J MEDICINE 2016; 17: 21-26

Association of Hypertriglyceridemia with Ischemic Stroke, Study in

a Tertiary Care Hospital in Bangladesh
MD. ENAMUL KARIM,1 SHEKHAR KUMAR MONDAL,2 AKM HUMAYON KABIR,3 PARTHA PRATIM DAS,4
SARMISTHA BISWAS,3 NIGAR SULTANA AHMED2

Abstract
Background: Hypertriglyceridemia fosters the development of atherosclerosis via several mechanisms and
Background:
lead to ischemic stroke (IS) through its contribution to thrombogenicity. The association of
hypertriglyceridemia with ischemic stroke was evaluated in this study.
Methods: This was a case control study conducted in the Department of Medicine, Dhaka Medical College
Hospital and data was collected in a questionnaire from January to June’2013. Patients presented with
ischemic stroke, confirmed by CT scan of Head/ MRI of brain from 1 day to 6 months and other than
ischemic stroke patients were considered as case and control respectively.
Results: The mean age was found 61.0±8.3 years in case group and 60.5±8.1 years in control group. Male
were predominant in both groups which was 80 (80.0%) in case group and 84 (84.0%) in control group.
More than two third (68.0%) in cases and one fourth (25.0%) in controls patients had hypertension. 12
(12.0%) in cases and 2 (2.0%) in controls patients had heart disease. Normal triglycerides was found 52
(52.0%) in cases and 72 (72.0%) in control. The mean TG was found 179.9±62.8 mg/dl in cases and
148.0±51.9 mg/dl in controls. Desirable cholesterol was found 16 (16.0%) in cases and 25 (25.0%) in controls.
The mean cholesterol was found 238.0±4.0 mg/dl in cases and 213.0±42.0 in controls. Optimal LDL was
found 12 (12.0%) and 18 (18.0%) in case and control group respectively. Mean LDL was found 167.0±35.2
mg/dl in cases and 141.0±36.1 mg/dl in controls. Low HDL was found 64 (64.0%) in cases and 26 (26.0%)
in controls. Mean HDL was found 41.2±10.6 mg/dl in case group and 49.0±8.6 mg/dl in control group.
Conclusion: Ischemic stroke is significantly associated with a higher level of TC, TG, LDL and HDL
(inversely). Therefore, Hypercholesterolemia and Hypertriglyceridemia may be a risk factor for ischemic stroke.
Keywor
ywor ds: Ischemic stroke, Triglyceride (TG), Low density lipoprotein (LDL), High density lipoprotein
ords:
(HDL).

Introduction: population lives in Asia, but stroke is the predominant

Stroke is one of the leading causes of death in the world, vascular disease in many parts of Asia.1 In1990 alone, World
and the leading cause of acquired disability in adults in most Health Organization estimated that there were over 2.1
regions.1-2 Countries of low and middle income have the million people who died of stroke In Asia.2 The burden of
largest burden of stroke, accounting for more than 85% of stroke is likely to increase substantially in the near future
stroke mortality worldwide, but few reliable data are
because of the aging population. Stroke is the second leading
available to identify risk factors for stroke in most of these
cause of death worldwide, and the leading cause of acquired
regions, and particularly for hemorrhagic stroke.1-5
disability in adults in most regions. Apart from implementing
In Asia, the problem of stroke has a particularly strong effective stroke prevention programs, identification of factors
impact, not only because more than half of the world’s associated with more severe stroke may help to ease the
1. Professor & Head, Dept. of Medicine, Dhaka Medical College burden of this coming epidemic.3-5
& Hospital. Due to the tremendous burden that stroke places on our
2. Assistant Registrar, Dept. of Medicine, Dhaka Medical society, there have been major efforts to identify modifiable
College & Hospital.
risk factors that could reduce the incidence of ischemic stroke
3. Assistant Professor of Medicine, Dhaka Medical College &
Hospital.
(IS). Multiple independent risk factors for IS have been
4. Associate Professor of Medicine, Dhaka Medical College & identified. The most prevalent of these include hypertension,
Hospital. diabetes mellitus, smoking, atrial fibrillation, coronary artery
Corresponding author: Prof. Dr. Md. Enamul Karim, Professor disease, congestive heart failure and disorders of lipid
& Head, Dept. of Medicine, Dhaka Medical College & Hospital, metabolism. Epidemiologic studies suggest that elevated total
Dhaka, Bangladesh. E-mail: [email protected]. cholesterol and low-density lipoprotein cholesterol (LDL-
Association of Hypertriglyceridemia with Ischemic Stroke, Study in a Tertiary Care Hospital in Bangladesh JM Vol. 17, No. 1

