Admission blood glucose and in-hospital clinical outcome among patients with acute stroke in Inner Mongolia, China


Nil:


Ning Wang MPH1

Dawei Qiao MD2

Weijun Tong MD1

Fengshan Zhang MD2

Zhong Ju MD3

Tan Xu MD PhD1

Erdunchaolu Jin MD4

Huan Zhang MPH1

Yonghong Zhang MD PhD1


1 Department of Epidemiology, School of Radiation Medicine and Public Health, Medical College of Soochow University, Suzhou, China.

2 Department of Neurology , Tongliao Municipal Hospital, Tongliao, Inner Mongolia, China.

3 Department of Neurology , First Hospital of Kerqin District, Tongliao, Inner Mongolia, China.

4 Department of Neurology, Teaching Hospital of Inner Mongolia University for Nationality, Tongliao, Inner Mongolia, China.

 

Manuscript submitted 2nd December, 2008

Manuscript accepted 28th February, 2009

 

Clin Invest Med 2009; 32 (2): E151-E157.


Nil:


Abstract

Purpose: There is still controversy about the association between admission blood glucose concentration and outcome of acute stroke. We studied the association between admission blood glucose and in-hospital death / dependency among acute stroke patients in Inner Mongolia, China.

Methods: 2,178 acute ischemic and 1,760 hemorrhagic stroke patients in six hospitals were included in the study. Blood glucose and other study variables were collected within the first 24-hr of hospital admission. Clinical outcomes were evaluated by neurologists during hospitalization. The associations between admission blood glucose and the risk of in-hospital death/dependency were analyzed using a multiple logistic model.

Results: There were associations between admission blood glucose and in-hospital death/dependency among patients with acute ischemic or hemorrhagic stroke. Compared with patients with blood glucose<6.1mmol/L, multivariate-adjusted odds ratio (95% confidence interval) of death/dependency were 0.53 (0.23, 1.27), 2.22 (1.21, 4.11), 1.92 (1.12, 3.33) and 1.91 (1.00, 3.64) for ischemic stroke patients, and 0.93 (0.44, 1.96), 1.42 (0.65, 3.10), 1.98 (1.10, 3.55) and 2.93 (1.40, 6.11) for hemorrhagic stroke patients, with blood glucose 6.1-6.9, 7.0-7.7, 7.8-11.0 and ≥11.1mmol/L, respectively.

Conclusion: Increased admission blood glucose was associated with death/dependency among patients with acute hemorrhagic and ischemic stroke

 

 

Stroke is the leading cause of death and long-term disability worldwide.1 In China, Stroke is the third leading cause of death for males and the second for females .2 The incidence and proportion of hemorrhagic stroke, especially, is much higher in the Chinese population than in western populations.3 Diabetes mellitus is one of the most important risk factors for stroke4-6, 20% to 50% of acute stroke patients are hyperglycemic at presentation.7-9 Several studies have found a detrimental effect of acute hyperglycemia on outcome from ischemic and hemorrhagic stroke.10-14 Increased admission blood glucose (BG) concentrations in acute stroke have also been associated with longer in-hospital stay, increased cost, and mortality.12 There are also studies15-16 that did not find an association between admission BG level and outcome after the onset of stroke when adjusted for other confounding factors. Therefore, there is still controversy about the association between admission BG level and outcome.

Although stroke is a leading cause of death and disability in China, there is no data on the relationship between admission BG level and short term clinical outcome among acute stroke patients in the Chinese population. The purpose of the present study is to examine the association between admission BG level and clinical outcomes, including death and dependency among acute ischemic and hemorrhagic stroke patients in Inner Mongolia, China.

 

