Clinical question: Do the benefits of statin use in secondary stroke prevention apply equally to younger patients as they do elderly patients?
Background: The 2003 SPARCL trial assigned stroke patients with LDL of 100 mg/dL to 190 mg/dL to treatment with 80 mg atorvastatin or placebo. Over median of 4.9 years of followup, 13.1% of patients in the placebo group had a recurrent stroke, compared with 11.2% of patients in the atorvastatin group, resulting in a significant, 2.2% absolute reduction of stroke risk.
Study design: Secondary analysis of a randomized, double-blind, placebo-controlled trial.
Setting: Multicenter study.
Synopsis: Using data from the original SPARCL trial, 2,482 patients in the younger cohort (<65)—a mean age of 54 years—were compared with 2,249 patients in the elderly group (>65) with a mean age of 72.4 years. There was comparable reduction of LDL cholesterol in both groups and no significant differences in adverse drug events.
The magnitude of reduction in fatal or nonfatal second strokes was greater for younger patients (RRR 26%, P=0.02) than for older patients (RRR 10%, P=0.33). However, in the elderly cohort, secondary endpoints including stroke or TIA (HR 0.79, P=0.01), major coronary events (HR 0.68, P=0.035), or any coronary heart event (HR 0.61, P=0.0006) were significantly reduced by statin use. Mortality was not reduced in either group.
The authors found a lack of heterogeneity of benefit in treatment-age interaction analysis and concluded that the results support use of statins in the elderly after stroke. This study is limited by its post-hoc analysis, which might have been underpowered to detect a difference in the primary endpoint when separated into the age groups.
Bottom line: Elderly patients derive less stroke-reduction benefit from high-dose, high-potency statins compared with younger patients in the post-stroke period. Even so, statins continue to derive statistically significant reductions in other cerebrovascular and cardiac events.
Citation: Chaturvedi S, Zivin J, Breazna A, et al. Effect of atorvastatin in elderly patients with a recent stroke or transient ischemic attack. Neurology. 2009;72:688-694.
Reviewed for TH eWire by Erin A. Egan, MD, JD, Ethan Cumbler, MD, Jodie Grout, RN, MS, ANP-C, Jeannette Guerrasio, MD, Nichole Zehnder, MD, and Judy Zerzan, MD, MPH, Hospital Medicine Group, University of Colorado Denver