From the Guidelines
Statin therapy is indicated for secondary prevention of lacunar infarct, with the goal of achieving a target LDL cholesterol consistently less than 2.0 mmol/L or >50% reduction of LDL cholesterol from baseline. According to the most recent and highest quality study, the 2021 guideline for the prevention of stroke in patients with stroke and transient ischemic attack 1, high-intensity statin use is supported for patients with intracranial atherosclerosis, which includes those with lacunar infarcts. The study suggests that high-intensity statins can lower the rate of cerebrovascular events and that lower LDLs are associated with lower vascular event rates in patients with intracranial atherosclerosis.
The 2018 Canadian stroke best practice recommendations also support the use of statins for secondary prevention of ischemic stroke or transient ischemic attack, including lacunar infarcts, to achieve a target LDL cholesterol consistently less than 2.0 mmol/L or >50% reduction of LDL cholesterol from baseline 1. The recommended statin regimens include high-intensity options such as atorvastatin 40-80 mg daily or rosuvastatin 20-40 mg daily, as well as moderate-intensity options.
Key points to consider when prescribing statins for secondary prevention of lacunar infarct include:
- Monitoring for potential side effects, including myalgias, elevated liver enzymes, and rarely rhabdomyolysis
- Combining statins with lifestyle modifications, such as a heart-healthy diet, regular exercise, smoking cessation, and blood pressure control, to provide optimal secondary prevention
- Continuing treatment indefinitely as secondary prevention
- Achieving a target LDL cholesterol consistently less than 2.0 mmol/L or >50% reduction of LDL cholesterol from baseline.
Overall, the use of statins for secondary prevention of lacunar infarct is supported by the most recent and highest quality evidence, and should be considered a key component of comprehensive stroke prevention strategies.
From the Research
Statin Indication for Secondary Prevention of Lacunar Infarct
- Statins, or HMG-CoA reductase inhibitors, are indicated for the secondary prevention of cardiovascular events, including lacunar infarct, as they lower total and LDL cholesterol and decrease the risk of cardiovascular events 2.
- The absolute benefits of statins are greater in patients with a higher baseline cardiovascular risk, making them particularly suited for secondary prevention 2.
- Early initiation of statin therapy after admission for acute coronary syndromes, stroke, or transient ischemic attack (TIA) is associated with improved cardiovascular outcomes 3.
- Statins have been shown to reduce morbidity and mortality in patients with established atherosclerosis-related cardiovascular disease, including those with a history of lacunar infarct 3.
- The use of statins in secondary prevention is supported by numerous studies, including those that have demonstrated a reduction in the risk of cardiovascular events, all-cause mortality, cardiovascular mortality, revascularization, and stroke 4, 3, 5.
Mechanism of Action
- Statins inhibit platelet function via reduction of circulating low-density lipoprotein-cholesterol (LDL-C) levels and a more direct inhibition of platelet function 4.
- Statins also upregulate endothelial NO-synthase and improve endothelial oxygen defense by inhibition of NADPH-oxidase, which contributes to their beneficial effects in secondary prevention 4.
Clinical Evidence
- Clinical studies have consistently shown that statin treatment reduces the risk of further cardiovascular events and lowers overall mortality in patients with a history of cardiovascular disease, including lacunar infarct 2, 3, 5.
- The evidence supports the use of statins in secondary prevention, regardless of the specific type of statin used, although some studies suggest that high-dose statin treatment may be more effective in reducing cardiovascular events 3, 5.