Effect of Statin Use During Hospitalization for Intracerebral Hemorrhage on Mortality and Discharge Disposition

Abstract

IMPORTANCE Statin use during hospitalization is associated with improved survival and a better discharge disposition among patients with ischemic stroke. It is unclear whether inpatient statin use has a similar effect among patients with intracerebral hemorrhage (ICH). OBJECTIVE To determine whether inpatient statin use in ICH is associated with improved outcomes and whether the cessation of statin use is associated with worsened outcomes. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study of 3481 patients with ICH admitted to any of 20 hospitals in a large integrated health care delivery system over a 10-year period. Detailed electronic medical and pharmacy records were analyzed to explore the association between inpatient statin use and outcomes. MAIN OUTCOMES AND MEASURES The primary outcome measures were survival to 30 days after ICH and discharge to home or inpatient rehabilitation facility. We used multivariable logistic regression, controlling for demographics, comorbidities, initial severity, and code status. In addition, we used instrumental variable modeling to control for confounding by unmeasured covariates at the individual patient level. RESULTS Among patients hospitalized for ICH, inpatient statin users were more likely than nonusers to be alive 30 days after ICH (odds ratio [OR], 4.25 [95% CI, 3.46-5.23]; P < .001) and were more likely than nonusers to be discharged to their home or an acute rehabilitation facility (OR, 2.57 [95% CI, 2.16-3.06]; P < .001). Patients whose statin therapy was discontinued were less likely than statin users to survive to 30 days (OR, 0.16 [95% CI, 0.12-0.21]; P < .001) and were less likely than statin users to be discharged to their home or an acute rehabilitation facility (OR, 0.26 [95% CI, 0.20-0.35]; P < .001). Instrumental variable models of local treatment environment (to control for confounding by unmeasured covariates) confirmed that a higher probability of statin therapy was associated with a higher probability of 30-day survival (with an increase in probability of 0.15 [95% CI, 0.04-0.25]; P = .01) and a better chance of being discharged to home or an acute rehabilitation facility (with an increase in probability of 0.13 [95% CI, 0.02-0.24]; P = .02). CONCLUSIONS AND RELEVANCE Inpatient statin use is associated with improved outcomes after ICH, and the cessation of statin use is associated with worsened outcomes after ICH. Given the association between statin cessation and substantially worsened outcomes, the risk-benefit balance of discontinuing statin therapy in the acute setting of ICH should be carefully considered.

Impact of Increased Early Statin Administration on Ischemic Stroke Outcomes: A Multicenter Electronic Medical Record Intervention

“…Exposure to statins in the acute phase of experimental stroke appears to promote angiogenesis and synaptogenesis,15 and additional pleiotropic statin effects such as vasodilatory and antithrombotic properties have been reported 16. These experimental observations are supported by clinical findings of improved outcomes with acute statin use in myocardial infarction,17, 18, 19 stroke,3, 4, 20, 21 and major vascular surgery 22, 23…”

Immune interventions in stroke

“…Evidence that supports the use of this approach comes from retrospective studies that showed statin use to decrease PHO and improve outcomes of ICH. 81,82 Several studies have tested other approaches to reducing brain swelling.…”

Statins in Intracerebral Hemorrhage

“…Similarly, discontinuation of statins within 24 h after an ischemic stroke in a randomized setting has been shown to increase infarct size, the rates of early neurologic deterioration, and to worsen functional outcome after 3 months [62]. In a retrospective cohort study of 3481 patients with ICH admitted to one of 20 hospitals in a large integrated health care delivery system over a 10-year period, continued statin use as an inpatient was associated with improved outcomes after ICH, while the cessation of statin use was associated with worsened outcomes after ICH [63]. Analysis of 2466 consecutive patients with ICH from the Registry of the Canadian Stroke Network enrolled between 2003 and 2008 showed that discontinuation of statins was related to poor outcome even after adjustment for baseline stroke severity, but this association was no longer significant after excluding patients treated palliatively [64••].…”