Methods

Study Participants

The study was approved by Soochow University School of Public Health and Radiation Medicine Ethics Committee. Acute stroke patients were recruited from 6 hospitals (Tongliao Municipal Hospital, Teaching Hospital of Inner Mongolia University For Nationality, Kezuohou Banner (County) Hospital, Kezuozhong Banner Hospital, Zalute Banner Hospital, and First Hospital of Kerqin District) in Tongliao, a prefecture-level city in eastern Inner Mongolia, China. Written informed consent was obtained for all study participants. The 6 hospitals are the only western medicine facilities in this region and serve a population of 2.04 million; most of whom are of Han or Mongolian ethnicity.  All patients with a clinical diagnosis of acute stroke admitted to the 6 hospitals from January 1, 2003 to December 31, 2005 were potentially eligible for the study. However, only those cases confirmed by a computed tomography (CT) scan or magnetic resonance imaging (MRI) were included. All subtypes of stroke, including ischemic stroke (thrombosis, embolism, or lacunar infarction) and hemorrhagic stroke (intracerebral hemorrhage or subarachnoid hemorrhage) were included in this study.  A team of investigators, including neurologists, reviewed the eligibility of study participants. Among 4,369 acute stroke patients admitted to the 6 hospitals during the study period, 3,938 had a CT scan or MRI confirming ischemic or hemorrhagic stroke and were included in this analysis. 431 patients were excluded from analysis because of a discharge diagnosis of transient ischemic attack or stroke of undetermined type (n=373) or lack of a CT scan or MRI test (n=58).

 

Data Collection

Baseline data were collected within the first 24-hr of hospital admission by in-person interview with patients or their family members, if patients were not able to communicate. Data on demographic characteristics, lifestyle risk factors, medical history, clinical laboratory tests, and imaging data (CT and MRI) were obtained using a standard questionnaire administered by trained staff. Cigarette smokers were defined as having smoked at least 1 cigarette per day for 1 year or more. The amount and type of alcohol consumed during the past year was collected. Alcohol consumption was defined as consuming one or more alcoholic drinks per day during the last year. Three BP measurements were taken within 30 min of admission while the study participants were in the supine position using a standard mercury sphygmomanometer according to a standard protocol.17

Blood glucose (BG) was measured using a modified hexokinase enzymatic method. Total cholesterol, HDL-cholesterol, and triglycerides were analyzed enzymatically on a Beckman Synchron CX5 Delta Clinical System (Beckman Coulter, Inc., Fullerton, CA, USA) using commercial reagents. LDL-cholesterol levels were calculated by use of the Friedewald equation for the participants.

The study outcomes included death and dependency during hospitalization. If a patient died in the hospital, a study staff member recorded the death on the event form and obtained the death certificate. If a patient survived the acute stroke, the study neurologists conducted a comprehensive clinical evaluation at discharge. Dependency was defined as moderate or severe disability using a Modified Rankin’s scale >2.18

 

Statistical Analysis

The mean and standard deviation of continuous variables and proportion of categorical variables at hospital admission were calculated for both ischemic and hemorrhagic strokes. Patients were grouped by stroke subtype and BG concentration (<6.1, 6.1-6.9, 7.0-7.7, 7.8-11.0, and ≥11.1 mmol/L). Multivariate logistic regression analysis was used to examine the association between BG and clinical outcome (death/dependency) adjusted for age, sex, ethnicity (Mongol vs. Han), education, alcohol consumption, cigarette smoking, physical activity, systolic blood pressure (SBP), diastolic blood pressure(DBP), history of hypertension, history of diabetes, and dyslipidemia. Statistical analysis were conducted using SAS statistical software (version 9.1; SAS Institute Inc, Cary, North Carolina, USA).

 

Results

2,178 ischemic stroke and 1,760 hemorrhagic stroke patients were included in our analysis. Table 1 presents the demographic and clinical characteristics by stroke subtypes of stroke patients at admission. Those with acute ischemic stroke were more likely to be older, smoke cigarettes and have a history of diabetes or dyslipidemia; whereas those with acute hemorrhagic stroke were more likely to be of Mongolian ethnicity, have a profession involving manual labour, have both a personal and family history of hypertension, and have higher SBP and DBP level, and have hyperglycemia. There was no difference in sex or alcohol consumption between patients with acute ischemic and hemorrhagic strokes.

The median time from onset of symptom to admission was 9.3 hr (11.1 hr for ischemic, 8.8 hr for hemorrhagic). The median duration of hospitalization was 7 days for ischemic stroke and 10 days for hemorrhagic stroke. 142 stroke patients (39 ischemic and 103 hemorrhagic) died during hospitalization and 1506 stroke patients (900 ischemic and 606 hemorrhagic) were disability on discharge. The in-hospital case-fatality rate was higher for acute hemorrhagic stroke (5.9%) than for acute ischemic stroke (1.8%).  However, the disability rate was higher for those with acute ischemic stroke (41.3%) than those with acute hemorrhagic stroke (34.4%). 

