Cholesterol lowering to prevent stroke: who, when, and how?

The epidemiologic link between increased low-density-lipoprotein (LDL) cholesterol and ischemic stroke is controversial. However, recent trials make it clear that LDL reduction by statin agents in high-risk patients reduces the risk of ischemic stroke. The risk of first stroke is reduced within 1 to 2 years of statin therapy in patients at high risk for ischemic vascular disease. Patients with any history of cerebrovascular disease who are treated with statins have a reduced risk of coronary ischemic events and of all major vascular ischemic events, independent of any history of coexisting coronary artery disease. In particular, patients with recent transient ischemic attack or ischemic stroke show significantly reduced risks of both recurrent stroke and coronary events when they are treated with high-dose statin therapy. Most patients with ischemic cerebrovascular disease should be placed on statin drugs. However, most stroke patients are not currently treated to recommended levels with these agents, providing ample room for improvement in physician performance.