C), as well as low levels of high-density lipoprotein AF, MI (within 6 weeks of acute stroke), prosthetic heart
cholesterol (HDL-C) are possible risk factors for IS.6-7 valve, endocarditis were excluded from this study.
Cholesterol and triglycerides are the 2 main lipids found in
Stroke was defined as a clinical syndrome characterized by
the body. Triglycerides (triacylglycerols) are the main storage
rapidly developing clinical symptoms and/or signs of focal
form of fatty acids. They are esters of fatty acids and
and at times global loss of brain function, with symptoms
trihydric-alcohol-glycerol.
lasting >24 hours or leading to earliar death, and with no
The metabolic pathways of triglycerides and HDL-C are apparent cause other than that of vascular origin.
related, and an increase in one will usually be accompanied Hypertriglyceridemia is defined as plasma levels of TG ≥200
by a decrease in the other (a rise in the HDL-C level will be mg/dL12. (it corresponds to a high hypertriglyceridemia
accompanied by a drop in the triglyceride level, and vice according to the ATP III).Serum total cholesterol, HDL
versa).8-9 cholesterol (HDL-C), LDL cholesterol (LDL-C) and
triglycerides were measured by standard enzymatic
Hypertriglyceridemia may lead to IS through its contribution
procedures.
to atherosclerosis and/or thrombogenicity. Studies suggest
that hypertriglyceridemia fosters the development of After collection of information, these data were checked,
atherosclerosis via several mechanisms. Postprandial verified for consistency and edited for result. After editing
hypertriglyceridemia in diabetic patients was found to and coding, the coded data were entered directly into the
produce endothelial dysfunction, oxidative stress due to lipid- computer by using software. Data cleaning validation and
derived free radicals, and impairment of endothelium- analysis were performed using the SPSS\PC software and
dependent vasodilatation.10 Triglyceride-rich lipoproteins, graph and chart by MS Excel. The result was presented in
including very-low-density lipoprotein and intermediate- tables in mean, standard deviation (SD) and percentage. A
density lipoprotein, in addition to LDL-C particles, become “p“ value <0.5 were considered as significant.
trapped in blood vessel walls and have been demonstrated
in human atherosclerotic plaques. 11 Transient Results:
hypertriglyceridemia, induced by intravenous infusion of a 100 patients with ischemic stroke and 100 control subjects
triglyceride emulsion, was associated with decreased were included in the study. It was observed that male were
vascular reactivity in young healthy men who had no risk predominant in both groups which was 80 (80.0%) in case
factors for coronary heart disease (CHD). 12 Chronic group and 84 (84.0%) in control group. The difference was
hypertriglyceridemia was independently associated with not statistically significant (p>0.05) between two groups.
endothelial dysfunction in an observational study of patients Among the study patients according to past medical history
with normal LDL-C.13 Increased expression of adhesion cell (n=200) it was observed that more than two third (68.0%) in
molecules is considered to be a marker of endothelial cell cases and one fourth (25.0%) in controls patients had
dysfunction.14 An increase in cell adhesion molecules has hypertension. Ten (10.0%) patients had diabetes in cases
been noted in patients with hypertriglyceridemia.14-15 Many and 4 (4.0%) in controls. Twelve (12.0%) in cases and 2
prospective epidemiological studies have reported a positive (2.0%) in controls patients had heart disease. Hypertension
relationship between serum triglyceride levels and incidence and heart disease difference was statistically significant
of CHD.16-18 (p<0.05) between two groups. In this Normal triglycerides
were found in 52 (52.0%) cases and in 72 (72.0%) of control.
Materials and Methods
The mean TG was found to be 179.9±62.8 mg/dl in cases
This case control study was carried out in Department of
and 148.0±51.9 mg/dl in controls. Desirable cholesterol was
Medicine, Dhaka Medical College Hospital from January
found 16 (16.0%) in cases and 25 (25.0%) in controls. The
2013 to June 2013. A total of 100 Ischemic stroke patients
mean cholesterol found was 238.0±4.0 mg/dl in cases and
who met the inclusion criteria were recruited as cases from
the admitted patient of Medicine Department, DMCH. Age 213.0±42.0 in controls. Optimal LDL was found 12 (12.0%)
and sex matched apparently healthy persons were recruited and 18 (18.0%) in case and control group respectively. Mean
as controls. Those who give informed written consent were LDL was found to be 167.0±35.2 mg/dl in cases and
finally enrolled in this study. All patients presenting with 141.0±36.1 mg/dl in controls. Low HDL was found in 64
ischemic stroke, confirmed by CT scan of head/MRI of brain (64.0%) cases and 26 (26.0%) in controls. Mean HDL was
from 01 day to 6 months were included as cases. Patients of found to be 41.2±10.6 mg/dl in case group and 49.0±8.6
venous thrombosis, severely ill patients, those who were mg/dl in control group. The difference was statistically
taking anti lipid drugs, history of Cardioembolic events – significant (p<0.05) between two groups.

