Background: Diabetes is an established risk factor for stroke. Compared to nondiabetic patients, diabetic patients also have an increased risk of new vascular events and death after stroke. We analyzed how differences in long-term survival between diabetic and nondiabetic stroke patients have changed over time, and if differences varied with respect to sex and age. Methods: This population-based study included 12,375 first-ever stroke patients, 25–74 years old, who were registered in the Northern Sweden MONICA Stroke Registry 1985–2005. Uniform diagnostic criteria for stroke case ascertainment were used throughout the study period. The diagnosis of diabetes was based on medical records or diabetes diagnosed during the acute stroke event. Patients were separated into four cohorts according to year of stroke and followed for survival until August 30, 2008. Results: The diabetes prevalence at stroke onset was 21%, similar in men and women, and remained stable throughout the study period. The diabetic patients were an average of 2 years older, more often nonsmokers and more likely to have antihypertensive treatment, antithrombotics, atrial fibrillation, and a history of myocardial infarction or transient ischemic attack than the nondiabetic patients. The total follow-up time was 86,086 patient-years during which a total of 1,930 (75.7%) of the diabetic patients and 5,744 (58.5%) of the nondiabetic patients died (p < 0.001). Median survival was 60 months (95% CI: 57–64) in diabetic patients and 117 months (113–120) in the nondiabetic patients. Survival improved significantly in both groups (p < 0.001). A Cox regression, adjusting for possible confounders (age, sex, antihypertensive medication, antithrombotics or other thrombolytic agents, history of myocardial infarction, type of stroke, diabetes, cohort and the diabetes-by-sex, diabetes-by-age and diabetes-by-cohort interactions), showed a hazard ratio of 1.67 (1.58–1.76) comparing survival in diabetic versus nondiabetic patients. The reduced survival in diabetic stroke patients was more pronounced in women (p = 0.02) and younger patients (p < 0.001). There was a tendency that the difference in survival decreased between the earlier cohorts and the 2000–2005 cohort, but the test for interaction did not reach statistical significance (p = 0.08). Conclusion: Long-term survival after a first stroke has improved in both diabetic and nondiabetic patients. Survival is markedly lower in diabetics, especially in women and younger patients, and the disparity persisted over 24 years. Decreasing the disparity in stroke survival is a challenge for stroke and diabetes care. New treatment methods in combination with intense secondary prevention in diabetic patients, especially in younger women, are needed.

Air EL, Kissela BM: Diabetes, the metabolic syndrome, and ischemic stroke: epidemiology and possible mechanisms. Diabetes Care 2007;30:3131–3140.
Sander D, Sander S, Poppert H: Stroke in type 2 diabetes. Br J Diabetes Vasc Dis 2008;8:222–229.
Kissela BM, Khoury J, Kleindorfer D, Woo D, Schneider A, Alwell K, Miller R, Ewing I, Moomaw CJ, Szaflarski JP, Gebel J, Shukla R, Broderick JP: Epidemiology of ischemic stroke in patients with diabetes: the greater Cincinnati/Northern Kentucky Stroke Study. Diabetes Care 2005;28:355–359.
Registry of Causes of Death. Stockholm, National Board of Health and Welfare, 2011.
Andersen KK, Olsen TS: One-month to 10-year survival in the Copenhagen stroke study: interactions between stroke severity and other prognostic indicators. J Stroke Cerebrovasc Dis 2011;20:117–123.
Jia Q, Zhao X, Wang C, Wang Y, Yan Y, Li H, Zhong L, Liu L, Zheng H, Zhou Y: Diabetes and poor outcomes within 6 months after acute ischemic stroke: the China National Stroke Registry. Stroke 2011;42:2758–2762.
Rautio A, Eliasson M, Stegmayr B: Favorable trends in the incidence and outcome in stroke in nondiabetic and diabetic subjects: findings from the Northern Sweden MONICA Stroke Registry in 1985 to 2003. Stroke 2008;39:3137–3144.
Winell K, Paakkonen R, Pietila A, Reunanen A, Niemi M, Salomaa V: Prognosis of ischaemic stroke is improving similarly in patients with type 2 diabetes as in nondiabetic patients in Finland. Int J Stroke 2011;6:295–301.
Venketasubramanian N, Rother J, Bhatt DL, Pasquet B, Mas JL, Alberts MJ, Hill MD, Aichner F, Steg PG: Two-year vascular event rates in patients with symptomatic cerebrovascular disease: the REACH registry. Cerebrovasc Dis 2011;32:254–260.