There was an association between BG on admission and death/dependency during hospitalization among patients with acute stroke (Table 2). Compared with those with BG<6.1mmol/L, multivariate-adjusted odds ratio (95% confidence interval) of death/dependency were 0.73 (0.42, 1.26), 1.84 (1.14, 2.97), 1.98 (1.34, 2.93), and 2.30 (1.42, 3.71), respectively, for patients with BG 6.1-6.9, 7.0-7.7, 7.8-11.0 and ≥11.1mmol/L. Furthermore, there was a positive association between BG on admission and death/dependency during hospitalization among ischemic or hemorrhagic stroke patients. Multivariate-adjusted odds ratio (95% confident interval) of death/dependency were 0.53 (0.23, 1.27), 2.22 (1.21, 4.12), 1.92 (1.12, 3.33) and 1.91 (1.00, 3.64), respectively, among ischemic stroke patients with BG 6.1-6.9, 7.0-7.7, 7.8-11.0 and ≥11.1 mmol/L. Multivariate-adjusted odds ratio (95% confidence interval) of death/dependency were 0.93 (0.44, 1.96), 1.42 (0.65, 3.10), 1.98 (1.11, 3.55) and 2.93 (1.40, 6.11), respectively, among hemorrhagic stroke patients with BG 6.1-6.9, 7.0-7.7, 7.8-11.0 and ≥11.1 mmol/L.

 

Discussion

The overall mortality of acute stroke patients during hospitalization in the present study was 3.6%. The mortality of ischemic stroke and hemorrhagic stroke was 1.8% and 5.9%, respectively, which was lower than that of other reports.15,19,20 Our study showed the disability rates of ischemic stroke and hemorrhagic stroke were 41.3% and 34.4%, respectively, which was consistent with that of other reports in China.21,22 We have discussed mortality and disability rates during hospitalization among ischemic and hemorrhagic stroke patients in a previous report.23 The purpose of this study is to examine the relationship between BG on admission and clinical outcome (death or dependency during hospitalization). We found that higher BG on admission correlated independently with clinical outcome during hospitalization among patients with acute ischemic or hemorrhagic stroke. For example, baseline BGs 7.0-7.7, 7.8-11.0 and ≥11.1mmol/L were associated with 1.84, 1.98 and 2.30-fold increase in the risk of death/dependency among acute stroke patients compared with BG <6.1mmol/L. We also found that the odds ratio of death /dependency associated with BG 7.0-7.7, 7.8-11.0 and ≥11.1mmol/L among ischemic stroke patients, and associated with 7.8-11.0 and ≥11.1mmol/L among hemorrhagic stroke patients were positive and significant. We have reported that BP on admission was associated with death/dependency during hospitalization among acute hemorrhagic stroke patients (but not acute ischemic stroke patients).23 Hence, in the present analysis, some factors including SBP/DBP were adjusted by using a multiple logistic model. These observational findings suggest that hyperglycemia on admission maybe predict the occurrence of poor outcome in short term for acute ischemic and hemorrhagic stroke patients. Our findings are consistent with previous reports20, 24 which demonstrated a positive association between hyperglycemia and poor outcome. A systematic review and meta-analysis by Capes25 showed that acute hyperglycemia predicted an increased risk of in-hospital mortality and poor functional recovery after onset of ischemic stroke in non-diabetic patients. Alvarez-Sabin26 showed that admission hyperglycemia was a powerful predictor of poor outcome in reperfused patients independently of possible confounders such as age, stroke severity, and diabetes mellitus. They believed that an elevated BG before reperfusion may partly counter-balance the beneficial effect of early restoration of blood flow, which lead to a lesser degree of neurological improvement, greater infarct size, and worse outcome in stroke patients. An MRI study27 demonstrated that elevated BG was associated with an increased progression of hypoperfused at-risk tissue to infarction and poor stroke outcome. Baird28 showed that persistent hyperglycemia on serial glucose monitoring was an independent determinant of infarct expansion and was associated with worse functional outcome. Two studies10,29 suggested that hyperglycemia might worsen the clinical outcome in non-lacunar stroke, but not in lacunar stroke during acute ischemic stroke. One of the latest studies30 found persistent hyperglycemia, hyperglycemia at baseline and at 24 hr was associated with poor outcomes in all the end points studied. A randomized trial31 demonstrated that lowering BG after onset improved long-term prognosis in diabetic patients with acute myocardial infarction. Pache’s study32 also suggested that lowering BG with a glucose–insulin–potassium infusion may exert a positive effect on myocardial salvage in diabetic patients with acute myocardial infarction. There is also a study33 showing that decreasing BG with glucose-insulin-potassium may also improve outcome in stroke patients. Our findings support the concept that acute stroke patients with hyperglycemia should be treated by lowering BG. We found that the effect of BG on death/dependency during hospitalization was different from BP among acute stroke patients. Elevated BP was associated only with the risk of death/dependency among hemorrhagic stroke patients, but not ischemic stroke.23 However, elevated BG was not only associated with the risk of death/dependency in hemorrhagic stroke patients, but also with ischemic stroke patients. Our findings imply that the mechanism of elevated BG increasing risk of poor outcome among acute stroke patients was different from elevated BP.

