Learning objectives
- What is role of lipids in stroke
- Appropriate investigations
- Managing the patient with raised lipids
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Introduction
- Lipid lowering reduces the risk of stroke and heart disease
- Cholesterol and LDL have a direct correlation with heart disease
- HDL has an inverse correlation with heart disease
- serum total cholesterol (TC) levels associated positively with thrombotic and negatively with haemorrhagic strokes.
Types
- Familial hypercholesterolaemia: Autosomal dominant cause of raised TC. Due to mutations in LDL receptor. Severe forms is homozygous. Corneal arcus, Coronary artery disease (CAD) and atherosclerosis, xanthelasmata,
- Polygenic hypercholesterolaemia: Increased risk of Coronary artery disease (CAD) and atherosclerosis
Evidence
- Heart Protection Study (HPS): showed that Simvastatin 40 mg OD in those at high risk of
cardiovascular events and showed a relative risk reduction of 17% in vascular death, 27% in major coronary
events and 25% in stroke. Long term follow up confirmed persisting benefits.
- SPARCL trial: showed that Atorvastatin 80 mg daily in patients with TIA or stroke in the preceding 6 months and demonstrated a relative risk reduction of 15% in stroke and 35% in major coronary events with treatment
- Other studies show that reducing LDL cholesterol by 1 mmol/L reduces the relative risk of major vascular events by 21%, total mortality by 9% and stroke by 15%
- The decision to initiate treatment should be determined by a person’s absolute cardiovascular risk rather than their cholesterol level.
Management as per RCP 2016
- Weight loss and other risk factors tackled together with advice on lifestyle factors with advice on diet, physical activity, weight, alcohol and smoking.
- Stains protect both from heart disease and stroke which often coexist and those with ischaemic stroke or TIA should be offered treatment with a statin drug unless contraindicated
- High intensity statin: Atorvastatin 20-80 mg daily (lower dose in those at high risk of adverse events or drug interactions.)
- Aim for a greater than 40% reduction in non-HDL cholesterol
- People with acute stroke or TIA who are already receiving statins should continue their statin treatment.
- Ezetimibe should be used only in people who also have familial hypercholesterolaemia
- Those with primary intracerebral haemorrhage should avoid statin treatment unless it is required for other indications.
References and further reading
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