Potential Biomarkers to Predict Acute Ischemic Stroke in Type 2 Diabetes

Abstract

Background and Purpose: Patients with type 2 diabetes (T2D) have increased risk of cardiovascular disease (CVD), encompassing myocardial infarction, stroke, and peripheral vascular disease. We hypothesized that those biomarkers indicative of acute ischemic stroke (AIS) seen in large vessel occlusion (LVO) may also be elevated in T2D and further enhanced by stress conditions; therefore, these proteins represent potentially predictive biomarkers for those T2D patients at high risk of AIS. Methods: We performed an exploratory proteomic analysis in control subjects (n = 23) versus those with type 2 diabetes (T2D) (n = 23) who underwent a hyperinsulinemic clamp study to transient severe hypoglycemia [blood glucose <2.0 mmol/L (36 mg/dl)] in a prospective case-control study. We compared these proteins described as diagnostic and prognostic biomarkers for AIS due to LVO: lymphatic vessel endothelial hyaluronic acid receptor-1 (LYVE1), thrombospondin-1 (THBS1), pro-platelet basic protein (PPBP), and cadherin 1 (CDH1). Results: At baseline (BL), PPBP (p < 0.05), THBS1 (p < 0.05), and CDH1 (p < 0.01) were elevated in T2D; LYVE1 was not different between controls and T2D subjects at BL or at subsequent timepoints. PPBP and THBS1 tended to increase at hypoglycemia in both cohorts, though reached significance only in controls (p < 0.05), returning to BL levels post-hypoglycemia. CDH1 levels were higher in T2D at BL, at hypoglycemia and up to 2-h posthypoglycemia, thereafter reverting to BL levels. Conclusion: Elevated levels of PPBP, THBS1, and CDH1, circulatory proteins suggested as biomarkers of AIS due to LVO, may, in T2D patients, be prognostically indicative of a cohort of T2D patients at increased risk of ischaemic stroke. Prospective studies are needed to determine if this reflects future clinical risk. Clinical trial reg. no: NCT03102801.

Keywords: biomarkers; endothelial proteins; ischemic stroke; predictive biomarkers; type 2 diabetes.

Conflict of interest statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Copyright © 2021 Moin, Nandakumar, Al-Qaissi, Sathyapalan, Atkin and Butler.

Figures

FIGURE 1

Schematic diagram of the insulin clamp study. The schematic indicates the intervention and blood sampling time points.

FIGURE 2

Circulatory levels of endothelial cell marker proteins at baseline, at hypoglycemia and post-hypoglycemia timepoints in T2D and control subjects. Blood sampling was performed at baseline (BL), at hypoglycemia (0 min) and post-hypoglycemia (30 min, 1-h, 2-h, 4-h, and 24-h) for controls (white circles) and for T2D (black squares). At baseline (BL), blood sugar (BS) was 7.5 ± 0.4 mmol/L (for T2D) and 5.0 ± 0.1 mmol/L (for control, C). At the point of hypoglycemia, blood sugar (BS) was 2.0 ± 0.03 mmol/L (for T2D) and 1.8 ± 0.05 mmol/L (for control). Proteomic (Somalogic) analysis of proteins was undertaken for platelet basic protein (PPBP) (A), thrombospondin-1 (THBS1) (B), cadherin-1 (CDH1) (C) and lymphatic vessel endothelial hyaluronic acid receptor 1 (LYVE1) (D). Statistics: T2D vs. control: *p < 0.05, **p < 0.01; T2D BL vs. subsequent timepoints: $p < 0.05, $$p < 0.01; T2D hypoglycemia vs subsequent timepoints: &p < 0.05, &&p < 0.01; Control BL vs. subsequent timepoints: @p < 0.05; Control hypoglycemia vs. subsequent timepoints: ^p < 0.05. ^^p < 0.01. RFU, relative fluorescent units.

FIGURE 3

Circulatory levels of previously reported AIS due to LVO biomarkers at baseline, at hypoglycemia, and post-hypoglycemia timepoints in T2D and control subjects. Blood sampling was performed at baseline (BL), at hypoglycemia (0 min) and post-hypoglycemia (30 min, 1-h, 2-h, 4-h, and 24-h) for controls (white circles) and for T2D (black squares). Proteomic (Somalogic) analysis of proteins was undertaken for Glial fibrillary acidic protein, GFAP (A) D-dimer (B) von Willebrand factor, vWF (C) Apolipoprotein A1, APOA1 (D) Apolipoprotein B, APOB, (E) the ratio of basal levels of apolipoprotein B and apolipoprotein A1 (APOB/APOA1), (F). Statistics: (A–E) T2D vs control: *p < 0.05, **p < 0.01; T2D BL vs. subsequent timepoints: $ p < 0.05, $$ p < 0.01; T2D hypoglycemia vs. subsequent timepoints: &p < 0.05, &&p < 0.01; Control BL vs. subsequent timepoints: @p < 0.05; Control hypoglycemia vs. subsequent timepoints: ^p < 0.05. ^^p < 0.01; (F) Data presented in the bar graph as mean ± SEM; ns, not significant.