The mechanism of how hyperglycemia leads to poor outcome of stroke is currently unclear, but the findings of animal experiment34 support the conclusion that hyperglycemia could cause further brain injury. Both moderate and severe hyperglycemia have been shown to be associated with worsening of mitochondrial function in the ischemic penumbra.35 Parsons and his colleagues 27 suggested that acute hyperglycemia may increase brain lactate production and facilitate conversion of hypoperfused at-risk tissue into infarction, which might adversely affect stroke outcome. A rat experiment conducted by Shi et al37 showed hyperglycemia aggravated the cerebral injury of ischemia-reperfusion, perhaps by its effect of inducing neuron apoptosis.

In summary, our study found that increased BG was associated with death/dependency among acute patients with ischemic stroke and hemorrhagic stroke. Blood glucose should be controlled in acute stroke patients during hospitalization.

 

 

References

1.     WHO. Global Burden of Disease 2002: Deaths by age, sex and cause for the year 2002. Geneva, Switzerland: World Health Organization 2003.

2.     He J, Gu D, Wu X, et al. Major causes of death among men and women in China. N Engl J Med 2005; 353:1124-34.

3.     Zhang LF, Yang J, Hong Z, et al. Proportion of different subtypes of stroke in China. Stroke 2003;34:2091-6.

4.     Bartnik M, Malmberg K, Norhammar A, Tenerz A, Ohrvik J, Rydén L. Newly detected abnormal glucose tolerance: an important predictor of long-term outcome after myocardial infarction. Eur Heart J 2004;25:1990-7.

5.     Baird TA, Parsons MW, Barber PA, et al. The influence of diabetes mellitus and hyperglycaemia on stroke incidence and outcome. J Clin Neurosci 2002;9:618-26.

6.     Zhao JB, Zhang WY, Fang QW, Wang XH, Gao SY, Li TY. Case-control study on risk factors of cerebral hemorrhage. Chin J Public Health (Chinese) 2000;16:99-100.

7.     Toni D, Sacchetti ML, Argentino C, et al. Does hyperglycemia play a role in outcome of acute ischaemic stroke patients? J Neurol 1992;239:382–6.

8.     VanKooten F, Hoogerbrugge N, Naarding P, Kandstaal PJ. Hyperglycemia in the acute phase of stroke is not caused by stress. Stroke 1993;24:1129–32.

9.     Foulkes MA, Wolf PA, Price TR, Mohr JP, Hier DB. The Stroke Data Bank: design, methods, and baseline characteristics. Stroke 1988;19:547–54.

10.  Bruno A, Biller J, Adams HP Jr, et al. Acute blood glucose level and outcome from ischemic stoke. Trial of ORG 10172 in Acute Stroke Treatment (TOAST) Investigators. Neurology 1999;52:280–4. 

11.  Weir CJ, Murray GD, Dyker AG, Lees KR. Is hyperglycaemia an independent predictor of poor outcome after acute stroke? Results of a long-term follow up study. BMJ 1997;314:1303–6.

12.  Bruno A, Levine SR, Frankel MR, et al. Admission glucose level and clinical outcomes in the NINDS rt-PA Stroke Trial. Neurology 2002;59:669–74.

13.  Fogelholm R, Murros K, Rissanen A, Avikainen S. Admission blood glucose and short term survival in primary intracerebral haemorrhage: a population based study. J Neurol Neurosurg Psychiatry 2005;76:349-53.

14.  Kimura K, Iguchi Y, Inoue T, et al. Hyperglycemia independently increases the risk of early death in acute spontaneous intracerebral hemorrhage. J Neurol Sci 2007;255:90-4.

