Journal of the Arab Board of Health Specializations Vol.

11, No 4, 2010

Original Article ‫مقال أصيل‬

The prevalence of metabolic syndrome in patients with stroke

‫انتشار المتالزمة األيضية لدى مرضى السكتة الدماغية‬
Mohammed Bamashmoos, MD; Kalid Alagbary, MD; Faizaa Asker, MD
‫ فايزة عسكر‬.‫ د‬،‫ خالد األغبري‬.‫ د‬،‫ محمد بامشموس‬.‫د‬
‫ملخص البحث‬

‫ تهدف هذه الدراسة إلى تحديد انتشار المتالزمة األيضية والعوامل اإلنذارية المرافقة لها عند مرضى السكتة الدماغية الحادة المقبولين‬:‫هدف البحث‬
.‫في مشفى الكويت الجامعي في مدينة صنعاء في اليمن‬
‫ تم‬.)2010-2009( ‫ مريضاً من المشخصين حديثاً بالسكتة الدماغية الحادة خالل الفترة بين عامي‬331 ‫ شملت هذه الدراسة المقطعية‬:‫طرق البحث‬
.)NCEP-ATPIII( ‫ معايير سلم معالجة البالغين الثالث‬-‫اعتماد تعريف المتالزمة األيضية تبعاً لبرنامج الكولسترول الوطني التثقيفي‬
‫ شكل ارتفاع‬.‫ كما لوحظ تأثر أكبر للذكور بهذه المتالزمة مقارن ًة باإلناث‬،%39.5 ‫ بلغت نسبة انتشار المتالزمة األيضية في هذه الدراسة‬:‫النتائج‬
‫ بينما احتلت البدانة المركزية المرتبة األخيرة‬،‫التوتر الشرياني أكثر العوامل اإلمراضية المرافقة عند مرضى السكتة الدماغية المصابين بالمتالزمة األيضية‬
.‫كعامل مرافق‬
‫ أو إلى‬،‫ تظهر هذه الدراسة شيوع المتالزمة األيضية عند مرضى السكتة الدماغية وهو ما يعزى إلى دور المتالزمة األيضية بحد ذاتها‬:‫االستنتاجات‬
.‫العوامل اإلمراضية األخرى المرافقة لها‬

ABSTRACT Conclusions: We conclude that metabolic syndrome

Objective: The objective of the study were to determine was common in stroke patients which could be explained
the prevalence and identify the associated and prognostic by metabolic syndrome perse or due to different
factors that influence the risk of metabolic syndrome metabolic co morbidities that are associated with it.
among patients with acute stroke admitted to medical
department in AL-kuwait University Hospital(KUH) in Introduction
Sanaa city, Yemen.
Methods: The study population of this cross sectional Several studies showed high prevalence of the
survey consisted of 331 patients recently diagnosed metabolic syndrome in different high risk populations,1,2
with acute stroke in the period between (2009-2010). but the magnitude of the metabolic syndrome MS
Metabolic syndrome was defined according to the becomes apparent when in an apparently healthy
National Cholesterol Education Program–Adult population prevalence of nearly 24% is found.3 In our
Treatment Panel III (NCEP –ATP III) criteria country there is no study dealing with the prevalence of
Results: The prevalence of metabolic syndrome in metabolic syndrome in acute stroke patients, therefore
our study was 39.5% males was more frequently affected we decided to start this study in Al-Kuwait University
than females. Hypertension was the most metabolic Hospital (KUH) in Sanaa City aiming to provide more
comorbidities in stroke patients with metabolic syndrome information about the prevalence of MS and other
while central obesity is the least. associated risk factors in patients with acute stroke.
*Mohammed Bamashmoos, MD, Assistant Professor of Internal Medicine, Sana'a University, Sana'a, Yemen. E-mail: [email protected].
*Kalid Alagbary, MD, Assistant Professor of Internal Medicine, Sana'a University, Sana'a, Yemen.
*Faizaa Asker, MD, Arab Board.

