Deintensification or No Statin Treatment Is Associated With Higher Mortality in Patients With Ischemic Stroke or Transient Ischemic Attack

Abstract

Background and Purpose: Practice guidelines recommend that most patients receive moderate- or high-potency statins after ischemic stroke or transient ischemic attack (TIA) of atherosclerotic origin. We tested the association of different patterns of potency for prescribed statin therapy—assessed before admission and at hospital discharge for ischemic stroke or TIA—on mortality in a large, nationwide sample of US Veterans. Methods: The study population included patients with an ischemic stroke or TIA occurring during 2011 at any of the 134 Veterans Health Administration facilities. We used electronic outpatient pharmacy files to identify statin dose at hospital admission and within 7 days after hospital discharge. We categorized statin dosing as low, moderate, or high potency; moderate or high potency was considered at goal. We created 6 mutually exclusive groups to reflect patterns of statin potency from hospital admission to discharge: goal to goal, low to goal, goal to low or goal to none (deintensification), none to none, none to low, and low to low. We used logistic regression to compare 30-day and 1-year mortality across statin potency groups. Results: The population included 9380 predominately White (71.1%) men (96.3%) who were hospitalized for stroke or TIA. In this sample, 34.1% of patients (n=3194) were discharged off a statin medication. Deintensification occurred in 14.0% of patients (n=1312) and none to none in 20.5% (n=1924). Deintensification and none to none were associated with a higher odds of mortality as compared with goal to goal (adjusted odds ratio 1-year mortality: deintensification versus goal to goal, 1.26 [95% CI, 1.02–1.57]; none to none versus goal to goal, 1.59 [95% CI, 1.30–1.93]). Adjustments for differences in baseline characteristics using propensity weighted scores demonstrated similar results. Conclusions: Underutilization of statins, including no treatment or underdosing after stroke (deintensification), was observed in approximately one-third of veterans with ischemic stroke or TIA and was associated with higher mortality when compared with patients who were at goal for statin prescription dosing.

Lack of Statin Therapy and Outcomes After Ischemic Stroke: A Population-Based Study

“… 4 After that, several randomized trials demonstrated the effect of statins on reducing the risk of recurrent stroke and major cardiovascular events in patients with a history of stroke. 28 Previous observational studies have associated the lack of statin therapy to increased short-term mortality 29 , 30 However, large-scale, long-term, follow-up studies of nonstatin users are not, for the best of our knowledge, available. We found that statin usage within the first 90 days after IS was associated with lower all-cause mortality and MACCE at both 1-year and 12-year follow-up.…”

Non-stenotic Carotid Plaques in Embolic Stroke of Unknown Source

“…Currently, patients with ESUS receive intensive lipid-lowering therapy (e.g., statins, ezetimibe) to achieve a level of LDL cholesterol <70 mg/dL (1.8 mmol/L) as early as possible after stroke (122)(123)(124). The treatment is maintained long-term if well-tolerated, even in older adults (125)(126)(127)(128). Specific targets of LDL cholesterol have not been assessed in patients with ESUS and it is unknown if the presence of an ipsilateral nonstenotic carotid plaque would modify the effect of lipid-lowering drugs as suggested by findings of the Stroke Prevention by Aggressive Reduction in Cholesterol Levels (SPARCL) (129).…”

There is urgent need to treat atherosclerotic cardiovascular disease risk earlier, more intensively, and with greater precision: A review of current practice and recommendations for improved effectiveness

“…Desire for ‘natural’ approach. Poor compliance and long-term adherence [ 356 , 357 ]. Unjustified fear of LLT medications [36] Mental health [358] Depression (associated and possibly causal [359] ), stress [360] , anxiety or anger syndromes [361] .…”