Statins in Stroke Prevention: Present and Future.

BACKGROUND: Over the last decades, the reduction of the mortality and morbidity of stroke has been a high- priority objective worldwide. Statins, or 3-hydroxy-3- methylglutaryl coenzyme A (HMG- CoA) reductase inhibitors, have emerged as the predominant preventive strat egy to tackle the worldwide stroke burden. Currently, statins are considered the most important advance in stroke prevention since the introduction of aspirin and antihypertensive treatments. METHODS: In this paper we review the current evidence regarding the role of statins in the stroke prevention and future directions in this field. RESULTS: A meta-analysis of random ised trials of statins has shown that each 1 mmol/L (39 mg/dL) decrease in low-density lipoprotein cholesterol, equates to a reduction in relative risk for stroke of 21.1%. Statins are now recommended for the primary prevention of ischemic stroke in patients estimated to have a high 10-year risk for cardiovascular events. Nevertheless, until recently there was little evidence that statin therapy reduced the risk of stroke recurrence. The SPARCL, published in 2006, was the first trial to show the benefits of statin therapy in preventing recurrent stroke. Now we know that statins reduce the risk of stroke recurrence by 12-16% and statins are recommended among patients with ischemic stroke or TIA presumed to be of atherosclerotic origin or with other comorbid atherosclerotic cardiovascular disease. CONCLUSION: Traditionally, there has been no clear data demonstrating that adding other lipid-modifying drugs to statins results in a further decrease in stroke or other cardiovascular event, but now things have changed and future directions include combinations with ezetimibe and new treatments such as PCSK9 inhibitors. Only time will tell the real roll of these new promising non-statin lipidmodifying therapies on stroke prevention.

Statins in stroke prevention: what an internist should know.

Historically, the etiological link between hypercholesterolemia and stroke has been less clear than for coronary heart disease. The lack of association between cholesterol levels and stroke in most epidemiological and observational studies has brought about this controversy. Many recent, long-term clinical studies have confirmed that statin therapy results in a reduced risk of strokes, even in so-called "normocholesterolemic" patients. The magnitude of the effect is great. A large-scale analysis of more than 90,000 individuals showed that every 10% reduction in the concentration of LDL-cholesterol reduces the risk of stroke by 15.6%. The positive effect of statins on stroke depends mainly on LDL cholesterol reduction, but other non-lipid mechanisms, so-called "pleiotropic" effects, have been shown to play a role. This review seeks to summarize the role of statins in stroke prevention. Despite the fact that our understanding of the benefits of statins in stroke prevention is still evolving, we find marked room for improvement in stroke risk factor management. Internists must face this challenge and integrate this new knowledge into their daily clinical practice.