What is the importance of statin (HMG-CoA reductase inhibitor) therapy after a cerebrovascular accident (CVA) or stroke?

From the Guidelines

Statin therapy is crucial after a stroke because it significantly reduces the risk of recurrent strokes and other cardiovascular events, and patients who have experienced a stroke should typically be started on a high-intensity statin such as atorvastatin 40-80mg daily or rosuvastatin 20-40mg daily, regardless of their baseline cholesterol levels, as recommended by the 2021 guideline for the prevention of stroke in patients with stroke and transient ischemic attack 1. The importance of statin therapy after a stroke can be attributed to its ability to lower LDL cholesterol levels and its pleiotropic effects, including anti-inflammatory properties, plaque stabilization, and improved endothelial function, which help prevent the formation of new atherosclerotic plaques and stabilize existing ones, reducing the likelihood of future strokes. Some key points to consider when prescribing statins after a stroke include:

• Starting with a high-intensity statin, such as atorvastatin or rosuvastatin, to achieve a target LDL cholesterol level of <70 mg/dL, as recommended by the 2021 guideline 1 and the 2018 Canadian Stroke Best Practice Recommendations 1.
• Continuing statin therapy indefinitely as long-term therapy, as the benefits of statin therapy after stroke far outweigh the potential risks for most patients.
• Monitoring patients periodically for liver function and muscle symptoms, as recommended by the 2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline 1.
• Considering the use of statins in patients with extracranial carotid or vertebral atherosclerosis who sustain ischemic stroke, as recommended by the 2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline 1. Overall, the evidence suggests that statin therapy is a crucial component of post-stroke preventive care, and its benefits in reducing the risk of recurrent strokes and other cardiovascular events make it a cornerstone of treatment for patients who have experienced a stroke, as supported by the 2021 guideline 1, the 2018 Canadian Stroke Best Practice Recommendations 1, and other studies 1.

From the FDA Drug Label

To reduce the risk of: Myocardial infarction (MI), stroke, revascularization procedures, and angina in adults with multiple risk factors for coronary heart disease (CHD) but without clinically evident CHD MI and stroke in adults with type 2 diabetes mellitus with multiple risk factors for CHD but without clinically evident CHD. Non-fatal MI, fatal and non-fatal stroke, revascularization procedures, hospitalization for congestive heart failure, and angina in adults with clinically evident CHD.

The importance of statins after a stroke is to reduce the risk of another stroke and other major adverse cardiovascular events, such as myocardial infarction and revascularization procedures. Statins, like atorvastatin 2 and rosuvastatin 3 and 3, are indicated to reduce the risk of these events in adults with multiple risk factors for coronary heart disease, including those with a history of stroke. Key benefits of statin therapy after a stroke include:

• Reduction in risk of non-fatal and fatal stroke
• Reduction in risk of myocardial infarction
• Reduction in risk of revascularization procedures
• Reduction in risk of hospitalization for congestive heart failure and angina.

From the Research

Importance of Statins after Stroke

• Statins are effective in reducing the risk of major vascular events after ischemic stroke, even in patients with low baseline low-density lipoprotein cholesterol (LDL-C) levels 4.
• The use of statins has been shown to improve vascular outcomes after ischemic stroke, with a lower risk of recurrent stroke, myocardial infarction, and death 4, 5, 6.
• Statins have been found to reduce the risk of stroke of any type in patients with an initial ischemic stroke, with a significant reduction in the odds of recurrent ischemic stroke 7.

Mechanism of Action

• Statins work by lowering LDL-C levels, which is the primary lipid treatment target for reducing stroke risk 5.
• Statins also have pleiotropic effects, which contribute to their beneficial effects in preventing stroke 6.

Benefits of Statins in Different Types of Stroke

• In patients with cardioembolic stroke, the use of statins may be beneficial in preventing stroke recurrence and improving functional outcomes 8.
• In patients with atherosclerotic stroke, statins have been shown to reduce the risk of recurrent stroke and improve vascular outcomes 4, 5, 6.

Dosage and Intensity of Statins

• The intensity of statin therapy may vary depending on the subtype of stroke, with high-intensity statins being more beneficial in some cases 4.
• The use of simvastatin 40 mg has been associated with a significantly lower incidence of stroke recurrence and better functional recovery in patients with cardioembolic stroke 8.