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 Journal of the Arab Board of Health Specializations Vol.11, No 4, 2010

The presence of metabolic syndrome has been asso- hyperlipedemia (high TG, low HDL, high LDL),
ciated with an increased risk of prevalent stroke in the smoking and ischaemic heart disease was also recorded.
existing literature. In the National Health and Nutrition Hypertension was defined as a previous record of at
Examination survey among 10357 subjects,4 the preva- least two blood pressure reading of ≥130/85mmHg.
lence of metabolic syndrome was significantly higher Hyperlipedemia was defined as serum TG ≥150 mg/
in persons with self reported history of stroke (43.5%) dl, Low HDL ≤40 mg/dl in males and ≤50 mg/dl in
than in subjects with no history of vascular disease females.
(22.8%).
Waist circumference was measured with a tap measure
Metabolic syndrome was independently associated mid way between lower rib margin and the iliac crest.
with stroke history in all ethnic groups and in both sexes
(OR, 2.16 ;95% CI, 1.48 to 3.160).5 The association Blood pressure was measured in the right arm of
between metabolic syndrome and stroke has been seated subjects using mercury sphygmomanometer
confirmed in other populations integrated by elderly after 10-15 minutes of rest. Each subject had two
subjects, and the frequency of metabolic syndrome has measurements of blood pressure at 5-minutes. interval.
been reported to be significantly higher in patients with Venous blood sampling was performed in the morning
a history of atherothrombotic or non embolic ischemic after an overnight fast for determination of fasting plasma
stroke.5-6 glucose, triglyceride, and high density lipoprotein.

METHODS Metabolic syndrome was diagnosed according to the

NCEP-ATP 111(4) as the presence of three or more of
The sampling frame of this study included all nationals the following five criteria:
and non-national patients who were admitted with acute
stroke to Al-Kuwait University Hospital (KUH) medical - Waist circumference ≥103 cm in males, or ≥88 in
departments in Sana'a city. The diagnosis of acute females.
stroke was defined as rapidly developing clinical signs - Blood pressure ≥130/85 mmHg.
of focal or global disturbance of cerebral function of - Triglycerides ≥150 mg/dl.
presumed vascular origin lasting more than 24 hours. - High density lipoprotein ≤40 mg/dl in males or ≤50
mg/dl in females.
In total, 400 patients were approached by the authors - Fasting blood sugar ≥110 mg/dl.
out of which 331 (82.7%) patients agreed to enroll. The The results were expressed a s mean±SD. Statistical
study was approved by the Joint Ethics Committee of analysis were performed using the statistical package
the Faculty of Medicine and Health Sciences of Sanaa for the social sciences (window version 11.0; SPSS inc,
University. The data were collected between May 2009 Chicago IL USA). Differences between groups were
and May 2010. tested statistically using the Chi square test. Data were
considered statistically significant when the p-value
Data collection was ≤0.05.
After receiving a prior informed consent (a written
one from literate patients and a verbally informed one RESULTS
from illiterate patients), a standardised data sheet was
used to record the demographic variables including age, We studied 331 consecutive acute stroke patients, 211
sex and presence of DM. DM was defined as a fasting (63.7%) were males and 120 (36.2%) were females.
plasma glucose level of > 7.8 mmol/l, random plasma
glucose of > 11.1 mmol/l, or the requirement of regular There age ranges were between 35-78 years, mean
hypoglycaemic drug(s). History of hypertension, (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 The overall prevalence of the metabolic syndrome
(19.6%) had hemorrhagic stroke. was 39.5%, with prevalence of 54.9% in males and 45%
in females. However, there is no significant difference
Factors Male (211) Female (120) Total (331) in the prevalence of metabolic syndrome between males
Age, (years) 40-78 35-70
and females.
Smoking habit 85 (25%) 35 (10%) 120 (36%)
Stroke ischemic 171 (51.6%) 95 (28.7%) 266 (80.3%) The physical and metabolic characteristics of stroke
type hemorrhagic 40 (12%) 25 (7.5%) 65 (19.6%) patients with and without metabolic syndrome are
Type-2 DM 65 (19.6%) 43 (12.9%) 108 (32.6%) shown in Table 2.
IFG 15 (4.5%) 10 (3%) 25 (7.5%)
Waist circumference 31 (9.%) 39 (11.7%) 70 (21.1%) The main age for patients with metabolic syndrome
HTN 125 (37.7%) 59 (17.8%) 184 (55.5%) was (58.5±43) versus (55.3±21) for patients without
TG mg/dI 66 (19.9%) 37 (11%) 103 (31.1%) metabolic syndrome p=0.001, Also metabolic syndrome
HDL mg/dI 43 (12.9%) 45 (13.5%) 88 (26.5%)
with stroke was more prevalent in males.
Metabolic syndrom 72 (21.7%) 59 (17.8%) 131 (39.5%)
64.8% of patients with metabolic syndrome are
Table 1. Baseline characteristics of patients smokers versus 17.5% without metabolic syndrome
with stroke. (p=0.0001).