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JM Vol. 17, No. 1 Association of Hypertriglyceridemia with Ischemic Stroke, Study in a Tertiary Care Hospital in Bangladesh

Table-I Table-III
Distribution of the study patients according to age Distribution of the study patients according to
(n=200) complications (n=200)

Age (years) Case Control P Complications Case Control P

(n=100) (n=100) value
(n=100) (n=100) value n % n %
n % n % Weakness of the 64 64.0 0 0.0 0.001s
26 - 35 4 4.0 3 3.0 body (Rt)
36 - 45 8 8.0 6 6.0 Weakness of the 36 36.0 0 0.0 0.001s
46 - 55 24 24.0 25 25.0 body (Lt)
56 - 65 20 20.0 19 19.0 Aphasia 40 40.0 0 0.0 0.001s
Unconsciousness 25 25.0 0 0.0 0.001s
66 - 75 28 28.0 33 33.0
Headache 11 11.0 8 8.0 0.469ns
>75 16 16.0 14 14.0 Vomiting 16 16.0 4 4.0 0.004s
Mean±SD 61.0±8.3 60.5±8.1 0.667ns Others 8 8.0 88 88.0 0.001s
Range (min,max) (26 -77) (27-79) Table-IV
Table-II Distribution of the study patients according to past
Distribution of the study patients according to medical history (n=200)
occupational status (n=200) Past medical history Case Control P
Occupational status Case Control (n=100) (n=100) value
n % n %
(n=100) (n=100)
Hypertension
n % n %
Yes 68 68.0 25 25.0 0.001s
House-wife 20 20.0 19 19.0 No 32 32.0 75 75.0
Day labour 28 28.0 30 30.0 Diabetes
Non govt. service 16 16.0 15 15.0 Yes 10 10.0 4 4.0 0.096ns
No 90 90.0 96 96.0
Govt. service 8 8.0 7 7.0
Heart Disease
Business 20 20.0 22 22.0 Yes 12 12.0 2 2.0 0.005s
Others-Farmer 8 8.0 7 7.0 No 88 88.0 98 98.0
Table-V
Distribution of the study patients according to fasting lipid profile (n=200)
Fasting lipid profile Case (n=100) Control (n=100) P value
n % n %
Triglycerides (TG) Normal (< 150 mg/dl) 52 52.0 72 72.0
Borderline high (150-199 mg/dl) 32 32.0 22 22.0
High (200-499 mg/dl) 14 14.0 6 6.0
Very high (>500 mg/dl) 2 2.0 0 0.0
Mean±SD 179.9 ±62.8 148.0 ±51.9 0.001s
Range (min,max) (110 ,520) (100,290)
Total cholesterol Desirable (< 200 mg/dl) 16 16.0 25 25.0
Increased (> 200 mg/dl) 84 84.0 75 75.0
Mean±SD 238.0 ±43.0 213.0 ±42.0 0.001s
Range (min,max) (150 ,280) (150 ,250)
Low-density lipoprotein (LDL) Optimal (< 130 mg/dl) 12 12.0 18 18.0
Increased (> 130 mg/dl) 88 88.0 82 82.0
Mean±SD 167.0±35.2 141.0±36.1 0.001s
Range (min,max) (120,189) (100,159)
High-density lipoprotein (HDL) Low (< 40 mg/dl) 64 64.0 26 26.0
Increased (> 40 mg/dl) 36 36.0 74 74.0
Mean±SD 41.2±10.6 49.0 ±8.6 0.001s
Range (min,max) (38,60) (39 ,66)

