What is the target low-density lipoprotein (LDL) level in patients with a history of stroke?

From the Guidelines

For stroke patients, the goal LDL cholesterol level should be less than 70 mg/dL (1.8 mmol/L). This aggressive target is recommended because stroke patients are at high risk for recurrent cardiovascular events, as supported by the 2021 guideline for the prevention of stroke in patients with stroke and transient ischemic attack 1 and further reinforced by a systematic review and synthesis of global stroke guidelines in 2023 1. To achieve this goal, high-intensity statin therapy is typically prescribed, such as atorvastatin 40-80 mg daily or rosuvastatin 20-40 mg daily. If statins alone are insufficient to reach the target LDL level, additional medications may be added, including ezetimibe 10 mg daily or PCSK9 inhibitors like evolocumab or alirocumab, as suggested in the 2023 systematic review 1.

Key considerations for managing LDL cholesterol in stroke patients include:

• Starting treatment as soon as possible after the stroke and continuing indefinitely
• Regular lipid panel monitoring, typically at 1–3 months after treatment initiation, followed by regular assessments and dose adjustments every 3–12 months thereafter, as recommended in the 2023 guidelines 1
• Accompanying medication therapy with lifestyle modifications, including a heart-healthy diet, regular exercise, smoking cessation, and weight management, for optimal results
• Considering referral to an expert in lipid management for adding a PCSK9 inhibitor if a target LDL-cholesterol level is not achievable, as suggested in the 2023 systematic review 1

The importance of achieving and maintaining the target LDL cholesterol level cannot be overstated, as it significantly reduces the risk of recurrent stroke and other cardiovascular events by decreasing atherosclerotic plaque formation and stabilizing existing plaques, as demonstrated by the SPARCL and TST trials cited in the 2021 guideline 1.

From the Research

Goal LDL in Stroke Patients

• The goal LDL level in stroke patients is a topic of ongoing research, with various studies suggesting different target levels 2, 3, 4, 5, 6.
• A study published in The New England Journal of Medicine in 2020 found that patients with ischemic stroke who had a target LDL cholesterol level of less than 70 mg per deciliter had a lower risk of subsequent cardiovascular events than those who had a target range of 90 mg to 110 mg per deciliter 2.
• Another study published in Clinical Neurology and Neurosurgery in 2020 suggested that obtaining fasting lipid levels in addition to random lipid levels may prompt changes in hyperlipidemia management of acute stroke patients, particularly in those with random LDL levels between 70-99 mg/dL 3.
• A study published in Diabetes in 2021 found that targeting an LDL cholesterol of <70 mg/dL compared with 100 ± 10 mg/dL consistently reduced the risk of subsequent stroke and other major vascular events in patients with and without diabetes 4.
• A study published in the Journal of the American Heart Association in 2023 found that statin treatment was significantly associated with a reduced risk of the 3-month primary composite outcomes and all-cause death in patients with first-ever ischemic stroke with baseline low-density lipoprotein cholesterol levels <70 mg/dL 5.
• A study published in Stroke in 2014 found that only 19.8% of patients with stroke had LDL levels <70 mg/dL, and management of dyslipidemia in high-risk patients with preexistent CAD or stroke continues to be suboptimal 6.

Key Findings

• Targeting an LDL cholesterol level of <70 mg/dL may be beneficial in reducing the risk of subsequent cardiovascular events in stroke patients 2, 4.
• Statin treatment may be effective in reducing the risk of early vascular events in patients with stroke, even in those with baseline LDL levels <70 mg/dL 5.
• Fasting lipid levels may be useful in determining lipid-lowering therapy in acute stroke patients, particularly in those with random LDL levels between 70-99 mg/dL 3.
• Management of dyslipidemia in high-risk patients with preexistent CAD or stroke remains suboptimal, with only a small percentage of patients achieving LDL levels <70 mg/dL 6.