Intensive LDL Cholesterol Lowering Improves Cardiovascular Outcomes in Patients With Recent TIA or Stroke
Ravinder-Jeet Singh, MBBS, DM
Amarenco P, Kim JS, Labreuche J, Charles H, Abtan J, Béjot Y, et al; Treat Stroke to Target Investigators. A Comparison of Two LDL Cholesterol Targets after Ischemic Stroke. N Engl J Med. 2020;382:9-19.
Several observational studies have investigated the effects of serum cholesterol levels (or its subfractions) on cardiovascular health and disease. These studies have shown that increased serum cholesterol is a strong risk factor for coronary artery disease, though association with stroke is less clear.(1-3) The inconsistent association between cholesterol and stroke could partly be explained by the difference in the effects of total cholesterol levels or its subfractions (especially LDL cholesterol) on the risk of ischemic vs hemorrhagic stroke, which are often combined in many epidemiologic studies. High total cholesterol is associated with higher risk of ischemic stroke, while low total cholesterol increases hemorrhagic stroke risk, and similar observations are noted with LDL cholesterol (LDL-C) levels as well.(2-6) Nonetheless, control of serum LDL-C levels constitutes standard recommendation for primary and secondary stroke prevention.(7)
Use of high-dose statins after a recent TIA or stroke was shown to reduce the incidence of stroke and other cardiovascular events in the Stroke Prevention by Aggressive Reduction in Cholesterol Levels (SPARCL) trial, despite a small increase in the incidence of hemorrhagic stroke.(8) Further, multiple clinical trials and their meta-analysis showed that more intensive LDL-C lowering is associated with greater reduction in cardiovascular events.(9) Whether intensive LDL-C lowering among patients with recent TIA/stroke lowers future stroke risk was not assessed in the previous trials. In the January issue of NEJM, Amarenco et al. reported the results of the Treat Stroke to Target (TST) trial, which compared two LDL-C targets after recent TIA and ischemic stroke.