What are the statin (3-hydroxy-3-methylglutaryl-coenzyme A reductase inhibitor) recommendations for patients post ischemic stroke?

From the Guidelines

Statin therapy is strongly recommended for patients post ischemic stroke to prevent recurrent strokes and other cardiovascular events, with atorvastatin 80 mg daily indicated for patients with LDL cholesterol >100 mg/dL and no known coronary heart disease. The American Heart Association/American Stroke Association guideline [ 1 ] recommends lipid-lowering therapy with a statin, and also ezetimibe if needed, to a goal LDL-C of <70 mg/dL to reduce the risk of major cardiovascular events in patients with ischemic stroke or TIA and atherosclerotic disease.

Some key points to consider when prescribing statins for secondary prevention of stroke include:

• High-intensity statins such as atorvastatin 40-80 mg daily or rosuvastatin 20-40 mg daily are preferred for secondary prevention [ 1 ].
• For patients who cannot tolerate high-intensity therapy, moderate-intensity statins like atorvastatin 10-20 mg, rosuvastatin 5-10 mg, simvastatin 20-40 mg, or pravastatin 40-80 mg daily are alternatives.
• Treatment should begin as soon as possible after stroke onset, ideally within 24-48 hours, and continue indefinitely.
• The target LDL-cholesterol level is generally below 70 mg/dL (1.8 mmol/L) for secondary prevention [ 1 ].
• Regular monitoring of liver function tests and creatine kinase is recommended, particularly in the first few months of therapy [ 1 ].
• Patients should be counseled about potential side effects including muscle pain, which occurs in approximately 5-10% of patients.

The evidence from recent studies, including the SPARCL and TST trials [ 1 ], supports the use of statins in secondary prevention of stroke, with significant benefits in reducing vascular events, including stroke. Therefore, statin therapy should be initiated as soon as possible after ischemic stroke, with a goal of achieving a LDL-C level <70 mg/dL.

From the Research

Statin Recommendations for Post-Ischemic Stroke Patients

• The use of statins in patients with post-ischemic stroke has been extensively studied, with evidence suggesting that statin therapy can reduce the risk of recurrent stroke and cardiovascular events 2, 3, 4, 5, 6.
• High-intensity statin therapy is recommended for patients with ischemic stroke or transient ischemic attack (TIA) presumed to be of atherosclerotic origin or with other comorbid atherosclerotic cardiovascular disease 2, 4, 6.
• The SPARCL trial demonstrated that high-dose atorvastatin (80 mg/day) reduced the risk of recurrent stroke by 16% and the risk of major cardiovascular events by 20% in patients with recent stroke or TIA 2.
• Other studies have shown that statin therapy can reduce the risk of stroke recurrence by 12-16% and improve survival in patients with atrial fibrillation-related stroke 3.
• The benefits of statin therapy in ischemic stroke prevention are thought to be due to their ability to reduce low-density lipoprotein (LDL) cholesterol levels, with each 1 mmol/L (39 mg/dL) decrease in LDL cholesterol associated with a 21.1% reduction in relative risk for stroke 4.

LDL-Cholesterol Targets and Statin Therapy

• LDL-cholesterol remains the primary lipid treatment target for reduction of stroke risk, with randomized trials showing that each reduction of 40 mg/dL in LDL-cholesterol levels reduces the stroke risk by approximately one quarter 6.
• High-intensity statin therapy is advocated for the treatment of ischemic stroke, with the goal of achieving an LDL-cholesterol level of less than 70 mg/dL 5, 6.
• The addition of non-statin lipid-modifying therapies, such as ezetimibe and PCSK9 inhibitors, to statin therapy may provide further reductions in stroke risk 6.

Safety and Efficacy of Statin Therapy

• While statin therapy is generally well-tolerated, there are concerns regarding the adverse effects associated with statin use in ischemic stroke, such as intracranial hemorrhage 5.
• The benefits of statin therapy in ischemic stroke prevention are thought to outweigh the risks, with good adherence to statin therapy associated with better clinical outcomes and statin withdrawal associated with poor functional outcomes 5.