15.  Karagiannis A, Mikhailidis DP, Tziomalos K, et al. Serum uric acid as an independent predictor of early death after acute stroke. Circ J 2007;71:1120–7.

16.  Matchar DB, Divine GW, Heyman A, Feussner JR. The influence of hyperglycemia on outcome of cerebral infarction. Ann Intern Med 1992;117:449-56.

17.  Perloff D, Grim C, Flack J, et al. Human blood pressure determination by sphygmomanometry. Circulation 1993;88:2460-70.

18.  Bonita R, Beaglehole R. Recovery of motor function after stroke. Stroke 1988;19:1497-500.

19.  Feigin VL, Lawes CM, Bennett DA, Anderson CS. Stroke epidemiology: a review of population-based studies of incidence, prevalence, and case-fatality in the late 20th century. Lancet Neurol 2003;2:43-53.

20.  Wong KS. Risk factors for early death in acute ischemic stroke and intracerebral hemorrhage: a prospective hospital-based study in Asia. Asian Acute Stroke Advisory Panel. Stroke 1999;30:2326-30.

21.  CAST (Chinese Acute Stroke Trial) Collaborative Group. CAST: randomised placebo-controlled trial of early aspirin use in 20,000 patients with acute ischemic stroke. Lancet 1997;349:1641-9.

22.  Liu X, Lv Y, Wang B, Zhao G, Yan Y, Xu D. Prediction of functional outcome of ischemic stroke patients in northwest China. Clin Neurol Neurosurg 2007;109:571-7.

23.  Zhang YH, Reilly KH, Tong WJ, et al. Blood pressure and clinical outcome among patients with acute stroke in Inner Mongolia, China. J Hypertens 2008;26:1446-52.

24.  Paolino AS, Garner KM. Effects of hyperglycemia on neurologic outcome in stroke patients. J Neurosci Nurs 2005;37:130-5.

25.  Capes SE, Hunt D, Malmberg K, Pathak P, Gerstein HC. Stress hyperglycemia and prognosis of stroke in nondiabetic and diabetic patients: a systematic overview. Stroke 2001;32:2426-32.

26.  Alvarez-Sabín J, Molina CA, Montaner J, et al. Effects of admission hyperglycemia on stroke outcome in reperfused tissue plasminogen activator–treated patients. Stroke 2003;34:1235-41.

27.  Parsons MW, Barber PA, Desmond PM, et al. Acute hyperglycemia adversely affects stroke outcome: a magnetic resonance imaging and spectroscopy study. Ann Neurol 2002;52:20–8.

28.  Baird TA, Parsons MW, Phanh T, et al. Persistent poststroke hyperglycemia is independently associated with infarct expansion and worse clinical outcome. Stroke 2003;34:2208-14.

29.  Uyttenboogaart M, Koch MW, Stewart RE, Vroomen PC, Luijckx GJ, De Keyser J. Moderate hyperglycaemia is associated with favourable outcome in acute lacunar stroke. Brain 2007;130:1626-30.

30.  Yong M, Kaste M. Dynamic of hyperglycemia as a predictor of stroke outcome in the ECASS-trial. Stroke 2008;39:2749-55.

31.  Malmberg K, Rydén L, Efendic S, et al. Randomized trial of insulin-glucose infusion followed by subcutaneous insulin treatment in diabetic patients with acute myocardial infarction (DIGAMI study): effects on mortality at 1 year. J Am Coll Cardiol. 1995;26:57-65.

32.  Pache J, Kastrati A, Mehilli J, et al. A randomized evaluation of the effects of glucose insulin-potassium infusion on myocardial salvage in patients with acute myocardial infarction treated with reperfusion therapy. Am Heart J 2004;148:e3.

33.  Scott JF, Robinson GM, French JM, et al. Blood pressure response to glucose potassium,insulin therapy in patients with acute stroke with mild to moderate hyperglycaemia. J Neurol Neurosurg Psychiatry 2001,70:401-4.

34.  Song EC, Chu K, Jeong SW, et al, Hyperglycemia exacerbates brain edema and perihematomal cell death after intracerebral hemorrhage. Stroke 2003;34:2215-20.

35.  Anderson RE, Tan WK, Martin HS, Meyer FB. Effects of glucose and PaO2 modulation on cortical intracellular acidosis, NADH redoxstate, and infarction in the ischemic penumbra. Stroke 1999;30:160–70.

