New insights in LDL-Cholesterol levels after a stroke

The administration of statins to decisively lower LDL levels in patients who have had a transient ischemic attack (TIA) or an atherosclerotic ischemic stroke reduces the risk of further severe cardiovascular events.

Lowering LDL-Cholesterol decreases cardio-cerebrovascular problems

The administration of statins to decisively lower low-density lipoproteins (LDL) levels in patients who have had a transient ischemic attack (TIA) or an atherosclerotic ischemic stroke reduces the risk of further severe cardiovascular events. This is supported by the "Treat Stroke to Target" study presented at the AHA Scientific Sessions in late 2019.

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Professor Pierre Amarenco, of the University of Paris, France, conducted research on lowering LDL cholesterol levels in patients with TIA or ischemic stroke, the results of which were published in the New England Journal of Medicine. The research was not completed due to a lack of funding.

The "Treat Stroke to Target" study, which involved patients with TIA or ischemic stroke and evidence of atherosclerotic disease, compared the follow-up of those with statins and, if necessary, ezetimibe with LDL cholesterol targets below 70 mg/dl with those with a target between 90 and 110 mg/dl. 

The study was conducted at 77 sites in Korea and France, with planned recruitment of 3,786 patients. Recruitment was so slow, however, that when the steering committee discontinued the study, only 2,873 patients were enrolled. The baseline LDL-cholesterol value for the entire cohort was 135 mg/dl. By the end of the 3.5-year follow-up, randomized patients in the most aggressive target group had reached an average LDL level of 65 mg/dl, while the comparison group averaged 95 mg/dl.

The study shows that, during the follow-up period, patients with lower LDL targets had an ischemic stroke, myocardial infarction, symptomatology leading to urgent coronary or carotid revascularization, or death from cardiovascular causes, in 8.5% of cases. The control group presented these in 10.9% of cases.

It is important to note that the incidence of intracranial hemorrhage (ICH), a key concern for aggressive LDL lowering in these patients, did not increase in patients in the lower target group. In the only previous study of lipid reduction in these patients, the 2006 SPARCL study, a 66% increase in ICH was observed. Differences were not found in rates of new diabetes, a recognized risk of statin therapy.

The study results opened a lively debate since the guidelines for the management of lipidemia have been subject to different and controversial changes in recent years. According to some, these fit quite well in the 2018 guidelines, which emphasize lowering high LDL values by at least 50% in high-risk patients, and therefore to intensify efforts if they remain above 70 mg/dl.

Amarenco P, Kim JS, Labreuche J, Charles H, Abtan J, Béjot Y, Cabrejo L, Cha JK, Ducrocq G, Giroud M, Guidoux C, Hobeanu C, Kim YJ, Lapergue B, Lavallée PC, Lee BC, Lee KB, Leys D, Mahagne MH, Meseguer E, Nighoghossian N, Pico F, Samson Y, Sibon I, Steg PG, Sung SM, Touboul PJ, Touzé E, Varenne O, Vicaut É, Yelles N, Bruckert E; Treat Stroke to Target Investigators. A Comparison of Two LDL Cholesterol Targets after Ischemic Stroke. N Engl J Med. 2019 Nov 18. doi: 10.1056/NEJMoa1910355.