uni- versity of Science and Technology Affiliated Hospital between January 1, 2015, and December 31, 2015, were retrospectively reviewed. These cases were followed up since the onset of ischemic stroke for 2 years. Univariate and multivariate Cox’s proportional haz- ard regression model was used to analyze risk factors associated with the recurrence rate. Thus, a recurrence model and personal prognosis index were set up.

Results: During the follow-up period, 44 cases relapsed. Furthermore, the 1-year recurrence rate was 16.48%, while the 2-year recur- rence rate was 24.18%. The univariate and multivariate Cox proportional hazard regression model revealed that the independent risk factors associated with recurrence were TOAST criteria (X1) (RR = 1.663; 95% CI = 1.015 - 2.760, P = 0.032), hypertension grade (X2) (RR = 1.897; 95% CI = 1.097 - 3.280, P = 0.022), duration of diabetes mellitus (X3) (RR = 1.151; 95% CI = 1.009 - 1.991, P = 0.039), total cholesterol (X4) (RR = 1.13; 95% CI = 1.006 - 1.876, P = 0.035), and Essen stroke risk score (ESRS) (X5) (RR = 2.055; 95% CI = 1.357 - 3.134, P = 0.001). The

personal prognosis index of the recurrence model was as follows: PI = 0.504 X1 + 0.640 X2 + 0.345 X3 + 0.759 X4 + 0.823 X5. Conclusions: TOAST criteria, hypertension grade, duration of diabetes mellitus, total cholesterol, and ESRS were the independent risk factors associated with the recurrence of ischemic stroke with diabetes mellitus. The recurrence model and personal prognosis index equation were successfully established.



