Should statins be withheld in intracerebral hemorrhage?

Large observational study offers reassuring data

DOCTORS FEEL a little wary in prescribing statins to high-risk patients when they develop intracerebral hemorrhage (ICH). A previous study–the SPARCL trial (Stroke Prevention through Aggressive Reduction of Cholesterol Levels)—gave some reasons causing the doctors’ apprehension. (N Engl J Med 2006; 355:549)

The SPARCL study was a landmark study in the field of stroke prevention, comparing those given high-dose atorvastatin with those assigned to placebo. The authors reported that patients with transient ischemic attack or stroke taking 80 mg of atorvastatin had a subsequent 16 percent reduction in stroke and a reduction in ischemic stroke, but they also had an apparent increase in hemorrhagic stroke.

In this latest study, researchers assessed the effects of in-hospital statin use on outcomes in 3,481 patients diagnosed with ICH over a 10-year period. (JAMA Neurol 2014 Sep 22)

The researchers reported that despite having higher rates of hypertension, coronary artery disease, atrial fibrillation, and congestive heart failure, in-patients who received statins were significantly more likely to survivie 30 days after stroke onset compared with nonusers of statins (82 percent vs. 61 percent; odds ratio adjusted for confounders except stroke severity, 4.25).

Better outcome with statin users was also shown since they (statin users) were significantly more likely to be transferred home or to in-patient rehabiliataion (51 percent vs. 35 percent; adjusted odds ratio, 2.57).

Patients who discontinued their statin during the hospital stay had a significantly higher unadjusted mortality rate than those who maintained their statin therapy (58 percent vs. 19 percent). Although adjustment for stroke severity and do-notresuscitate status reduced these odds, they remained statistically significant.

“This large multicenter study provides a dose of reassurance that continuing statins after ICH may not only be safe but could also be beneficial,” wrote Seemant Chatuvedi, MD in his review of the study in Journal Watch Hospital Medicine.

Although some limitations in the study are present (Clinicians might not have used statins in patients thought to have a poor prognosis at ICH diagnosis, and adjustment for code status may not have eliminated this bias completely. The study is also limited by its inclusion of various ICH etiologies), it offers a good basis not to be wary about statin use in patients with ICH.

“More-focused studies with specific ICH causes (e.g., hypertension, amloid angiopathy) would be worthwhile,” recommended Dr. Chaturvedi. With JAMA and JWHM reports

VitalSigns Issue 68 Vol. 3, October 1-31, 2014