Statins in Stroke Prevention

Pierre Amarenco; Philippa C Lavallëe; Mikael Mazighi; Julien Labreuche

Disclosures

Future Lipidology. 2008;3(3):319-325. 

In This Article

Abstract and Introduction

Beside blood pressure-lowering drugs and, in certain circumstances, antithrombotic agents, statins are among the most effective drugs in reducing the risk of stroke in populations of patients at high vascular risk, as well as reducing the risk of major coronary events. The meta-analysis of trials with intensive reduction of LDL-cholesterol (LDL-C) levels with high-dose statin compared with the usual dosage of statin, shows that stroke was reduced by 17% (95% CI: 4.0-28.0) and the risk of stroke, myocardial infarction and cardiovascular death by 20% (95% CI: 14.0-26.0%), with no heterogeneity between trials. In secondary prevention of stroke, statins clearly reduced the risk of major coronary events. In the Stroke Prevention by Aggressive Reduction in Cholesterol Levels (SPARCL) trial, compared with placebo, the patients with a recent stroke or transient ischemic attack without coronary heart disease randomized to atorvastatin 80 mg/day had a significant 16% relative risk reduction of stroke, and a 35% reduction in the risk of major coronary events. This was obtained despite the fact that 25% of patients allocated to the placebo arm were prescribed a commercially available statin outside the trial. A post hoc analysis used blinded LDL-C measurements (taken at study visits during the trial) as a marker of adherence to lipid-lowering therapy. Compared with the group demonstrating no change or an increase in LDL-C (the group adherent to placebo or not taking a statin), the group with a 50% or greater reduction in LDL-C had a significant 31% reduction in the risk of stroke. The next step is to define whether achieving a LDL-C level less than 70 mg/dl after a stroke or a transient ischemic attack is better than a standard dose of statin (LDL ∼100-110 mg/dl).

It is estimated that stroke affects 10 million people worldwide every year. Ischemic stroke is more frequent than myocardial infarction (MI) in Asia, and we now have evidence that it has become more frequent in Europe as well.[1] This should prompt considerable interest in both the primary and secondary prevention of stroke in the coming decades. The occurrence of stroke increases with age, particularly affecting the elderly, a population at higher risk for coronary heart disease (CHD). Regardless of stroke subtype, the prevalence of coronary atherosclerosis in patients with stroke is 75%.[2] After a first stroke, the 5-year risk of having another stroke is 20% and the 5-year risk of MI is 10%,[3] which qualifies stroke as a CHD risk equivalent (i.e., a 10-year risk of MI of 20%).

High blood pressure is the most important risk factor for stroke,[4] and by controlling high blood pressure, it is well established that the risk of first ever or recurrent stroke can be reduced by 40%.[5] Epidemiologic and observational studies have not shown a clear association between cholesterol levels and all causes of stroke.[6] Nonetheless, large, long-term statin trials in patients with established or who are at high risk of CHD have demonstrated that statins decrease stroke incidence.

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