Statins in stroke prevention

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% Cl: 4.0-28.0) and the risk of stroke, myocardial infarction and cardiovascular death by 20% (95% Cl: 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 similar to 100-110 mg/dl).