36.  Shi J, Zhang YD, Lin XJ, Dong JD. Effect of hyperglycemia and insulin intervention on the cerebral injury after ischemia-reperfusion in rats. J Clin Neurol (Chinese) 2007;20:284-7.

 

 

 

 

 

 

Correspondence to:

 

Yonghong Zhang, MD, PhD

Department of Epidemiology

School of Radiation Medicine and Public Health, Medical College of Soochow University

199 Renai Road, Dushu lake high education Area,

Suzhou, China.. 215123.

Email: yhzhang@suda.edu.cn

 

TABLE 1. Characteristics of stroke patients at hospital admission.

Characteristics

Ischemic

Hemorrhagic

N

2178

1760

AgeMean±SD)(yr

61.5±12.02

55.9±11.7

Male%

135162.0

105059.7

EthnicityMongolian)(%

51223.5

47326.9

Manual Labour Profession, n (%)

817 (37.5)

932 (53.0)

Hypertension%

1192(54.8)

1020(58.0)

Diabetes%

24611.3

382.2

Cigarette smoking%

528(22.2)

358(20.3)

Alcohol drinking%

449(20.6)

382(21.7)

Dyslipidemia*, n (%)

896 (67.5)

400 (62.7)

Family History Hypertension, n (%)

109 (5.0)

117 (6.6)

Hyperglycemia(≥6.1mmol/L)(%

68640.1

69255.0

SBPMean±SD(mmHg)

152.1±28.9

172.3±34.6

DBPMean±SD(mmHg)

92.0±16.8

103.9±19.5

Median time onset to admission (hr)

11.1

8.8

Median duration of hospitalization (d)

7

10

* Total cholesterol ≥200 mg/dL or LDL ≥130 mg/dL or HDL<40 mg/dL or triglyceride ≥150 mg/dL

 

TABLE 2. Odds ratio and 95% confidence intervals of clinical outcomes (death/dependency) associated with admission BG among acute stroke patients.

BG mmol/L

Unadjusted

Multivariate adjusteda

OR (95% CI)

P

OR (95% CI)

P

<6.1

1.00 (ref)

 

1.00 (ref)

 

6.1-6.9

0.76 (0.45, 1.29)

0.306

0.73 (0.42, 1.26)

0.252

7.0-7.7

1.98 (1.26, 3.12)

0.003

1.84 (1.14, 2.97)

0.013

7.8-11.0

2.26 (1,57, 3.25)

<0.001

1.98 (1.34, 2.93)

0.001

≥11.1

2.75 (1.77, 4.28)

<0.001

2.30 (1.42. 3.71)

0.001

aAdjusted for age, sex ethnicity (Mongol vs. Han), education, alcohol consumption, cigarette smoking, physical activity, SBP, DBP, history of hypertension, history of diabetes, and dyslipidemia.

 

TABLE 3. Odds ratio and 95% confidence intervals of clinical outcomes (death/dependency) associated with admission BG among acute patients with ischemic stroke and hemorrhagic stroke.

BG mmol/L

Unadjusted

Multivariate adjusteda

OR (95% CI)

P

OR (95% CI)

P

Ischemic Stroke

<6.1

1.00 (ref)

 

1.00 (ref)

 

6.1-6.9

0.51 (0.22, 1.19)

0.119

0.53 (0.23, 1.27)

0.154

7.0-7.7

2.22 (1.22, 4.05)

0.009

2.22 (1.21, 4.11)

0.010

7.8-11.0

1.95 (1.16, 3.30)

0.012

1.92 (1.12, 3.33)

0.018

≥11.1

2.00 (1.08, 3.71)

0.027

1.91 (1.00, 3.64)

0.050

Hemorrhagic Stroke

<6.1

1.00 (ref)

 

1.00 (ref)

 

6.1-6.9

1.07 (0.52, 2.19)

0.854

0.930.441.96

0.846

7.0-7.7

1.81 (0.89, 3.65)

0.100

1.420.653.10

0.383

7.8-11.0

2.63 (1.53, 4.50)

<0.001

1.981.113.55

0.022

≥11.1

4.11 (2,12, 7.95)

<0.001

2.931.406.11

0.004

a adjusted for age, sex, ethnicity (Mongol vs. Han), education, alcohol consumption, cigarette smoking, physical activity, SBP, DBP, history of hypertension, history of diabetes, and dyslipidemia.

 

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