Statins and stroke prevention

Four randomized trials with a statin and one trial with a fibrate showed a modest but significant absolute reduction in the incidence of stroke in patients with a previous myocardial infarction. The reasons for the positive effect of statins on stroke end-point are unclear since, paradoxically, the link between serum cholesterol level and stroke has never been fully established. Furthermore, the positive results of statins trials were mainly obtained in patients with an average or a low serum cholesterol level. This suggests nonhypolipidemic effects of these drugs, so-called pleiotropic effects, acting on the biologic promoters of plaque instability. Statins have a good overall safety profile with no increase of hemorrhagic stroke and no increase in cancer. They have positive effects in primary prevention of cardiovascular disease in high-risk young as well as elderly populations. Statins reduced stroke incidence in high-risk (mainly CHD, diabetics and hypertensives) population even with a normal baseline blood cholesterol level, which argues for a global cardiovascular risk-based treatment strategy. In patients with prior strokes, statins likely reduce the incidence of cononary events, but it is not yet proven that statins actually reduce the incidence of recurrent strokes in secondary prevention. If current hypotheses are verified by ongoing trials, we may expect between 20 to 30 more stroke events avoided per 1,000 patients treated during 2 years with a lipid-lowering agent, which adds to the 28 stroke events prevented with an antiplatelet agent over the same time period. This would be one of the most significant advances in stroke and vascular dementia prevention since the era of aspirin therapy.