ยาลดไขมัน: The meta-analysis(again)

ยาลดไขมันที่มีประโยชน์อย่างแน่นอนในผู้ป่วยโรคหลอดเลือดแข็งตัวต่าง ๆเช่น myocardial infarction ได้ตอกยำ้ความมั่นใจในการใช้ใน stroke prevention โดยออก Meta-analysis

The meta-analysis, ตีพิมพ์ลงใน May 2009 issue of Lancet Neurology, โดยมีผู้ป่วยมากกว่า 165,000 patients และ พบว่าการลดระดับ ทุก ๆ 39-mg/dL ของ LDL-cholesterol levels จะลด relative risk reduction ของ stroke ประมาณ 21%

 

Study Highlights

 

  • The meta-analysis was based on a previous meta-analysis, which extracted data from PubMed from 1966 to 2003.
  • The current search updated the data to 2008 and included abstracts from the 2008 American Heart Association meeting.
  • Participants were 18 years or older, and trials were of randomized controlled design with at least 100 enrollees, with data on stroke events (both infarction and hemorrhage).
  • Single or multiple interventions were permitted.
  • The relative risk for all stroke, fatal stroke, and hemorrhagic stoke events was calculated.
  • Statin trials were identified with a total of 165,792 individuals at high risk for stroke.
  • The incidence of stroke with statin treatment was reduced by 18% (P < .0001).
  • The incidence of fatal stroke was reduced by 13% (P = .10, not significant).
  • The incidence of hemorrhagic stroke did not increase overall with the use of statins.
  • Each 1-mmol/L (39 mg/dL) decrease in concentration of LDL cholesterol equated to a relative risk reduction for stroke of 21.1% (= .009).
  • Secondary stroke prevention was examined in 2 trials, but only 1 trial examined outcomes of noncardioembolic stroke and TIA within 6 months of the qualifying event.
  • In this trial (SPARCL), 11.2% of those receiving atorvastatin vs 13.1% of those receiving placebo had a recurrent stroke with a significant difference (hazard ratio [HR], 0.84; P = .03).
  • There was also a significant decrease in cardiovascular events (HR, 0.80; P = .002).
  • The SPARCL trial also suggested a benefit (28% relative risk reduction) of a target level of less than 1.8 mmol/L (70 mg/dL) vs less than 2.6 mmol/L (150 mg/dL) for the prevention of secondary stroke, and this finding needs to be confirmed by further research.
  • This treatment effect did not differ between men and women, for those 65 years and older vs younger than 65 years, and for those with vs without carotid stenosis.
  • 2 trials on secondary stroke prevention suggested an increase in the risk for hemorrhagic stroke with a relative risk of 67%, and the authors thus recommended caution in using statins in patients with a history of cerebral hemorrhage.
  • The role of lowering triglyceride levels and increasing HDL cholesterol levels is uncertain, and future research is needed to address the efficacy of these measures.
  • The authors suggested that lipid lowering with statins was associated with risk reduction in initial and recurrent stroke but that more data were needed to examine the benefits of LDL-cholesterol lowering to less than 1.8 mmol/L (70 mg/dL).
  • An ongoing study, the Treat Stroke to Target trial in France, currently has 3000 patients with stroke enrolled, and these patients will be observed for up to 3 years.

 

Clinical Implications

 

  • Use of statins is associated with a significant reduction in stroke risk but not in fatal stroke.
  • Use of statins is associated with reduced risk for recurrent cardioembolic stroke and cardiovascular events.
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