Thursday, August 24, 2006

Statins for stroke prevention

Atherosclerosis is a diffuse disease that affects all arteries in the body, once it starts. Obviously it is best known for its effect on the heart, as in coronary artery disease. We know that patients with peripheral artery disease have a high incidence of coronary artery disease and vice versa. So also with strokes and heart disease.

This necessarily mean that medication preventing one may also prevent the other. One of the first study about this was the HOPE study, the use of Ramipril (an ACE-I) to prevent CAD events. It did not seem to do much in the prevention of strokes.

The latest issue of New England J of Medicine just reported the SPARCL study. This is a study in the use of high dose atorvastatin within 6 mths of the first stroke, and it significantly reduced a second stroke. This is something doctors like to hear, and I am sure Pfizer (the maker of atorvastatin) likes it too. After all, we believe that atherosclerosis is a diffuse disease of cholesterol accumulation in the walls of most of the arteries of the body. If atorvastatin reduces cholesterol, it should reduce cholesterol in the artery wall. If atorvatatin is anti inflammatory, then it should also reduce the inflammatory process in the arterial wall, and so reduces atheroma, and as shown in SPARCL, that resulted in less strokes.

However, there is a tradeoff. There were more hemorrhagic strokes in those given the 80mg atorvastatin. I reckon that this was due to the relative increase from a true reduction in occlusive strokes, without a concommitant reduction in the placebo arm. There were so many hemorrhagic strokes and occlusive strokes. Lipitor reduces occlusive strokes but not hemorrhagic strokes. The placebo of course did neither. In the end, the number of hemorrhagic strokes in the treatment arm will seem relatively higher. Perhaps that is why. Well, I suppose what SPARCL taught me is that my stroke patients should receive statins early to prevent a second stroke. Atorvastatin at 80 mg will do that, at least in US patients.

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