The base line characteristics of patients with stroke is There is no significant difference regarding the
shown in Table 1. prevalence of metabolic syndrome in patients with
either ischemic or hemorrhagic stroke (p=0.44).
It shows that the most important risks factor in most
patients was hypertension (55.5%) and metabolic Seventy seven percent (77%) of the stroke patients
syndrome (39.5%). with metabolic syndrome had raised blood pressure
versus 41.5% of patients without metabolic syndrome
Other traditional risk factors like smoking, type-2 (p-value=0.00001), while 74% of them had high
diabetes, obesity and dyslipidaemia (high TG, low FBS or type 2 DM versus 18% had normal FBS
HDL) was seen in a less proportion of patients. (p-value=0.00001), 53.4% had high serum TG versus

Factors All patients (331) With MS (131) Without MS (200) p-value

Age (years) 54±31 58.5±43 55.3±21 0.001
Male sex 211 (63.7%) 72 (54.9%) 139 (69.5%)
0.0071
Smoking 120 (36.2) 58 (64.8%) 35 (17.5%)
Type of ischemic 266 (80.3%) 108 (82.4%) 158 (79%) 0.44
stroke hemorrhagic 65 (19.6) 23 (17.5%) 42 (21%) 0.44
Type-2 DM 108 (32.6%) 82 (62.5%) 36 (18%) 0.00001
IFG 25 (7.5%) 8 (6%) 17 (8.5%) 0.02
Obesity 70 (21%) 52 (39.6%) 18 (9%) 0.0001
HTN 184 (55.5%) 101 (77%) 83 (41.5%) 0.00001
TG mg/dl 103 (31.1%) 70 (53.4%) 33 (16.5%) 0.0001
HDL mg/dl 88 (26.5%) 66 (50.3%) 22 (11%) 0.0001
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% elevated blood pressure or previously diagnosed
had low HDL cholesterol versus 11% had normal HDL hypertension has high prevalence in patients with stroke
cholesterol (p-value=0.0001). (68.9% and 68%) respectively.

