October 27, 2014 / 5:10 PM / 5 years ago

Stroke patients miss cholesterol-lowering targets

NEW YORK (Reuters Health) – - More than half of patients with a recurrent stroke or other cerebrovascular attack failed to meet recommended targets for so-called bad cholesterol levels, a new study showed.

The research examined more than 900,000 patients admitted to U.S. hospitals from 2003 to 2012 after suffering a stroke or transient ischemic attack (a brief episode of brain dysfunction, also called a TIA).

Of nearly 195,000 who’d already had a stroke or TIA in the past, more than 106,000 had high levels of low-density lipoprotein (LDL) cholesterol in their blood. (During the study period, experts were advising that LDL levels be kept below 100 milligrams per deciliter.)

Only 62 percent of the patients admitted for stroke or TIA who already had coronary artery disease met the recommended LDL targets. And only 52 percent of those with diabetes met the targets, the researchers reported in the journal Stroke.

The American Heart Association explains (here: bit.ly/1tS3rX0) that when there's too much LDL cholesterol in the blood, it can build up in the arteries that feed the heart and brain, helping to form a thick, hard plaque that prevents enough blood from getting through. If the artery is completely blocked, a heart attack or stroke can result.

“We need better mechanisms in place to emphasize the importance of cardiovascular and stroke prevention strategies to help our patients to decrease the risks of heart attacks and strokes,” lead author Dr. Gustavo Saposnik told Reuters Health.

He directs the Stroke Outcome Research Center at the University of Toronto’s St. Michael’s Hospital.

All the patients should have been on cholesterol-lowering medications and should have been counseled on diet and exercise, Saposnik said.

Women were even less likely to meet goals for cholesterol than men, the study found.

“I think our study reveals that there is a good opportunity for improving stroke and cardiovascular prevention,” Saposnik said. “This is an opportunity.”

The challenge, however, is determining why patients failed to meet the goals for reducing harmful cholesterol levels.

Saposnik suggested four factors that could be at play. Doctors might not have prescribed the recommended lipid-lowering medications; patients might not have taken the medicine; patients may not have been able to afford the medicine; or patients who were taking the medicine may have had such high LDL cholesterol that it remained above the recommended target.

But in an editorial published with the study, Dr. Larry B. Goldstein from Duke University Medical Center in Durham, North Carolina notes the challenge in using the study to help patients in the future.

“The implication is that better adherence to treatment targets would reduce the incidence of cerebrovascular events,” the editorial says. “The interpretation of the data and consequences for current practice, however, are not entirely straightforward.”

Since 2003, when the study started, the guidelines have changed several times. The latest guidelines – which completely drop the idea of specific targets – have sparked fierce debate (see Reuters story of March 19, 2014 here: reut.rs/1tpQLZJ).

Instead of working to lower a patient’s “bad” LDL cholesterol to specific numeric targets, the 2013 recommendations from the American Heart Association and the American College of Cardiology ask doctors to use an online calculator to consider risk factors such as smoking and obesity.

Patients with a 7.5 percent or greater chance of having heart disease within 10 years would be considered eligible for treatment with a statin.

Critics say the risk calculator overestimates the number of people in need of treatment.

One of the reasons the 2013 guidelines don’t encourage using LDL cholesterol targets is because a committee investigating the question concluded there was no evidence that hitting a specific goal lowers heart attack or stroke risk.

But some doctors are still convinced it does.

Cardiologist Dr. David Frid is one of them. While he recognizes that there was never a randomized trial that took patients to the LDL cholesterol goal, he continues to treat his patients to the target, he told Reuters Health.

Frid is from the Cleveland Clinic in Ohio and was not involved in the current study.

“It’s been shown that statin medications significantly reduce risk in conjunction with diet and exercise,” he said.

“What the researchers found was unfortunately the majority of patients were not treated as aggressively as they should be,” he said.

Part of the problem, in Frid’s view could stem, from the fact that neurologists, who take care of stroke patients, might not be as keen to prescribe cholesterol-lowering drugs as cardiologists.

“This article tells me we’re not doing as good a job as we should be,” he said.

SOURCE: bit.ly/ZykkvN and bit.ly/1CRXeNO Stroke, online October 9, 2014.

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