Importance of cholesterol and cholesterol-lowering in secondary stroke prevention

Background. Intensive lipid lowering therapy using statin is recommended after transient ischemic attack (TIA) or ischemic stroke of atherosclerotic origin. There is some uncertainty, however about the target level of LDL cholesterol that is appropriate to reduce cardiovascular events after stroke. Methods. Patients with ischemic stroke in the previous 3 months or TIA within the previous 15 days and evidence of cerebrovascular or coronary artery atherosclerosis were randomly assigned in a 1:1 ratio to a target LDL cholesterol of less than 70 mg/dL or 100 10 mg/dL, using statin alone or in combination with ezetimibe. The primary criterion was the composite of ischemic stroke, myocardial infarction, new symptoms requiring urgent coronary or carotid revascularization and vascular death. Results. A total of 2860 patients were enrolled, 1430 assigned to each group, with a mean baseline LDL cholesterol of 135 mg/dL and followed for a median of 3.5 years. The mean achieved LDL cholesterol levels were 65 and 96 mg/dL, respectively. The primary composite endpoint occurred in 121 (8.5%) and in 156 (10.9%) patients, respectively (adjusted hazard ratio, 0.78; 95% confidence interval, 0.61-0.98; P=0.036). The incidence of intracranial hemorrhages and newly diagnosed diabetes did not differ between groups. Conclusions. After an ischemic stroke with evidence of atherosclerosis, a target LDL cholesterol of less than 70 mg/dL compared to 100 10 mg/dL, reduced the risk of subsequent cardiovascular events. (C) 2020 l'Academie nationale de medecine. Published by Elsevier Masson SAS. All rights reserved.