Statins for Stroke Prevention

Primary Prevention of Stroke

The European Society of Cardiology recommends statin therapy in patients at high or very high cardiovascular risk for primary prevention of stroke (Class I, Level A evidence) 1
For primary prevention, each 1 mmol/L (39 mg/dL) decrease in LDL cholesterol is associated with a 21.1% reduction in stroke risk 3
In patients with an estimated 5-year risk of major vascular events <10%, every 39-mg/dL reduction in LDL results in a 24% reduction in stroke risk, similar to higher-risk categories 2
The American Heart Association recommends statin treatment to reduce the incidence of fatal and nonfatal stroke compared with placebo in healthy individuals with LDL cholesterol <130 mg/dL and elevated hs-CRP levels 2

The European Society of Cardiology recommends intensive statin therapy in patients with a history of non-cardioembolic ischemic stroke or TIA for secondary prevention of stroke (Class I, Level A evidence) 1
Early initiation of statins after stroke is supported by evidence showing reduced recurrent early stroke risk in patients with carotid stenosis 1
The American Heart Association recommends a statin should be prescribed for secondary prevention in patients who have had an ischemic stroke or TIA to achieve a target LDL cholesterol consistently less than 2.0 mmol/L or >50% reduction of LDL cholesterol from baseline 4, 5

More intensive statin therapy that achieves an LDL cholesterol of 55 to 80 mg/dL results in a lower risk of stroke than less intensive therapy that achieves an LDL cholesterol of 81 to 135 mg/dL (OR, 0.80; 95% CI, 0.71–0.89) 2, 3
Higher versus lower statin doses show a significant reduction in the composite of fatal and nonfatal strokes (RR, 0.86; 95% CI, 0.77–0.96) 2, 3

The beneficial effect of statins on ischemic stroke is primarily related to their capacity to reduce progression or induce regression of atherosclerosis 2
Statin therapy slows the progression of carotid IMT, with the magnitude of LDL cholesterol reduction correlating inversely with the progression 2
High-dose statin therapy can reduce carotid plaque inflammation and deplete carotid plaque lipid 2

Adults with diabetes and ischemic stroke are at high risk of further vascular events and should be treated with a statin to achieve an LDL cholesterol <2.0 mmol/L 4, 5
Patients with peripheral arterial disease (including carotid artery disease) are considered very high-risk and lipid-lowering therapy (mostly statins) is recommended (Class I, Level A evidence) 1

Concerns about statin therapy increasing the risk of hemorrhagic stroke are not supported by evidence 2
Meta-analyses have found no significant difference in the incidence of intracerebral hemorrhage with statin therapy (OR, 1.08; 95% CI, 0.88–1.32) 2
Statin therapy is not indicated for prevention of intracerebral hemorrhage 4, 5