Background: The beneficial role of high-intensity statins in secondary prevention of recurrent atherosclerotic stroke is well established. It is uncertain whether the observed benefit was from a reduction in the cholesterol level or to other pleotropic effects of atorvastatin. The ideal target cholesterol level for secondary prevention is unclear. This trial was conducted to help determine an ideal target LDL-C level in the prevention of CV events following ischemic stroke.
Study design: Randomized, parallel-group, event-driven trial.
Setting: Conducted in France and South Korea.
Synopsis: In this study, patients with an ischemic stroke within the last 3 months or TIAs within 15 days were randomly assigned to receive statins with or without ezetimibe (Zetia) to achieve a higher-target LDL-C level (90-110 mg/dL) vs. lower-target LDL-C (less than 70 mg/dL). The composite primary endpoint was a major cardiovascular event, which included ischemic stroke, MI, new symptoms leading to urgent coronary or carotid revascularization, or death from CV causes.
There were 2,860 patients enrolled, 1,430 were assigned to each target group. At the end of 3.5 years, the primary endpoint occurred in 8.5% of patients in the lower target group, compared with 10.9% in the higher target group (hazard ratio, 0.78; 95% confidence interval, 0.61-0.98; P = .04). Unfortunately, the trial was stopped early because of a lack of funding.
Bottom line: Using medications including statins to lower the LDL-C to less than 70 mg/dL leads to better cardiovascular outcomes following ischemic stroke.
Citation: Amarenco P et al. A comparison of two LDL cholesterol targets after ischemic stroke. N Engl J Med. 2020 Jan 2;382:9-19.
Dr. Garg is assistant professor in the division of hospital medicine, Loyola University Medical Center, Maywood, Ill.