What is the best statin (HMG-CoA reductase inhibitor) use for an elderly patient with a history of ischemic stroke detected on computed tomography (CT) scan?

From the Guidelines

For an elderly patient with a history of ischemic stroke detected on computed tomography (CT) scan, atorvastatin 80 mg daily is the recommended statin therapy to reduce stroke recurrence, as evidenced by the most recent and highest quality study 1. The goal of statin therapy in this context is to reduce LDL cholesterol levels to below 70 mg/dL, which has been shown to be effective in preventing vascular events, including stroke 1. Key points to consider when prescribing statin therapy for secondary stroke prevention include:

• The patient's LDL cholesterol level should be monitored 1-3 months after treatment initiation, followed by regular assessments and dose adjustments every 3-12 months thereafter 1
• The target LDL cholesterol level should be < 1.8 mmol/L (70 mg/dL), and ezetimibe can be added to atorvastatin to reach this goal if necessary 1
• In patients who are unable to achieve the target LDL cholesterol level, consideration should be made to refer to an expert in lipid management for adding a PCSK9 inhibitor 1
• Regular monitoring of liver function tests and checking for muscle symptoms is important, especially in the first few months of therapy
• Combining statins with a Mediterranean diet, regular physical activity, and smoking cessation provides optimal protection against recurrent stroke 1

From the FDA Drug Label

In a clinical study of patients treated with simvastatin 80 mg daily, patients ≥65 years of age had an increased risk of myopathy, including rhabdomyolysis, compared to patients <65 years of age A pharmacokinetic study with simvastatin use showed the mean plasma level of total inhibitors to be approximately 45% higher in geriatric patients between 70-78 years of age compared with patients between 18-30 years of age

The best statin for an elderly patient with a history of ischemic stroke is not explicitly stated in the provided drug labels. However, considering the increased risk of myopathy in geriatric patients, simvastatin may not be the best option due to its increased risk of myopathy in elderly patients.

• Geriatric patients may require closer monitoring and a lower dose due to the increased risk of myopathy.
• The pharmacokinetic study suggests that geriatric patients may have higher plasma levels of simvastatin, which could increase the risk of adverse effects. However, without direct information comparing different statins in elderly patients with a history of ischemic stroke, no conclusion can be drawn about the best statin for this specific patient population 2, 2, 2.

From the Research

Statin Therapy for Elderly Patients with Ischemic Stroke

• The use of statins, specifically atorvastatin, has been widely investigated in elderly patients with a history of ischemic stroke 3, 4.
• Atorvastatin has been shown to reduce the risk of stroke and improve clinical outcomes in older patients, making it a suitable option for elderly patients with ischemic stroke 3, 4.
• The pharmacokinetic properties of atorvastatin allow it to be used every other day, which may decrease adverse events and be especially important in the elderly 3.

Efficacy of Atorvastatin in Reducing Stroke Risk

• Atorvastatin has been shown to reduce the risk of fatal or nonfatal stroke by 16% in patients with a history of stroke or transient ischemic attack (TIA) 4, 5.
• High-dose atorvastatin (80 mg/day) has been shown to reduce the risk of stroke and cardiovascular events in patients with recent stroke or TIA and without known coronary heart disease 5.
• Atorvastatin has also been shown to reduce the risk of recurrent ischemic stroke in diabetic patients, with a hazard ratio of 2.03 compared to simvastatin 6.

Comparison of Atorvastatin with Other Statins

• Atorvastatin has been compared to simvastatin and ezetimibe-simvastatin combination therapy in reducing the risk of recurrent ischemic stroke in diabetic patients 6.
• Atorvastatin 40 mg plus ezetimibe 10 mg has been shown to be more effective than atorvastatin 80 mg in reducing LDL cholesterol levels in patients with ischemic stroke or TIA 7.
• The combination of atorvastatin and ezetimibe has been shown to be safe and well-tolerated, with a low number of secondary effects 7.

Considerations for Elderly Patients

• Elderly patients are at increased risk of coronary heart disease and account for a majority of coronary heart disease deaths 3.
• Statin therapy remains under-utilized among the elderly, despite the beneficial effects of statins in reducing the risk of stroke and improving clinical outcomes 3.
• The choice of statin and dosage should be individualized based on the patient's risk factors, medical history, and tolerance to the medication 3, 4, 5, 7.