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ARTICLES: O. Y. Bang, J. L. Saver, D. S. Liebeskind, S. Starkman, P. Villablanca, N. Salamon, B. Buck, L. Ali, L. Restrepo, F. Vinuela, G. Duckwiler, R. Jahan, T. Razinia, and B. Ovbiagele Cholesterol level and symptomatic hemorrhagic transformation after ischemic stroke thrombolysis Neurology 2007; 68: 737-742 [Abstract] [Full text] [PDF]

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Cholesterol level and symptomatic hemorrhagic transformation after ischemic stroke thrombolysis

Luca Mascitelli, Francesca Pezzetta, MD, Ospedale di San Vito Tagliamento, San Vito al Tagliamento, Italy   (1 April 2007)

Cholesterol level and symptomatic hemorrhagic transformation after ischemic stroke thrombolysis 1 April 2007
Luca Mascitelli, Comando Brigata Alpina Julia 8 Via S. Agostino, Udine 33100 Italy, Francesca Pezzetta, MD, Ospedale di San Vito Tagliamento, San Vito al Tagliamento, Italy Send Correspondence to journal: Re: Cholesterol level and symptomatic hemorrhagic transformation after ischemic stroke thrombolysis lumasci{at}libero.it Luca Mascitelli, et al.	Bang et al found that lower LDL-cholesterol levels with or without statin treatment were strongly and independently related to a higher risk of symptomatic hemorrhagic transformation after recanalization therapy. [1] These findings, added to those of the industry-driven SPARCL trial, [2] should place into question the widely-held assumption of beneficial effects of statin therapy in the prevention of stroke. In the SPARCL trial, [2] it was reported that, as compared with placebo, the use of high-dose statin in patients who had a stroke or TIA reduced the risk of nonfatal stroke from 11.8% to 10.4% over a period of 5 years, but it did so without improving survival (five more deaths in the statin arm), and with 66% increase in the relative risk of hemorrhagic stroke among the patients receiving high-dose atorvastatin. To the best of our knowledge, no statin trial has demonstrated a net reduction in all-cause mortality when studying primary or secondary prevention of stroke. What is the point of decreasing the number of events without decreasing overall mortality, when considering that statin therapy might increase the risk of hemorrhagic infarction, and when the harm caused by the side effects of statins is considered? It is very possible that the numbers of side effects are much larger in clinical practice where the drugs may be given to most patients usually excluded in randomized trials, in which ingenious criteria used for selecting the test individuals and generous limits for what is considered as normal laboratory results are usually used. [3] Furthermore, in the accompanying editorial, [4] Goldstein (from the Steering Committee for the SPARCL study) highlighting the beneficial effects of statins in reducing vascular events, discussed the global beneficial action of statins in the prevention of stroke. However, he did not mention any other statin-related side effects. We don’t share Goldstein’s optimism and think that concerns about efficacy and safety of statins remain. References 1. Bang OY, Saver JL, Liebeskind DS, et al. Cholesterol level and symptomatic hemorrhagic transformation after ischemic stroke thrombolysis. Neurology 2007; 68: 737-742. 2. Amarenco P, Bogousslavsky J, Callahan A 3rd, et al.; Stroke Prevention by Aggressive Reduction in Cholesterol Levels (SPARCL) Investigators. High-dose atorvastatin after stroke or transient ischemic attack. N Engl J Med 2006; 355: 549-559. 3. Mascitelli L, Pezzetta F. Statins for primary prevention of coronary artery disease. Lancet 2007; 369: 1078-1079. 4. Goldstein LB. Low LDL cholesterol, statins, and brain hemorrhage: should we worry? Neurology. 2007; 68: 719-720. Disclosure: The authors report no conflicts of interest.