New evidence will spark questions about whether to aim for an LDL goal in patients with a prior ischemic stroke or TIA. For several years, we’ve been using target DOSES of statins shown to reduce cardiovascular (CV) risk rather than titrating to an LDL goal.
Now data suggest treating to an LDL below 70 mg/dL instead of about 95 mg/dL prevents a recurrent CV event in about 1 in 42 ischemic stroke or TIA patients treated for 3.5 years. This is in patients on statins plus ezetimibe (Choletimb) if needed to reach their LDL target. Consider this evidence more support for recent cholesterol guideline changes that bring back some emphasis on LDL for high-CV-risk patients.
Continue to start with a high-intensity statin like atorvastatin (Lipitor, Ator) 80 mg/day for most stroke patients. But don’t use a “fire and forget” approach. Check an LDL 4 to 12 weeks after starting the statin and then about annually. Evaluate adherence to lifestyle changes and statins if LDL stays above 70 mg/dL, since many patients need help sticking with a statin.
Consider adding a non-statin if that’s not enough, especially in stroke patients with CV risks, such as high blood pressure, diabetes, or smoking. When a non-statin is needed for LDL reduction, generally add ezetimibe (Choletimb) 10 mg once. It’s well tolerated and NOT expensive. Injectable PCSK9 inhibitors (Praluent, Repatha) still very cost.
REFERENCES
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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. 2020 Jan 2;382(1):9. Available at: https://www.nejm.org/doi/10.1056/NEJMoa1910355
Grundy SM, Stone NJ, Bailey AL, Beam C, Birtcher KK, Blumenthal RS, Braun LT, de Ferranti S, Faiella-Tommasino J, Forman DE, Goldberg R, Heidenreich PA, Hlatky MA, Jones DW, Lloyd-Jones D, Lopez-Pajares N, Ndumele CE, Orringer CE, Peralta CA, Saseen JJ, Smith SC Jr, Sperling L, Virani SS, Yeboah J. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2019 Jun 25;73(24):e285-e350. Available at: https://www.sciencedirect.com/science/article/pii/S073510971839034X?via%3Dihub
Kernan WN, Ovbiagele B, Black HR, Bravata DM, Chimowitz MI, Ezekowitz MD, Fang MC, Fisher M, Furie KL, Heck DV, Johnston SC, Kasner SE, Kittner SJ, Mitchell PH, Rich MW, Richardson D, Schwamm LH, Wilson JA; American Heart Association Stroke Council, Council on Cardiovascular and Stroke Nursing, Council on Clinical Cardiology, and Council on Peripheral Vascular Disease. Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2014 Jul;45(7):2160-236. Available at: https://www.ahajournals.org/doi/10.1161/STR.0000000000000024