The lowest prevalence of comorbidity in patients Rodriguez, et al11 found that all metabolic syndrome
with metabolic syndrome was obesity (39.6% VS 9%) components contributed to stroke risk, they found that
(p-value=0.0001). groups with elevated blood pressure or elevated blood
sugar were at greatest risk for stroke.
Discussion
Hypertension remain the most common modifiable
This study analyzes the prevalence of the metabolic risk factors for stroke in population including the
syndrome in stroke patients who attended the medical elderly.12,13,14
department in (KUH) using the NCPE panel III criteria
for definition of the metabolic syndrome.
Presence of hypertension as apart of metabolic
syndrome was associated with increased risk of acute
The result of this study provide valuable information
stroke. This association was high statistically significant
about the metabolic syndrome in patients with stroke.
in our study between stroke patients with and without
metabolic syndrome (p-value=0.00001).
The overall prevalence of the metabolic syndrome
among patients with stroke in the present study is 39.5%
Many researchers believe that insulin resistance is the
which is equal to that in other comparable studies in
patho physiological process underlining the clustering
stroke patients conducted in Italy 40% and 40% in
of vascular risk factors in the metabolic syndrome.15
Netherland.7,8 The similarity in the prevalence might
Indices of insulin resistance predict atherosclerosis
be due to the same definition used for the criteria of
and vascular events independently of other risk factors
metabolic syndrome in the different study population.
including fasting glucose and lipid levels.16
The increased prevalence of the metabolic syndrome
in patients with stroke may be explained by individual Current NCEP/ATP III guidelines used impaired
risk factors of the metabolic syndrome in association fasting glucose (>110 mg/dl or previously diagnosed
with other not routinely measured aspects of the type-2 diabetes as one of criterion for identifying
metabolic syndrome as impaired fibrinolysis oxidative subjects with metabolic syndrome, insulin resistance
stress, increased small dense LDL, hypercoagulability, with normal, impaired glucose tolerance or diabetes
inflammation and hyperinsulinemia.9 may play a role as risk factors for stroke.

Patients with stroke and metabolic syndrome were Dyslipidaemia is the hall mark of the metabolic
older than those without metabolic syndrome (mean syndrome. Its characterized by elevated TG and low
58.5±43 years). HDL cholesterol levels.17,18 In our analysis there is a
significant correlation between high TG and low HDL
The prevalence of individual metabolic comorbidities in stroke patients with and without metabolic syndrome.
of the metabolic syndrome in our study was high. There is controversy regarding the association between
Hypertension (77%) was the most common finding in serum TG levels and stroke.19 It has been shown that
our study. this was followed by the prevalence of type-2 postprandial hypertriglyceridemia is associated with
diabetes and IFG (74%), high TG (53.4), low HDL carotid artery atherosclerosis.20
50.3% and obesity 39.6%.

Similar finding was observed in the study by Chen Nonetheless, in the Copenhagen city heart study, a
et al in Taiwan,9 and by Arenilly et al in Spain10 where long linear association between serum TG 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 syndrome is associated with advanced vascular damage
of age and sex.21 in patients with coronary heart disease, stroke, peripheral
arterial disease or abdominal aortic aneurism. Eur Heart
In the majority of studies, there was inverse association J 2004;25:342-8.
between HDL–C and stroke.22,23 9. Chen H J, Bai HC, Yeh T, et al. Influence of metabolic
syndrome and general obesity on the risk of ischemic
stroke Stroke 2006;37:1060-4.
There is evidence that excess body weight is a 10. Arenillas FJ, Sandoval P, Perez N, et al. The metabolic
predictor of stroke (total, ischemic, hemorrhagic) in syndrome is associated with higher resistance to
men.23 Even though obesity is regarded as modifiable intravenous thrombolysis for acute ischemic stroke in
risk factor for vascular disease, high value of waist women than men. Stroke 2009;40:344-9.
circumference increases the risk for stroke in 20 years 11. Rodriguez SM, Mo J, Duan Y, et al. Metabolic
syndrome clusters and the risk of incid ent stroke: The
old men but not in women. atherosclerosis risk in communities (ARIC) study. Stroke
2009;40:200-5.
Conclusions 12. Seshari S, Woif PA, Beiser A, et al. Elevated midlife blood
pressure increase stroke risk in elderly persons. The
We conclude that metabolic syndrome was common Framingham study. Arch intern Med 2001:101:2343-56.
in stroke patients which could be explained by the 13. Bonita R. Epidemiology of stroke. Lancet
metabolic syndrome perse or due to different metabolic 1992;339:342-4.
co morbidities that are associated with it. 14. Haralampos J, Milionis MD, Rizos E. Components of
the metabolic syndrome and risk for first–ever acute
ischemic non embolic stroke. Stroke 2005;36:1372–6.
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