Neuroprotective effects of statins: evidence from preclinical and clinical studies

The benefits of statins for both primary and secondary prevention of ischemic stroke are clearly established. Evidence is accumulating that statin withdrawal after ischemic stroke may lead to worse outcome and that initiation of statins after ischemic stroke may reduce mortality and improve outcome. Current treatment guidelines recommend starting statins before discharge in patients with stroke related to atherosclerosis or who have elevated cholesterol. The primary treatment question then is not if to start statins in most ischemic stroke patients, but when. Our recommendation would be start a statin as soon as the patient passes a dysphagia screen and can safely take oral medication. Based on the results of the Heart Protection Study and the SPARCL trial, either simvastatin 40 mg or atorvastatin 80 mg are appropriate alternatives. Clinical trials are needed to demonstrate unequivocal efficacy of improved outcome and to determine if lower doses may have this effect. Additionally, improved outcome needs to be established in cardioembolic stroke patients before routine use of statins in this stroke subtype can be recommended.