Statins and ICH: New Meta-Analysis

May 04, 2020

A new meta-analysis has concluded that the benefit of statin therapy in the prevention of ischemic stroke "greatly exceeds" the risk for intracerebral hemorrhage (ICH).

The meta-analysis was released on AAN.com as part of the 2020 American Academy of Neurology Science Highlights. The meeting, like many others, was cancelled because of the COVID-19 pandemic.

Coauthor Abhi Pandhi, MD, the University of Tennessee Health Science Center, Memphis, explained to Medscape Medical News that some previous studies have suggested that statin therapy may be associated with an increased risk for ICH, especially at higher doses. Other studies, however, have failed to confirm this and have shown an increase in cardiovascular events if statins are stopped.

To look further into this issue, the researchers conducted a meta-analysis of 19 clinical studies involving patients who had a history of cardiovascular or cerebrovascular events and who had been treated with statins. A total of 35,842 patients were included.

Results showed that statin use was not significantly associated with the risk for combined primary and secondary ICH (relative risk [RR], 1.03; 95% confidence interval [CI], 0.85 – 1.08). But the risk for cerebral ischemia (stroke and transient ischemic attack) was significantly lower in those who received statins (RR, 0.79; 95% CI, 0.61 – 0.87).

"Overall, we found no effect of statins on the risk of ICH, and benefits on reducing ischemic events are clear," Pandhi said.

Increased Secondary ICH?

However, a sensitivity analysis showed a trend toward a higher risk for secondary ICH among those who were assigned to statin treatment (odds ratio, 1.87; 95% CI, 0.91 – 3.86).

"While this may suggest an increased risk of secondary ICH, when we look at the big picture, putting all the data together, and given that ischemic events are far more common than ICH, the risk of stopping statins and losing the protection against ischemic events is probably greater than any harm even in patients with underlying risk factors for ICH," Pandhi concluded.

Commenting on the study for Medscape Medical News, Michael Szarek, PhD, who has also conducted research in this field, said: "The results of this meta-analysis appear to be consistent with individual randomized trials of statins in patients with cerebrovascular disease that have shown clear benefit in terms of ischemic stroke or TIA and potential harm in terms of hemorrhagic stroke."

Szarek is chair and professor in the Department of Epidemiology and Biostatistics at the SUNY Downstate Health Sciences University, New York City.

"However, the much greater frequency of ischemic events, coupled with benefits in coronary and peripheral vascular territories, suggest the risk/benefit of statin treatment remains favorable in this patient population, with the possible exception of patients with a history of hemorrhagic stroke," he added.

Also commenting on this latest meta-analysis, Pamela Rist, ScD, associate epidemiologist at Brigham and Women's Hospital and assistant professor of medicine at Harvard Medical School, Boston, Massachusetts, who has also authored studies in this area, said the results of this study seem similar to prior results from meta-analyses of clinical trials.

"It will be interesting to see the full manuscript to learn more about the sensitivity analyses they conducted and why they may have observed a nonsignificant increased risk of secondary ICH among some individuals using statins," Rist added.

"Based on prior published meta-analyses of statin use and ICH, any potential increase in risk of hemorrhagic stroke is probably outweighed by the reduction in ischemic stroke and other cardiovascular events," she concluded.

Pandhi has disclosed no relevant financial relationships.

American Academy of Neurology (AAN) 2020 Annual Meeting: Abstract S9.010.

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