Start with HIGH-dose atorvastatin after stroke

Continue to start with a high-intensity statin like atorvastatin (Lipitor, Ator) 80 mg/day for most stroke patients....
Mahitab Hany, BS Pharm, PGDipClinPharm, PGDipClinNutrition

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

  1. Amarenco P, Kim JS, et al. A Comparison of Two LDL Cholesterol Targets after Ischemic Stroke. N Engl J Med. 2020 Jan 2;382(1):9.
  2. Grundy SM, Stone NJ, Bailey AL, et al. 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;73(24):e285-e350.
  3. Kernan WN, Ovbiagele B, et al. 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.