Benefit of Targeting a LDL (Low-Density Lipoprotein) Cholesterol <70 mg/dL During 5 Years After Ischemic Stroke

Abstract

Background and Purpose— The TST trial (Treat Stroke to Target) evaluated the benefit of targeting a LDL (low-density lipoprotein) cholesterol of &lt;70 mg/dL to reduce the risk of cardiovascular events in 2860 patients with ischemic stroke with atherosclerotic stenosis of cerebral vasculature or aortic arch plaque &gt;4 mm, in a French and Korean population. The follow-up lasted a median of 5.3 years in French patients (similar to the median follow-up time in the SPARCL trial [Stroke Prevention by Aggressive Reduction in Cholesterol Level]) and 2.0 years in Korean patients. Exposure duration to statin is a well-known driver for cardiovascular risk reduction. We report here the TST results in the French cohort. Methods— One thousand seventy-three French patients were assigned to &lt;70 mg/dL (1.8 mmol/L) and 1075 to 100±10 mg/dL (90–110 mg/dL, 2.3–2.8 mmol/L). To achieve these goals, investigators used the statin and dosage of their choice and added ezetimibe on top if needed. The primary outcome was the composite of ischemic stroke, myocardial infarction, new symptoms requiring urgent coronary or carotid revascularization and vascular death. Results— After a median follow-up of 5.3 years, the achieved LDL cholesterol was 66 (1.69 mmol/L) and 96 mg/dL (2.46 mmol/L) on average, respectively. The primary end point occurred in 9.6% and 12.9% of patients, respectively (HR, 0.74 [95% CI, 0.57–0.94]; P =0.019). Cerebral infarction or urgent carotid revascularization following transient ischemic attack was reduced by 27% ( P =0.046). Cerebral infarction or intracranial hemorrhage was reduced by 28% ( P =0.023). The primary outcome or intracranial hemorrhage was reduced by 25% ( P =0.021). Intracranial hemorrhages occurred in 13 and 11 patients, respectively (HR, 1.17 [95% CI, 0.53–2.62]; P =0.70). Conclusions— After an ischemic stroke of documented atherosclerotic origin, targeting a LDL cholesterol of &lt;70 mg/dL during 5.3 years avoided 1 subsequent major vascular event in 4 (number needed to treat of 30) and no increase in intracranial hemorrhage. Registration— URL: https://www.clinicaltrials.gov ; Unique identifier: NCT01252875.

Role of Blood Lipid Levels and Lipid-Lowering Therapy in Stroke Patients with Different Levels of Cerebral Artery Diseases: Reconsidering Recent Stroke Guidelines

“…The primary composite endpoint occurred in 121 (8.5%) and 156 (10.9%) participants, respectively (adjusted HR, 0.77; 95% CI, 0.61 to 0.98; P=0.035). Similar results were obtained when French participants were analyzed separately; 7 the primary endpoint occurred in 9.6% and 12.9% of the participants, respectively (HR, 0.74; 95% CI, 0.57 to 0.94; P=0.019). Myocardial infarction or urgent coronary revascularization occurred in 1.7% and 2.5% of the participants, respectively (HR, 0.66; 95% CI, 0.37 to 1.20; P=0.…”

Complex Aortic Arch Atherosclerosis in Acute Ischemic Stroke Patients with Non-Valvular Atrial Fibrillation

“…A previous study demonstrated that strict LDL-C control by rosuvastatin might stabilize atheromatous aortic plaques in acute ischemic stroke patients with large plaques ≥ 4 mm thick on TEE 33) . A recent trial, which evaluated the benefit of aggressive LDL-C control (LDL-C 70 mg/dL) via basal control with statins, reported a significant reduction of major cardiovascular events in patients with ischemic stroke and atherosclerotic disease including aortic arch plaques ≥ 4 mm in thickness 34) . These data suggest that in addition to oral anticoagulant, statin therapy may be a secondary prevention option for these patients.…”

Meta-Analysis of Dyslipidemia Management for the Prevention of Ischemic Stroke Recurrence in China

“…The results of the SPARCL study showed that lipid-lowering therapy reduced stroke recurrence in patients who achieved normal blood lipid levels (27). Recently, the TST trial demonstrated that targeting a LDL-C level <70 mg/dL (1.8 mmol/L) for 5.3 years avoided 25% of subsequent vascular events and ischemic stroke without increasing the risk of intracranial hemorrhage (8). These findings suggested that lowering LDL-C could further address the residual risks in patients with ischemic stroke.…”

“…Furthermore, studies have shown that elevated LDL and reduced HDL levels increase the risk of stroke (7). The Treat Stroke to Target (TST) trial evaluated the benefit of dyslipidemia management and showed that targeting a LDL cholesterol level <70 mg/dL after a recent ischemic stroke or TIA could significantly decrease the occurrence of cardiovascular events, cerebral infarction, and recurrent cerebral infarction or hemorrhage as compared with targeting a LDL cholesterol of 100 ± 10 mg/dL (8). However, consistent conclusions have not been reached regarding pharmacological interventions that raise HDL-C concentrations (7).…”