HMG-CoA Reductase Inhibitors Improve Acute Ischemic Stroke Outcome
To the Editor:
Dr. Moonis and colleagues are to be congratulated on an important study that provides further insight into the usefulness of statins in improving ischemic stroke outcome.1
However, I disagree with the premise of the first sentence of the introductory section of their article, which reads as follows: “Prospective studies have demonstrated that HMG-CoA reductase inhibitors (statins) reduce stroke recurrence by 20% to 25%.”2,3 Indeed, there is little basis for drawing this conclusion from the studies cited to support this statement.
The Scandinavian Simvastatin Survival Study demonstrated that statin treatment reduced the risk of primary stroke in a cohort of patients with coronary disease and high low-density lipoprotein cholesterol.2 Furthermore, although a post hoc analysis, not prespecified, of subjects entered into the Heart Protection Study with a history of symptomatic ischemic cerebrovascular disease revealed a significant reduction in major vascular events in favor of simvastatin, there was no beneficial treatment effect for stroke prevention by the statin agent.4 As such, currently there remains no convincing data that statins are beneficial in reducing recurrent stroke. The ongoing SPARCL study will likely shed further light on this issue.5
I want to thank the Dr. Bruce Ovbiagele for his thoughtful comments and his interest in our article.1 I agree that the data on risk reduction of recurrent ischemic stroke is largely based on studies in patients with ischemic heart disease.2 Interestingly, the American Stroke Association still recommends using statins in patients with ischemic stroke with or without ischemic heart disease with the aim of secondary prevention. Space limitation and the fact that the objective of this research report was to assess the effects of statins on stroke outcome and not stroke recurrence did not allow room for a more detailed discussion on statins and risk reduction of recurrent ischemic stroke. Results of the SPARCL trial should be helpful in answering this question.3
Moonis M, Kane K, Schwiderski U, Sandage BW, Fisher M. HMG-CoA reductase inhibitors improve acute ischemic stroke outcome. Stroke. 2005; 36: 1298–1300.
Waters DD, Schwartz GG, Olsson AG, Zeiher A, Oliver MF, Ganz P, Ezekowitz M, Chaitman BR, Leslie SJ, Stern T; MIRACL Study Investigators. Effects of atorvastatin on stroke in patients with unstable angina or non-Q-wave myocardial infarction: a Myocardial Ischemia Reduction with Aggressive Cholesterol Lowering (MIRACL) substudy. Circulation. 2002; 106: 1690–1695.