Should Statins Be Paused or Discontinued After Thrombolysis or Acute Intracerebral Hemorrhage? No!

Abstract

A 78-year-old male patient arrives at the emergency department 3 hours after sudden onset of aphasia and right-sided sensorimotor hemiparesis (National Institutes of Health Stroke Scale=8). There is a medical history of coronary artery disease, hypertension, and hyperlipidemia. Prior medication consists of 100 mg aspirin, 5 mg bisoprolol, and 40 mg simvastatin. Initial blood glucose is 5.6 mmol/L and blood pressure is 150/90 mm Hg. Computed tomography does not reveal any pathology. Intravenous recombinant tissue-plasminogen activator (rt-PA) is rapidly administered 225 minutes after symptom onset. There is uncertainty about how to proceed with preexisting statin treatment in the acute setting of thrombolysis. Several studies linked statin treatment with an increased risk of intracerebral hemorrhage (ICH) after stroke, and additional studies recently indicated an increased risk for ICH after thrombolysis.1–4 This is in line with earlier epidemiological evidence showing an inverse correlation of cholesterol and ICH risk.5,6 Should statin treatment be discontinued following the principle “primum nil nocere” (Latin: first of all, do not harm)? On the contrary, there is strong evidence that discontinuation of statin therapy during acute vascular events, including ischemic as well as hemorrhagic stroke, impairs vascular function and dramatically decreases the chances of good outcome and survival.7–10 In this opinion article, we would like to make a strong case that preexisting statin treatment should not be paused or abruptly discontinued, either in acute ischemic stroke patients receiving rt-PA or in patients with acute ICH. What is the evidence that stroke patients on statins have a higher risk of ICH? The evidence for risks and benefits of statins after stroke are mainly derived from the Heart Protection Study and the Stroke Prevention by Aggressive Reduction in Cholesterol Levels (SPARCL) trial.1,2 A subgroup analysis of the Heart …