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Association of Hypertriglyceridemia with Ischemic Stroke, Study in a Tertiary Care Hospital in Bangladesh JM Vol. 17, No. 1

Discussion: Hypertension is the most important modifiable risk factor

This case control study was carried out with an aim to for both ischemic stroke and ICH. However, hypertension
determine the level of triglyceride among ischemic stroke appears to be a stronger risk factor for ICH than for ischemic
patients and to measure and compare the serum triglyceride stroke reported by Qureshi et al.23, Lewington et al.24 The
level including comparing partial demographic variation risk of stroke increases exponentially with increasing
between cases and controls. diastolic blood pressure (DBP) mentioned by MacMahon
et al.25 However, hypertension is a highly preventable risk
In this present study it was observed that the age of 28.0%
factor; a systematic review of 17 randomized clinical trials
patients in case group and 33.0% in control group was within
showed that lowering DBP by 5– 6 mmHg and systolic blood
66-75 years and the mean age was 61.0±8.3 years varied
pressure (SBP) by 10–12 mmHg resulted in a 38% reduction
from 26 – 77 years in case group and 60.5±8.1 years varied
in strokes.23-25 Hypertension alone may also increase the
from 27 – 79 years in control group, which was almost alike
risk of rupture related to degenerative changes of small
between two groups, no difference was found. Similarly,
arterioles documented by Qureshi et al.23 In this present study
Tanne et al.11 showed the mean age was 61.8±6.5 years
it was observed that 28.0% patients had diabetes mellitus in
Ischemic Stroke/TIA and 59.6±7.1 years in no CVD patients.
case group and 7.0% in control groups. Al most one third
Similarly, Bowman et al.18 showed the mean age was
(32.0%) patients had hypertension in case group and 19.0%
61.5±7.2 years and 59.9±8.7 years in case and control
in control group. Alost one fourth (24.0%) patients had stroke
respectively. On the other hand, Hsieh et al.19 has observed
higher mean age in Ischemic Stroke Group and control group, in case group and 9.0% in control group. Only 4.0% and
which were 69±11 years and 63±23 years respectively. They 19.0% had obesity in cases and controls respectively. Eight
have stated that the higher age range maybe due to increased (8.0%) patients had dyslipidemia in cases and 18.0% in
life expectancy, geographical and racial influences may have controls. diabetes mellitus, hypertension and stroke were
significant impacts on Ischemic Stroke. significantly (p<0.05) higher in case group, however obesity
In this current study it was observed that male were and dyslipidemia were significantly (p<0.05) higher in
predominant in both groups which was 80.0% in case group control group. Bowman et al.18 found diabetes 12.8% and
and 84.0% in control group and male to female ratio was 3.4% in case and control respectively.
almost 4:1 in both groups. The difference was not statistically In only some a severe hypercholesterolemia (total-C levels
significant (p>0.05) between two groups. Similar > 8 mmol/L) was associated with ischemic stroke obtained
observations regarding the sex incidence were also made by by Lindenstrom et al.26 or non fatal stroke in men reported
Tanne et al.11, Hsieh et al.19 by Wannamethee et al.27. It was observed in this current
Regarding the complications it was observed in this present study that normal triglyceride was found 52.0% in cases and
