What is the recommended low-density lipoprotein (LDL) goal for stroke patients?

From the Guidelines

The recommended LDL goal for stroke patients is generally below 70 mg/dL (1.8 mmol/L). For patients who have experienced an ischemic stroke or transient ischemic attack (TIA), aggressive lipid management is crucial for secondary prevention, as supported by the 2021 guideline from the American Heart Association/American Stroke Association 1. To achieve this target, high-intensity statin therapy is typically recommended, such as atorvastatin 40-80 mg daily or rosuvastatin 20-40 mg daily. If patients cannot tolerate high-intensity statins, moderate-intensity statins like atorvastatin 10-20 mg or rosuvastatin 5-10 mg daily may be used. For patients who don't reach the target LDL level with statins alone, additional medications such as ezetimibe 10 mg daily or PCSK9 inhibitors (evolocumab or alirocumab) may be added.

Some key points to consider in lipid management for stroke patients include:

• The use of statin therapy to achieve a target LDL cholesterol consistently less than 2.0 mmol/L or >50% reduction of LDL cholesterol, from baseline, as recommended by the Canadian Stroke Best Practice Recommendations 1
• The consideration of more aggressive targets (LDL-C <1.8 mmol/L or >50% reduction) for individuals with stroke and acute coronary syndrome or established coronary disease 1
• The importance of regular lipid panel monitoring, typically 4-12 weeks after starting therapy and then every 3-12 months thereafter

The pathophysiological basis for this approach is that lower LDL levels help prevent atherosclerotic plaque formation and stabilize existing plaques, reducing the risk of arterial occlusion or embolism that could cause another stroke, as supported by the 2016 ESC/EAS guidelines for the management of dyslipidaemias 1. Overall, aggressive LDL management is recommended because lower LDL levels are associated with reduced risk of recurrent stroke and other cardiovascular events.

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 recommended LDL goal for stroke patients is not explicitly stated in the provided drug label. However, the label does indicate that atorvastatin is used to reduce the risk of stroke in adults with multiple risk factors for coronary heart disease (CHD) and in adults with type 2 diabetes mellitus with multiple risk factors for CHD.

• The label recommends assessing LDL-C when clinically appropriate, as early as 4 weeks after initiating atorvastatin, and adjusting the dosage if necessary.
• The dosage range for adults is 10 mg to 80 mg once daily, with a recommended starting dosage of 10 or 20 mg once daily.
• Patients requiring LDL-C reduction >45% may start at 40 mg once daily 2.

From the Research

LDL Goal for Stroke Patients

The recommended low-density lipoprotein (LDL) goal for stroke patients is a topic of ongoing research and debate. Several studies have investigated the optimal LDL target for reducing cardiovascular events in patients with ischemic stroke.

• A study published in 2020 in the journal Stroke found that targeting a LDL cholesterol level of <70 mg/dL reduced the risk of major vascular events in patients with ischemic stroke of atherosclerotic origin 3.
• Another study published in 2020 in The New England Journal of Medicine found that patients with ischemic stroke who had a target LDL cholesterol level of <70 mg/dL had a lower risk of subsequent cardiovascular events compared to those with a target range of 90-110 mg/dL 4.
• A subgroup analysis of patients with diabetes found that targeting a LDL cholesterol level of <70 mg/dL reduced the risk of subsequent cardiovascular events in patients with diabetes, with a number needed to treat of 17 5.
• A study published in 2014 in the journal Stroke found that only 19.8% of patients with stroke had LDL levels <70 mg/dL, and that management of dyslipidemia in high-risk patients with preexistent cardiovascular disease or stroke continues to be suboptimal 6.
• A review article published in 2019 in Current Treatment Options in Neurology noted that LDL-cholesterol remains the primary lipid treatment target for reduction of stroke risk, and that randomized trials have shown that each reduction of 40 mg/dL in the level of LDL-cholesterol reduces the stroke risk by approximately one quarter 7.

Key Findings

• Targeting a LDL cholesterol level of <70 mg/dL reduces the risk of major vascular events in patients with ischemic stroke of atherosclerotic origin.
• Patients with diabetes may benefit from a more aggressive LDL target, with a number needed to treat of 17.
• Management of dyslipidemia in high-risk patients with preexistent cardiovascular disease or stroke continues to be suboptimal.
• LDL-cholesterol remains the primary lipid treatment target for reduction of stroke risk.