Should a HMG-CoA (3-hydroxy-3-methylglutaryl-coenzyme A) reductase inhibitor, such as statin, be initiated after an intracerebral hemorrhage?

From the Guidelines

Starting a statin after hemorrhagic stroke should be individualized, considering the patient's overall cardiovascular risk profile and the cause of the hemorrhagic stroke, with careful weighing of the benefits of reducing ischemic events against the potential risks of recurrent hemorrhage, as stated in the Canadian Stroke Best Practice Recommendations, sixth edition practice guidelines, update 2017 1. When considering statin therapy after a hemorrhagic stroke, it is essential to assess the patient's risk factors for cardiovascular disease, such as atherosclerotic cardiovascular disease, diabetes, or elevated LDL cholesterol levels.

• The decision to start statin therapy should be based on the patient's individual risk profile, taking into account the potential benefits of statin therapy in reducing ischemic events, as well as the potential risks of recurrent hemorrhage.
• The Canadian Stroke Best Practice Recommendations, sixth edition practice guidelines, update 2017, suggest that statin therapy is not indicated for prevention of intracerebral hemorrhage, but may be considered for secondary prevention in patients who have had an ischemic stroke or transient ischemic attack 1.
• A study published in the International Journal of Stroke in 2015 found that statin therapy was associated with an increased risk of hemorrhagic stroke in patients with a past history of stroke, but the overall risk was still relatively low 1.
• Another study published in the same journal in 2010 found that statin therapy was not associated with an overall increase in the incidence of hemorrhagic stroke, but the risk may be higher in patients with certain characteristics, such as increasing age, male gender, and stage II hypertension 1.
• When initiating statin therapy, moderate-intensity options like atorvastatin 10-20 mg daily or rosuvastatin 5-10 mg daily are often preferred, with close monitoring for side effects, as recommended by the guidelines 1.
• Regular monitoring of liver function tests and assessment for muscle symptoms is also important when starting statin therapy after hemorrhagic stroke.
• The guidelines emphasize the importance of individualizing treatment decisions, taking into account the patient's unique risk profile and medical history, as well as the potential benefits and risks of statin therapy 1.

From the Research

Statin Therapy After Hemorrhagic Stroke

• The decision to start statin therapy after a hemorrhagic stroke is complex and depends on various factors, including the patient's overall health, medical history, and the specific characteristics of the stroke 2, 3, 4, 5.
• Some studies suggest that statins may not increase the risk of hemorrhagic stroke, and may even reduce the risk of recurrent ischemic stroke 2, 3, 4.
• However, other studies have raised concerns about the potential increased risk of hemorrhagic stroke associated with high-dose statin therapy in patients with a prior history of stroke 5.
• A recent study found that rosuvastatin may be associated with a reduced risk of recurrent stroke, myocardial infarction, and all-cause mortality compared to atorvastatin in patients with acute ischemic stroke 6.

Key Considerations

• The benefits and risks of statin therapy after a hemorrhagic stroke must be carefully weighed on an individual basis 2, 3, 4, 5.
• Patients who experience a stroke while on statins should not discontinue statins, as this may increase the risk of recurrent stroke 4.
• The use of statins in the acute phase of stroke may be associated with better survival and improved functional outcomes in statin-naive patients 4.
• However, statins may not confer any benefit in patients with acute ischemic stroke who receive thrombolysis 4.

Evidence Summary

• A systematic review and meta-analysis of randomized controlled trials and observational cohort studies found that statins reduce the odds of stroke of any type in patients with an initial ischemic stroke 2.
• A randomized, double-blind, multi-center trial found that rosuvastatin 20 mg did not increase the risk of hemorrhagic transformation in acute stroke patients 3.
• A narrative review of current evidence regarding the effect of statins in stroke management found that statins are effective in preventing stroke recurrence in patients with a previous cerebrovascular event 4.
• A review of the literature on the impact of statin use on hemorrhagic stroke found that epidemiological data suggest a possible negative impact of high-dose statin therapy on the risk of intracranial hemorrhage 5.