Statins for stroke: the second story?

Abstract

In the 100 years since Ignatovski demonstrated that high-fat diets promote atherosclerosis in rabbits,1 cardiologists have witnessed an extraordinary evolution in our understanding of atherothrombosis and lipid reduction, culminating in the publication of 5 landmark trials of HMG-CoA reductase inhibition within the past 6 years.2 3 4 5 6 In each of these trials, statin therapy was shown to significantly reduce the risks of coronary heart disease in populations with progressively lower degrees of overall risk. These data have had profound effects on preventive medicine and established the first clear success story for this class of therapy. Despite these triumphs, questions remain in our understanding of statins, how they work, and in what settings. As a result, clinical paradigms regarding cholesterol reduction continue to shift. In this sense, the large meta-analysis from the Prospective Pravastatin Pooling Project, which was published in this issue of Circulation , addresses a question that may represent a second success story for the statins.7 Does statin therapy lower the risk of stroke and, if so, why, given the controversy over the role of LDL cholesterol as a risk factor for stroke? These are some of the issues that Byington and colleagues7 address in their analysis of cerebrovascular events in the Prospective Pravastatin Pooling Project, a carefully performed systematic overview including 19 768 patients enrolled in the Long-term Intervention with Pravastatin in Ischaemic Disease (LIPID) trial, the Cholesterol and Recurrent Events (CARE) study, and West of Scotland Coronary Prevention Study (WOSCOPS), each of which randomly allocated study participants between 40 mg of pravastatin or placebo. As outlined in their article, a reduction in stroke events was observed in all 3 of …