Current status of statin therapy for stroke prevention

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Stroke is a leading cause of mortality and long-term disability in the Western world. Lipid abnormalities are a key risk factor for stroke, elevated LDL-cholesterol being the most common abnormality. No clear association has been demonstrated between elevated LDL-cholesterol and stroke incidence, possibly due to the lack of appropriate etiopathophysiological classification of stroke in most studies. Nonetheless, statin therapy is associated with significant reduction in first and recurrent stroke, and there remains a net benefit despite a significant but small increase in hemorrhagic stroke. Following a stroke, indirect evidence supports continuation of prestroke statin therapy while the impact of de novo statin therapy in acute stroke remains uncertain. International guidelines advise an objective assessment of cardiovascular risk to determine the appropriateness of statins for primary prevention and near universal use of statins for secondary prevention after the acute phase of ischemic stroke. There is lack of consensus with regard to the choice of agent, timing of initiation, dose and duration of therapy. Some guidelines advocate high-dose atorvastatin while others suggest the use of simvastatin owing to generic availability and low cost. While the benefits of preventive interventions for stroke are well established and clearly outlined in international guidelines, there is poor application of such measures in clinical practice. This article summarizes the current understanding of the role of statins in stroke prevention and early studies of potential interventions to overcome the barriers to effective statin therapy for secondary prevention. There is a clear need for further research into identifying deficiencies in long-term management, barriers to optimal secondary prevention and novel interventions to overcome these barriers.