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Statin discontinuation post-stroke increases risk for recurrence
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Discontinuation of statin therapy within 3 to 6 months following a first ischemic stroke was associated with a 42% higher risk for recurrent stroke within 1 year, researchers reported in the Journal of the American Heart Association.
The retrospective cohort study included 45,151 patients aged 20 years and older from the Taiwan National Health Insurance Research Database who were hospitalized for ischemic stroke from 2001 to 2012 and received high- or moderate-intensity statin within 90 days after discharge. Patients were divided into three groups based on statin status: statin discontinuation (n = 8,353; mean age, 66 years; 56% men), statin reduced (n = 3,175; mean age, 65 years; 58% men) or statin maintained (n = 33,623; mean age, 65 years; 57% men).
The primary outcome was first occurrence of recurrent ischemic or hemorrhagic stroke. Secondary endpoints included intracerebral hemorrhage, all-cause mortality, MI, ischemic stroke, any hospitalization during follow-up and all major events, which was a composite of MI, ischemic/hemorrhagic stroke and all-cause mortality.
From 90 days to 180 days post-discharge, 7% of patients were receiving reduced-statin therapy and 18.5% of patients received no statin therapy. During 1-year follow-up, 2,120 recurrent strokes occurred.
According to multivariable analyses, the risk for ischemic or hemorrhagic stroke was 6.2% among patients who discontinued statins vs. 4.4% among those who maintained their statin therapy (adjusted HR = 1.42; 95% CI, 1.25-1.57).
Statin discontinuation was also associated with elevated risk for ischemic stroke (5.6% vs. 3.9%; adjusted HR = 1.45; 95% CI, 1.3-1.61), all-cause mortality (1.4% vs. 1%; adjusted HR = 1.37; 95% CI, 1.1-1.7), all major events (7.8% vs. 5.6%; adjusted HR = 1.38; 95% CI, 1.26-1.51) and any hospitalization (31.7% vs. 27.1%; adjusted HR = 1.19; 95% CI, 1.14-1.24) compared with statin maintenance, according to the results. However, statin discontinuation had a neutral effect on MI and intracerebral hemorrhage (0.6% vs. 0.5%; adjusted HR = 1.19; 95% CI, 0.86-1.64).
Statin reduction did not increase the risk for ischemic stroke, intracerebral hemorrhage, all-cause mortality, MI or all major events.
Propensity score-matching analysis produced similar results.
“These findings suggest that providers and atherosclerotic stroke patients should not discontinue statin therapy unless there is a highly compelling reason for doing so,” Meng Lee, MD, from the department of neurology at Chang Gung University College of Medicine, Taiwan, and colleagues wrote. “Additional prospective studies should be carried out to clarify the underlying mechanisms, such as LDL-cholesterol rebound and/or inflammation, linking statin discontinuation to higher risk of recurrent stroke.” – by Darlene Dobkowski
Disclosure: The authors report no relevant financial disclosures.
Perspective
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Ralph L. Sacco, MD, MS, FAHA, FAAN
The findings show an alarming, higher than expected risk for stroke among those who discontinue statins. There are really two findings here. One, a high percentage of people discontinuing statins 3 to 6 months after a stroke and, two, among those who do discontinue, they have an additional risk of a subsequent stroke.
We’ve known for a while that statins are a very effective medication used post-stroke to prevent a recurrent stroke. The question still comes up as why are people discontinuing. I don’t know if the researchers addressed that, but there are concerns that people discontinue statins sometimes because of side effects. In some places, it’s because of cost. We need to alert patients as well as physicians that it’s important to continue statin therapy if you had a stroke.
Right now, at least in the United States, the use of statins post-stroke is a quality metric, so many patients with stroke who leave primary or comprehensive stroke centers are on statins. We need to make sure that patients and primary care physicians, in particular, keep patients on statins after stroke. It’s not a temporary therapy; it’s probably a lifelong therapy after having a stroke.
Better programs to improve compliance with statins among patients and better implementation of evidence-based programs to get physicians to keep patients on statins may help with adherence. We have to recognize that this study was done in Taiwan, so we don’t know about similar numbers for patients in the United States. If I had to guess, the United States is not 100% in terms of continuing use of statins, but I’d be surprised if we’d have this high of a rate of nonadherence to statins.
In patients post-stroke, it’s important that treatment does not just include statins. There are many other interventions that are used to reduce a recurrent stroke, such as maintaining good [BP] control, making sure diabetes is well controlled and making sure they’re taking antiplatelet or anticoagulant medications to thin the blood and reduce another stroke.
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