Intensive statin based LDL-C lowering helps prevent recurrence of ischemic stroke: JAMA

Taiwan: A recent study published in the Journal of American Medical Association - Neurology pointed out that, more intensive LDL-C–lowering statin-based therapies might be warranted for patients with ischemic stroke with evidence of atherosclerosis. However for patients without evidence of atherosclerosis, intensive low-density lipoprotein cholesterol (LDL-C) - lowering statin-based therapies might not be needed in most situations considering the uncertain benefits of secondary stroke prevention and increased risk of hemorrhagic stroke associated with intensive LDL-C lowering.

"Our data suggest that more intensive compared with less intensive LDL-C–lowering statin-based therapies might be linked to a reduced risk of recurrent stroke among patients with ischemic stroke, but this reduced risk might be limited to patients with evidence of atherosclerosis," Meng Lee and colleagues wrote in their study. 

The advantages and dangers of intensive LDL-C–lowering statin-based therapy to reduce the risk of recurrent stroke are unknown. Dr. Lee and colleagues undertook this investigation with the goal of doing a meta-analysis of randomized clinical trials to assess the connection of more intense versus less intensive LDL-C–lowering statin-based therapy with outcomes for patients with ischemic stroke.

From January 1, 1970, to July 31, 2021, Embase, PubMed, ClinicalTrials.gov, and the Cochrane Central Register of Controlled Trials were searched for this study. This meta-analysis comprised randomized clinical studies that evaluated more intense vs less intensive LDL-C–lowering statin-based therapy and tracked the outcome of recurrent stroke in stroke patients. For abstracting data and analyzing data quality and validity, the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting standard was used. The relative risk (RR) with 95% confidence interval (CI) was used to assess the relationship between more intense versus less intensive LDL-C lowering and main and secondary outcomes. The primary outcome was a recurrent stroke, with severe cardiovascular events and hemorrhagic stroke as secondary outcomes.

The key findings are as follow:

1. The final analysis comprised 11 randomized clinical trials with a total of 20 163 stroke patients. The average period of follow-up was four years (range, 1-6.1 years).

2. Pooled data indicated that more intensive LDL-C–lowering statin-based therapies were related to a lower risk of recurrent stroke compared to less intensive LDL-C–lowering statin-based therapies and that the benefit associated with these LDL–C–lowering therapies was not different across LDL–C–lowering strategies.

3. When compared to less intense LDL-C–lowering statin-based treatments, more intensive LDL-C–lowering statin-based therapies were linked with a lower risk of major cardiovascular events but an increased risk of hemorrhagic stroke.

4. When compared to less intensive LDL-C–lowering statin-based therapies, more intensive LDL-C–lowering statin-based therapies were related to a lower risk of recurrent stroke in trials where all patients had evidence of atherosclerosis, but not in trials where most patients did not have evidence of atherosclerosis.

In conclusion, more evidence from randomized clinical trials is needed to determine if intense LDL-C–lowering statin-based therapy benefits certain racial and ethnic groups, such as Asians.

Reference:

Lee M, Cheng C, Wu Y, Lee J, Hsu C, Ovbiagele B. Association Between Intensity of Low-Density Lipoprotein Cholesterol Reduction With Statin-Based Therapies and Secondary Stroke Prevention: A Meta-analysis of Randomized Clinical Trials. JAMA Neurol. Published online February 21, 2022. doi:10.1001/jamaneurol.2021.5578