Statins and stroke The SPARCL trial was the first study to look specifically at the effect of atorvastatin vs placebo in reducing the risk for stroke in patients with a prior stroke or TIA, but without a prior history of heart disease. The study randomly assigned 4731 patients with a stroke or TIA within the past one to six months to 80 mg/day of atorvastatin or placebo. Significant LDL reductions in the atorvastatin group translated into a significant 16% reduction in the primary end point of nonfatal or fatal stroke, occurring in 11.2% of atorvastatin and 13.1% of placebo patients, a five-year absolute risk reduction of 2.2% and an adjusted hazard ratio of 0.84 (p=0.03) [2]. Strikingly, given the lack of baseline CAD in this cohort, the risk of major coronary events was also significantly reduced in the atorvastatintreated patients, a 35% reduction in major coronary events (MCE) and a 42% reduction for any coronary heart disease (CHD). There was however, an incr'ed rate of hemorrhagic stroke in the atorvast grp. A post hoc analysis (presented at ACC 07) looked at the between TIA or CVA and 1st CAD episode (in pat w no h/o was estimated at 18.3% prior to stroke and increased to Statins had a hige impact on dercreasing the appearance or TIA: HR of 0.53 (p=0.042) w lipitor 80mg. realtionship CAD). 10 y risk 24.5% p stroke. of CAD p stroke
This brings the idea that TIA or CVA may have to be treated as a CADequivalent, just like DM. http://www.theheart.org/article/781639.do Amarenco. High-dose atorvastatin after stroke or transient ischemic attack. N Engl J Med 2006; 355:549-559. ---------------Statins and Hemorrhagic Stroke: Shedding Light on SPARCL A new analysis of influential trial data clarifies the risks associated with statins for secondary prevention of stroke. The manufacturer-funded SPARCL Study (Journal Watch Cardiology Aug 30 2006) was the first randomized trial to demonstrate that atorvastatin reduces the risk for subsequent stroke after recent stroke or transient ischemic attack. Although the results were convincing, concerns were raised when post-hoc analyses demonstrated an increased risk for hemorrhagic stroke in the atorvastatin arm. With the present analysis, SPARCL investigators sought to determine predictors of hemorrhagic stroke in the study cohort. Nearly 5000 patients were included in the analysis, 88 of whom experienced hemorrhagic stroke during follow-up. In multivariable models,
factors significantly associated with subsequent hemorrhagic stroke were atorvastatin treatment (hazard ratio, 1.68), hemorrhagic stroke at entry (HR, 5.65), male sex (HR, 1.79), increasing age (HR, 1.42 for each 10year increment), and stage 2 hypertension (systolic BP ³160 mm Hg or diastolic BP ³100 mm Hg) upon entry (HR, 6.19). LDL cholesterol level was not associated with hemorrhagic stroke risk. Comment: This post-hoc analysis confirms results of a large study of patients with recent stroke, which suggested that although atorvastatin is associated with a significant reduction in risk for subsequent stroke from any cause, it is also associated with an increased risk for hemorrhagic stroke. It seems reasonable to assume that these benefits and risks are a class effect of statins. Therefore, clinicians caring for stroke patients, particularly those with the predictors identified in this study Ñ prior hemorrhagic stroke, male sex, advanced age, and stage 2 hypertension Ñ should weigh the known benefits of statins in preventing ischemic stroke and cardiovascular events against the possibility that they may increase the risk for hemorrhagic stroke. Goldstein LB et al. on behalf of the SPARCL investigators. Hemorrhagic stroke in the Stroke Prevention by Aggressive Reduction in Cholesterol Levels study. Neurology 2007 Dec 12; [e-pub ahead of print].