Reader response: Low-density lipoprotein cholesterol and risk of intracerebral hemorrhage: A prospective study

Abstract

We read with great interest the article by Ma et al.1 on the relationship between reduced low-density lipoprotein cholesterol (LDL-C) levels and intracerebral hemorrhage (ICH). In our opinion, this possibly causal association needs to be better investigated to avoid ICH secondary to therapeutic LDL-C lowering. Indeed, international guidelines on acute coronary syndromes recommend early administration of high-intensity statins to satisfy “the lower, the faster, the better” concept.2 Nowadays, new lipid-lowering therapies—such as proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors—allow patients to reach very low LDL-C levels. Unfortunately, long-term follow-up for these drugs is not available, but it has been suggested that in patients with preexisting ischemic heart disease already on statin therapy, LDL-C levels do not necessarily need to be lowered below 70 mg/dL.3 For these reasons, we cautiously suggest that in patients with chronic ischemic heart disease, PCSK9 inhibitor therapy may be administered at greater intervals4 so as to obtain an optimal balance between cardiovascular risk reduction, hemorrhagic risk avoidance, and mitigation of side effects related to lipid-lowering therapy.