study that weakness of the body (Rt) (64.0%), weakness of 72.0% in control. The mean TG was found 179.9±62.8 mg/
the body (Lt) (36.0%), aphasia (40.0%) and unconsciousness dl in cases and 148.0±51.9 mg/dl in controls, which was
(25.0%) were more common in the case group whereas significantly (p<0.05) higher in case group. Austin MA et
headache was present in 11.0% and vomiting 16.0% in this al.13 found that the mean average of TG was 169.71 mg/dl
group. Islam20 showed that 50.0% of the Ischemic patients in patients and 148.68 mg/dl in controls. Tanne et al.11
presented with left sided abnormality, 40.0% had right sided, showed the mean TG 178±108 mg/dL in Ischemic Stroke/
10.0% had both sided abnormality and 24.0% had vomiting. TIA and 164±102 mg/dL in No CVD. Bowman et al.18
Report from Akbar and Mushtaq21 showed that the bilateral (2003) obtained that the mean average of TG was
stroke was 15.5% in the 103 study patients. 192.3±155.9 mg/dl in patients and 157.0±93.0 mg/dl in
Regarding the past medical history it was observed in this controls.
current study that more than two third of patients (68.0%) in
In this series it was observed that desirable cholesterol was
cases and one fourth (25.0%) in controls had hypertension.
found 16.0% and 25.0% in case and controls respectively.
Ten percent patients had diabetes in cases and 4.0% in The mean cholesterol was found 238.0±4.0 mg/dl in cases
controls. Twelve percent patients in cases and 2.0% in and 213.0±42.0 in controls. That was significantly (p<0.05)
controls had heart disease. Hypertension and heart disease higher in case group. Tanne et al.15 found the mean total
were significantly (p<0.05) higher in case groups. Tanne et cholesterol 228±43 mg/dL and 225±43 mg/dL in Ischemic
al.11 showed hypertension, in 43.0% Ischemic Stroke/TIA Stroke/TIA and No CVD respectively. Similarly, Bowman
group and 32.0% in NO CVD group. Diabetes mellitus found et al.18 obtained that the mean TC level was 231.7±51.1
34.0% and 20.0% in Ischemic Stroke/TIA and No CVD mg/dL in case group and 228.6±46.5 mg/dL in control group.
respectively. Similar identical findings also found by Hsieh et al.19.

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JM Vol. 17, No. 1 Association of Hypertriglyceridemia with Ischemic Stroke, Study in a Tertiary Care Hospital in Bangladesh

In this study it was observed that optimal LDL was found Limitations of the study
12.0% in case and 18.0% in control group. Mean LDL was 1. The study population was selected from one selected
found 167.0±35.2 mg/dl in cases and 141.0±36.1 mg/dl in hospital in Dhaka city, so that the results of the study
controls, which was significantly (p<0.05) higher in case may not be reflect the exact picture of the country.
group. Tanne et al.11 found the mean LDL-C level was 2. The present study was conducted within a very short
157±38 mg/dL in Ischemic Stroke/TIA and 54±37 mg/dL in period of time.
No CVD. Similar findings also obtained by Hsieh et al.19.
3. Small sample size was also a limitation of the present
The above findings are consistent with the current study.
study. Therefore, in future further study may be under
A low HDL-C level has been reported by Bowman et al.18 taken with large sample size.
to be associated with ischemic stroke in many studies. In
another, hypertriglyceridemia was weakly associated with Conflict of Interest : None
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