  1. Chen R, Ovbiagele B, Feng W. Diabetes and Stroke: Epidemiology, Pathophysiology, Pharmaceuticals and Outcomes. Am J Med Sci. 2016;351(4):380-6. doi: 10.1016/j.amjms.2016.01.011. [PubMed: 27079344]. [PubMed Central: PMC5298897].
  2. Lau LH, Lew J, Borschmann K, Thijs V, Ekinci EI. Prevalence of diabetes and its effects on stroke outcomes: A meta-analysis and literature review. J Diabetes Investig. 2019;10(3):780-92. doi: 10.1111/jdi.12932. [PubMed: 30220102]. [PubMed Central: PMC6497593].
  3. Zhang XB, Mu YM, Li HM. Type 2 diabetes mellitus and Ischemic Stroke. Chin J Clinicians. 2015;12(9):473-6.
  4. Tun NN, Arunagirinathan G, Munshi SK, Pappachan JM. Diabetes mellitus and stroke: A clinical update. World J Diabetes. 2017;8(6):235-48. doi: 10.4239/wjd.v8.i6.235. [PubMed: 28694925]. [PubMed Central: PMC5483423].
  5. Wang Y, Liu M, Pu C. 2014 Chinese guidelines for secondary prevention of ischemic stroke and transient ischemic attack. Int J Stroke. 2017;12(3):302-20. doi: 10.1177/1747493017694391. [PubMed: 28381199].
  6. Jiang G, Li W, Wang D, Shen C, Ji Y, Zheng W. Epidemiological transition and distribution of stroke incidence in Tianjin, China, 1988-2010. Public Health. 2016;131:11-9. doi: 10.1016/j.puhe.2015.10.008. [PubMed: 26615461].
  7. Tao Y, Xu J, Song B, Xie X, Gu H, Liu Q, et al. Short-term blood pressure variability and long-term blood pressure variability: which one is a reliable predictor for recurrent stroke. J Hum Hypertens. 2017;31(9):568-73. doi: 10.1038/jhh.2017.32. [PubMed: 28447627].
  8. Lawrence M, Pringle J, Kerr S, Booth J. Stroke survivors' and family members' perspectives of multimodal lifestyle interventions for secondary prevention of stroke and transient ischemic attack: a qualitative review and meta-aggregation. Disabil Rehabil. 2016;38(1):11-21. doi: 10.3109/09638288.2015.1031831. [PubMed: 25858490].
  9. An YC, Chen YX, Wang YX, Zhao XJ, Wang Y, Zhang J, et al. Analysis of risk factors for recurrence of ischemic stroke and establishment of Cox's regression model. Chin J Epidemiol. 2011;32(8):816-20.
  10. Peng LM, Jiang XD. Recent advance in hyperglycemia after acute ischemic stroke. Chin J Neuromed. 2014;9(13):969-72.
  11. Yue W, Wu H, Shi ZH, Zhang YJ, Wang H, Li X, et al. Relationships between plasm a hom ocysteine leveland both recurrence and m ortality in patientswith acuteischem icstroke. Chin J Neuromed. 2016;7(15):654-9.
  12. Putaala J, Liebkind R, Gordin D, Thorn LM, Haapaniemi E, Forsblom C, et al. Diabetes mellitus and ischemic stroke in the young: clinical features and long-term prognosis. Neurology. 2011;76(21):1831-7. doi: 10.1212/WNL.0b013e31821cccc2. [PubMed: 21606455].
  13. Licata G, Tuttolomondo A, Pinto A. Association between diabetes and stroke subtype on survival and functional outcome 3 months after stroke: data from the European BIOMED Stroke Project. Stroke. 2004;35(3). author reply e61. e61. doi: 10.1161/01.STR.0000117968.13015.C4. [PubMed: 14976331].
  14. Ergul A, Kelly-Cobbs A, Abdalla M, Fagan SC. Cerebrovascular complications of diabetes: focus on stroke. Endocr Metab Immune Disord Drug Targets. 2012;12(2):148-58. doi: 10.2174/187153012800493477. [PubMed: 22236022]. [PubMed Central: PMC3741336].
  15. Tuttolomondo A, Pinto A, Salemi G, Di Raimondo D, Di Sciacca R, Fernandez P, et al. Diabetic and non-diabetic subjects with ischemic stroke: differences, subtype distribution and outcome. Nutr Metab Cardiovasc Dis. 2008;18(2):152-7. doi: 10.1016/j.numecd.2007.02.003. [PubMed: 17702553].
  16. Isabel C, Calvet D, Mas JL. Stroke prevention. Presse Med. 2016;45(12 Pt 2):e457-71. doi: 10.1016/j.lpm.2016.10.009. [PubMed: 27816341].
  17. Filipov A, Ebert AD, Neumaier-Probst E, Alonso A. The Burden of Diabetes and the Chance of a Previous Stroke: Thrombolysis for Recurrent Stroke in Diabetics. J Stroke Cerebrovasc Dis. 2018;27(5):1343-9. doi: 10.1016/j.jstrokecerebrovasdis.2017.12.027. [PubMed: 29395641].
  18. Wang IK, Lien LM, Lee JT, Liu CH, Chen CH, Lin CH, et al. Renal dysfunction increases the risk of recurrent stroke in patients with acute ischemic stroke. Atherosclerosis. 2018;277:15-20. doi: 10.1016/j.atherosclerosis.2018.07.033. [PubMed: 30170219].
  19. Zhuo Y, Yu H, Yang Z, Zee B, Lee J, Kuang L. Prediction Factors of Recurrent Stroke among Chinese Adults Using Retinal Vasculature Characteristics. J Stroke Cerebrovasc Dis. 2017;26(4):679-85. doi: 10.1016/j.jstrokecerebrovasdis.2017.01.020. [PubMed: 28233623].
  20. Petrie JR, Guzik TJ, Touyz RM. Diabetes, Hypertension, and Cardiovascular Disease: Clinical Insights and Vascular Mechanisms. Can J Cardiol. 2018;34(5):575-84. doi: 10.1016/j.cjca.2017.12.005. [PubMed: 29459239]. [PubMed Central: PMC5953551].
  21. Roberts CK, Hevener AL, Barnard R. Metabolic Syndrome and Insulin Resistance: Underlying Causes and Modification by Exercise Training. Compr Physiol. 2013;3(1):1-58. doi: 10.1002/cphy.c110062.
  22. Vallon V. The proximal tubule in the pathophysiology of the diabetic kidney. Am J Physiol Regul Integr Comp Physiol. 2011;300(5):R1009-22. doi: 10.1152/ajpregu.00809.2010. [PubMed: 21228342]. [PubMed Central: PMC3094037].
  23. Rask-Madsen C, King GL. Vascular complications of diabetes: mechanisms of injury and protective factors. Cell Metab. 2013;17(1):20-33. doi: 10.1016/j.cmet.2012.11.012. [PubMed: 23312281]. [PubMed Central: PMC3546345].
  24. Tanaka R, Yamashiro K, Okuma Y, Shimura H, Nakamura S, Ueno Y, et al. Effects of Pioglitazone for Secondary Stroke Prevention in Patients with Impaired Glucose Tolerance and Newly Diagnosed Diabetes: The J-SPIRIT Study. J Atheroscler Thromb. 2015;22(12):1305-16. doi: 10.5551/jat.30007. [PubMed: 26269002].
  25. Lavie CJ, Milani RV, O'Keefe JH. Lipid intervention in diabetes, metabolic syndrome and beyond. Int J Cardiol. 2018;268:200-1. doi: 10.1016/j.ijcard.2018.05.035. [PubMed: 30041786].
  26. Sondergaard E, Johansen RF, Jensen MD, Nielsen S. Postprandial VLDL-TG metabolism in type 2 diabetes. Metabolism. 2017;75:25-35. doi: 10.1016/j.metabol.2017.07.002. [PubMed: 28964326].
  27. Cholesterol Treatment Trialists' (CTT) Collaborators;, Kearney PM, Blackwell L, Collins R, Keech A, Simes J, et al. Efficacy of cholesterol-lowering therapy in 18686 people with diabetes in 14 randomised trials of statins: a meta-analysis. The Lancet. 2008;371(9607):117-25. doi: 10.1016/s0140-6736(08)60104-x.
  28. Sposato LA, Salutto V, Beratti DE, Monti P, Riccio PM, Mazia C. Adverse outcome of early recurrent ischemic stroke secondary to atrial fibrillation after repeated systemic thrombolysis. Case Rep Vasc Med. 2013;2013:371642. doi: 10.1155/2013/371642. [PubMed: 23984177]. [PubMed Central: PMC3748420].
  29. Pineda E, McNeal C, Liao I, Godley P. Prevalence of Diabetes and Statin Treatment in Youth. Journal of Clinical Lipidology. 2018;12(2):519-21. doi: 10.1016/j.jacl.2018.03.008.
  30. Maki KC, Dicklin MR, Baum SJ. Statins and diabetes. Cardiol Clin. 2015;33(2):233-43. doi: 10.1016/j.ccl.2015.02.004. [PubMed: 25939296].