From the Guidelines
For patients with a history of stroke, atorvastatin 80 mg daily is recommended to reduce the risk of stroke recurrence, as supported by the 2021 guideline for the prevention of stroke in patients with stroke and transient ischemic attack 1. The goal of statin therapy in these patients is to reduce LDL cholesterol by ≥50% from baseline, which significantly lowers the risk of recurrent stroke and other cardiovascular events.
- High-intensity statin therapy, such as atorvastatin 80 mg daily, is the preferred option for patients with ischemic stroke and no known coronary heart disease, as it has been shown to reduce the risk of stroke recurrence 1.
- The target LDL-cholesterol level in patients with ischemic stroke and TIA should be < 1.8 mmol/L (70 mg/dL), and ezetimibe can be added to atorvastatin to reach this goal if necessary 1.
- Regular monitoring of liver function tests and creatine kinase is recommended, especially during the first year of therapy, and patients should be counseled about potential side effects such as muscle pain and advised to report these symptoms promptly.
- The use of statin therapy should be individualized, particularly in older adults, and consideration should be given to the potential for adverse effects, drug-drug interactions, and patient preferences 1.
From the FDA Drug Label
Adults:Recommended dosage range is 5 mg to 40 mg once daily. To reduce the risk of major adverse cardiovascular (CV) events (CV death, nonfatal myocardial infarction, nonfatal stroke, or an arterial revascularization procedure) in adults without established coronary heart disease who are at increased risk of CV disease based on age, high-sensitivity C-reactive protein (hsCRP) ≥2 mg/L, and at least one additional CV risk factor.
The recommended dose of statin (rosuvastatin) for a patient with a history of stroke is 5 mg to 40 mg once daily 2.
- The dosage should be adjusted based on individual patient needs and response to treatment.
- It is essential to assess LDL-C levels when clinically appropriate and adjust the dosage if necessary.
- Patients with a history of stroke may require closer monitoring and more aggressive lipid-lowering therapy to reduce the risk of future cardiovascular events.
From the Research
Statin Dosage for Patients with a History of Stroke
The recommended dose of statin (HMG-CoA reductase inhibitor) for a patient with a history of stroke is typically high-intensity, with a goal of achieving a low-density lipoprotein cholesterol (LDL-C) level of less than 70 mg/dl.
- The SPARCL trial 3 found that atorvastatin 80 mg/day significantly reduced the risk of stroke and major coronary events in patients with a recent stroke or transient ischemic attack.
- The study published in The New England Journal of Medicine 4 also found that 80 mg of atorvastatin per day reduced the overall incidence of strokes and cardiovascular events in patients with recent stroke or transient ischemic attack.
- A systematic review and network meta-analysis 5 found that high doses of statins (e.g., atorvastatin 80 mg/day) were associated with the greatest benefits in reducing the risk of ischemic stroke and cardiovascular events.
Comparison of Statin Intensities
- A nationwide cohort study 6 found that high-intensity statin treatment was associated with a similar risk of most effectiveness and safety outcomes compared to moderate-intensity statin treatment, but with a reduced risk of all-cause mortality and an increased risk of diabetes.
- The study published in BMC Medicine 5 found that the differences in effects among statins were modest, signaling potential therapeutic equivalence.
Additional Considerations
- The use of ezetimibe and PCSK9 inhibitors with or without statin therapy may also be considered for cardiovascular risk reduction, particularly in patients with very high or high cardiovascular risk 7.
- The choice of statin and dose should be individualized based on the patient's specific needs and risk factors.