What is the target low-density lipoprotein (LDL) level for a patient with a history of hypertension and dyslipidemia presenting with slurred speech suggestive of a potential stroke or transient ischemic attack (TIA)?

Target LDL Level for Stroke/TIA Patients

For a patient presenting with slurred speech suggestive of stroke or TIA with a history of hypertension and dyslipidemia, the target LDL cholesterol level is less than 1.8 mmol/L (70 mg/dL), which corresponds to answer A - Less than 2 mmol/L. 1, 2

Evidence-Based Target Goals

The most recent and authoritative guidelines establish clear LDL-C targets for patients with ischemic stroke or TIA:

• The 2021 American Heart Association/American Stroke Association guidelines (Class I, Level A recommendation) specify that patients with ischemic stroke or TIA and atherosclerotic disease should achieve an LDL-C goal of <70 mg/dL (<1.8 mmol/L). 1

• The 2023 World Stroke Organization guidelines reinforce this target, recommending LDL-cholesterol <1.8 mmol/L (70 mg/dL) for all patients with ischemic stroke and TIA across all resource settings. 2

Treatment Approach to Achieve Target

Initiate atorvastatin 80 mg daily immediately for patients with recent stroke/TIA and LDL-C >100 mg/dL (>2.6 mmol/L) without proven cardioembolic mechanism. 1, 2

• This high-intensity statin regimen reduces stroke recurrence by 16-18% and major cardiovascular events by 20%. 1, 3

Add ezetimibe 10 mg if the target of <1.8 mmol/L is not achieved with statin monotherapy. 1, 2

• Ezetimibe provides an additional 15-25% LDL-C reduction when combined with statins. 3

For patients still not reaching target on maximally tolerated statin plus ezetimibe, consider PCSK9 inhibitor therapy. 1, 2

• PCSK9 inhibitors provide an additional 45-64% LDL-C reduction. 3

Monitoring Requirements

Check lipid levels 1-3 months after treatment initiation to assess response, then continue monitoring every 3-12 months thereafter. 1, 2

• This ensures adherence and allows for dose adjustments to achieve the target LDL-C <70 mg/dL. 1

Why This Target Matters

The landmark TST (Treat Stroke to Target) trial confirmed that targeting LDL-C <70 mg/dL was superior to a target of 90-110 mg/dL for preventing major cardiovascular events in stroke patients. 1

• Patients at greatest cardiovascular risk (those with stroke/TIA plus hypertension and dyslipidemia) benefit most from aggressive LDL-C lowering. 1, 4

Common Pitfall to Avoid

Do not settle for the older, less aggressive target of <100 mg/dL (2.6 mmol/L). 1

• While the 2011 guidelines suggested LDL-C <100 mg/dL as acceptable, the 2021 guidelines based on newer trial evidence (SPARCL and TST) clearly establish <70 mg/dL as the evidence-based target for secondary stroke prevention. 1, 2