Secondary prevention of stroke

Abstract

Geoffrey Donnan and colleagues, in their Seminar on stroke (May 10, p 1612),1Donnan GA Fisher M Macleod M Davis SM Stroke.Lancet. 2008; 371: 1612-1623Summary Full Text Full Text PDF PubMed Scopus (2035) Google Scholar mention cholesterol reduction with statins among the proven secondary prevention strategies. However, although statin treatment might be effective in the prevention of stroke in patients with known coronary-artery disease but without a history of cerebrovascular disease, its role in the secondary prevention of stroke raises some serious concerns. Indeed, the SPARCL study2Amarenco P Bogousslavsky J Callahan 3rd, A et al.for the Stroke Prevention by Aggressive Reduction in Cholesterol Levels (SPARCL) InvestigatorsHigh–dose atorvastatin after stroke or transient ischemic attack.N Engl J Med. 2006; 355: 549-559Crossref PubMed Scopus (2297) Google Scholar found that, compared with placebo, the use of 80 mg atorvastatin per day in patients who had a stroke or transient ischaemic attack was associated with a non-significant 13% relative risk reduction of non-fatal stroke during a 5-year follow-up, without improving survival, and with a 66% increase in the relative risk of haemorrhagic stroke among patients receiving high-dose statin. Furthermore, a review3Vergouwen MD de Haan RJ Vermeulen M Roos YB Statin treatment and the occurrence of hemorrhagic stroke in patients with a history of cerebrovascular disease.Stroke. 2008; 39: 497-502Crossref PubMed Scopus (153) Google Scholar found that, in the secondary prevention of cerebrovascular events, statin therapy decreases the occurrence of ischaemic stroke but that this effect is counterbalanced by an increase in the occurrence of haemorrhagic stroke. Lower LDL cholesterol concentrations with or without statin treatment have also been shown to be strongly and independently related to a higher risk of symptomatic haemorrhagic transformation after ischaemic stroke thrombolysis.4Bang OY Saver JL Liebeskind DS et al.Cholesterol level and symptomatic hemorrhagic transformation after ischemic stroke thrombolysis.Neurology. 2007; 68: 737-742Crossref PubMed Scopus (142) Google Scholar Finally, an inverse relation has been shown between stroke severity and cholesterol concentrations.5Olsen TS Christensen RH Kammersgaard LP Andersen KK Higher total serum cholesterol levels are associated with less severe strokes and lower all-cause mortality. Ten-year follow-up of ischemic strokes in the Copenhagen Stroke Study.Stroke. 2007; 38: 2646-2651Crossref PubMed Scopus (93) Google Scholar Higher total serum cholesterol favours the development of minor stroke, and, owing to selection, major strokes are more often seen in patients with lower total serum cholesterol concentrations.5Olsen TS Christensen RH Kammersgaard LP Andersen KK Higher total serum cholesterol levels are associated with less severe strokes and lower all-cause mortality. Ten-year follow-up of ischemic strokes in the Copenhagen Stroke Study.Stroke. 2007; 38: 2646-2651Crossref PubMed Scopus (93) Google Scholar Therefore, it is also plausible that statin therapy might decrease only milder stroke subtypes. We declare that we have no conflict of interest. Secondary prevention of stroke – Authors' replyLuca Mascitelli and colleagues suggest that the effect of statins in the secondary prevention of stroke is modest, associated with an increased risk of haemorrhagic stroke, and might protect mild strokes only. We would argue against this at a number of levels. Full-Text PDF