Indicating statins to reach more aggressive LDL goals in patients that have suffered transient ischemic attack or ischemic stroke driven by atherosclerosis significantly reduces major cardiovascular events according to this study presented in the AHA 2019 scientific sessions simultaneously published in NEJM.
The study was prematurely ended because of lack of funding, but its outcomes are eloquent enough to close the knowledge gap about the best LDL targets after a stroke.
Researchers concluded that patients presenting an ischemic cerebrovascular event with evidence of atherosclerosis will benefit from a 70 mg/dl or lower LDL goal using statins and eventually adding ezetimibe, instead of a 90 and 110 mg/dl LDL goal.
The current clinical guidelines recommended intensive therapy with statins for these patients based mainly on the SPARCL outcomes, but it wasn’t yet clear what LDL goal we should aim at.
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The Treat Stroke to Target was carried out in 77 centers in Korea and France, aiming at including close to 4000 patients. Enrolment resulted slower than expected which is why the trial was ended with 2873 patients under statins, ezetimibe or both, randomized to a 70 mg/dl vs 90-110 mg/dl LDL target.
At 3.5 years, the cohort randomized to intensive therapy had reached a mean 65 mg/dl LDL vs 95 mg/dl in the more moderate branch.
Primary end point of new ischemic stroke, new symptoms leading to emergency coronary or carotid revascularization and cardiovascular death resulted 8.5% in the intensive group vs 10.9% in the more moderate group with a difference in terms of relative risk reduction of 22% (HR 0.78; CI 95% 0.61-0.98).
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One of the concerns about an aggressive statin therapy is the chance of increasing intracranial bleeding, but this was not the case in this study. Neither was there an increase in diabetes or other potential adverse effects of statins.
2019-11-26-treat-stroke-to-target
Original Title: A comparison of two LDL cholesterol targets after ischemic stroke.
Reference: Amarenco P et al. N Engl J Med. 2019; Epub ahead of print.
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