Rønning OM, Stavem K: Predictors of mortality following acute stroke: a cohort study with 12 years of follow-up. J Stroke Cerebrovasc Dis 2010, E-pub ahead of print.
Kamalesh M, Shen J, Eckert GJ: Long term postischemic stroke mortality in diabetes: a veteran cohort analysis. Stroke 2008;39:2727–2731.
Stegmayr B, Lundberg V, Asplund K: The events registration and survey procedures in the Northern Sweden MONICA Project. Scand J Public Health Suppl 2003;61:9–17.
Tunstall-Pedoe H: The World Health Organization MONICA Project (monitoring trends and determinants in cardiovascular disease): a major international collaboration. WHO MONICA Project Principal Investigators. J Clin Epidemiol 1988;41:105–114.
Asplund K, Tuomilehto J, Stegmayr B, Wester PO, Tunstall-Pedoe H: Diagnostic criteria and quality control of the registration of stroke events in the MONICA project. Acta Med Scand Suppl 1988;728:26–39.
Eriksson M, Holmgren L, Janlert U, Jansson JH, Lundblad D, Stegmayr B, Soderberg S, Eliasson M: Large improvements in major cardiovascular risk factors in the population of northern Sweden: the MONICA study 1986–2009. J Intern Med 2011;269:219–231.
Counsell C, Dennis M: Systematic review of prognostic models in patients with acute stroke. Cerebrovasc Dis 2001;12:159–170.
Hallstrom B, Jonsson AC, Nerbrand C, Norrving B, Lindgren A: Stroke incidence and survival in the beginning of the 21st century in southern Sweden: comparisons with the late 20th century and projections into the future. Stroke 2008;39:10–15.
Peltonen M, Stegmayr B, Asplund K: Time trends in long-term survival after stroke: the Northern Sweden Multinational Monitoring of Trends and Determinants in Cardiovascular Disease (MONICA) study, 1985–1994. Stroke 1998;29:1358–1365.
Terent A: Trends in stroke incidence and 10-year survival in Soderhamn, Sweden, 1975–2001. Stroke 2003;34:1353–1358.
Mulnier HE, Seaman HE, Raleigh VS, Soedamah-Muthu SS, Colhoun HM, Lawrenson RA, De Vries CS: Risk of stroke in people with type 2 diabetes in the UK: a study using the General Practice Research Database. Diabetologia 2006;49:2859–2865.
Eliasson M, Jansson JH, Lundblad D, Naslund U: The disparity between long-term survival in patients with and without diabetes following a first myocardial infarction did not change between 1989 and 2006: an analysis of 6,776 patients in the Northern Sweden MONICA Study. Diabetologia 2011;54:2538–2543.
Nilsson PM, Cederholm J, Zethelius BR, Eliasson BR, Eeg-Olofsson K, Gudbjörnsdottir S: Trends in blood pressure control in patients with type 2 diabetes: data from the Swedish National Diabetes Register (NDR). Blood Press 2011;20:348–354.
Towfighi A, Markovic D, Ovbiagele B: Current national patterns of comorbid diabetes among acute ischemic stroke patients. Cerebrovasc Dis 2012;33:411–418.
Reeves MJ, Vaidya RS, Fonarow GC, Liang L, Smith EE, Matulonis R, Olson DM, Schwamm LH: Quality of care and outcomes in patients with diabetes hospitalized with ischemic stroke: findings from Get With the Guidelines-Stroke. Stroke 2010;41:e409–e417.
Eriksson M, Jonsson F, Appelros P, Asberg KH, Norrving B, Stegmayr B, Terent A, Asplund K: Dissemination of thrombolysis for acute ischemic stroke across a nation: experiences from the Swedish stroke register, 2003 to 2008. Stroke 2010;41:1115–1122.
Callahan A, Amarenco P, Goldstein LB, Sillesen H, Messig M, Samsa GP, Altafullah I, Ledbetter LY, MacLeod MJ, Scott R, Hennerici M, Zivin JA, Welch KM: Risk of stroke and cardiovascular events after ischemic stroke or transient ischemic attack in patients with type 2 diabetes or metabolic syndrome: secondary analysis of the Stroke Prevention by Aggressive Reduction in Cholesterol Levels (SPARCL) trial. Arch Neurol 2011;68:1245–1251.
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