News Release

Statins reduce stroke risk by 1/5

Peer-Reviewed Publication

The Lancet_DELETED

A meta-analysis of 24 studies comprising more than 165,000 patients has shown that use of statins is associated with a reduction in stroke risk of around one fifth compared with placebo. The findings, and their implications for cholesterol control, are reported in a Review in the May edition of The Lancet Neurology, written by Dr Pierre Amarenco and Julien Labreuche, INSERM U-698 and Bichat University Hospital, Paris-Diderot University, Paris, France.

The meta-analysis of the randomised trials of statins, in combination with other preventive strategies, shows that each 1 mmol/L decrease in LDL (bad) cholesterol equates to a reduction of relative risk for stroke of 21%. Statins not only lower the overall risk of stroke but also slow the progression of blockage of the carotid arteries supplying the brain, reduce inflammation and endothelial dysfunction, decrease platelet aggregation, improve fibrinolysis (breakdown of fibrin clots), lower blood pressure, and decrease the risk of thromboembolic complications to the brain by reducing the incidence of heart attacks. Statins might also have a neuroprotective effect.

Only one of the 24 studies (SPARCL) assessed statin use for secondary prevention of stroke, and found that intense reduction of LDL cholesterol by statins also reduced the risk of recurrent stroke by 16% and of major cardiovascular events by 20%. The treatment effect did not differ in men versus women, in individuals aged less than 65 years versus those aged more than 65 years, in those with narrowing of the carotid arteries or no narrowing, in patients with diabetes versus without diabetes, and across stroke subtype at entry.

The authors also studied the effect of statins on haemorrhagic stroke (bleeding in the brain caused by rupture of a blood vessel) — representing 20% of all strokes. Two previous studies had suggested that statins might increase the risk of haemorrhage. However this meta-analysis found no evidence that statin use increased the risk of haemorrhagic stroke, except in patients with prior brain bleeds. They say: "Because of the increased incidence of haemorrhagic stroke seen in HPS and SPARCL, we recommend caution when considering statin therapy in patients with prior cerebral haemorrhage. Pending further data from other secondary prevention trials in patients with stroke, we would only prescribe statins to patients who are at high risk of major coronary or other atherothrombotic events, and would not aim to aggressively reduce cholesterol concentrations."

As the ratio of HDL (good) to LDL (bad) cholesterol is the best predictor of stroke and heart attacks (and better than LDL cholesterol alone), the authors discuss the importance of drugs that increase HDL cholesterol, as well as statins which reduce LDL cholesterol, since both methods of action will improve the HDL/LDL ratio. They say: "The benefits and risks of raising HDL cholesterol concentrations with specific drugs such as niacin or the new cholesteryl ester transfer protein inhibitors are worth investigation with the objective to reduce residual vascular risks after antihypertensive, statin, and platelet-inhibition therapies."

They add: "New strategies of care need to be investigated, such as prevention clinics with nurse practitioners trained in the prevention of vascular disease to monitor patients closely to ensure they are treated to target. The Suivi et Education Thérapeutique pour Optimiser la Prévention des Stroke (STOP-Stroke) trial in France is comparing usual follow-up by general practitioners with close monitoring by nurse practitioners plus follow-up by general practitioners."

The authors conclude by saying the next step in this field is to assess the safety and effectiveness of further reductions in LDL cholesterol after a stroke comparing two targets, eg, less than 2.6 mmol/L verus less than 1.8 mmol/L. They say: "Other approaches that might decrease the residual risk of stroke are triglyceride-lowering therapy with fibric acid compounds, or their combination with statins, and treatments to raise HDL cholesterol concentrations."

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Dr Pierre Amarenco, INSERM U-698 and Bichat University Hospital, Paris-Diderot University, Paris, France T) T) +33 1-4025-8726 / +33 1-4025-6023 E) pierre.amarenco@bch.aphp.fr

For full Review see: http://press.thelancet.com/tlnstatinstroke.pdf

Notes to editors: *SPARCL: Stroke Prevention by Aggressive Reduction of Cholesterol Levels; HPS= Heart Protection Study


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