Lipid treatment absolved of hemorrhagic transformation guilt

Aug 1 2012

By Eleanor McDermid, Senior MedWire Reporter

The lipid profiles of patients undergoing thrombolysis for acute stroke predict their mortality risk but not their risk for symptomatic intracerebral hemorrhage (ICH), shows a large study.

Low levels of triglycerides and high-density lipoprotein (HDL) cholesterol were associated with increased mortality risk, whereas low-density lipoprotein (LDL) cholesterol levels did not predict mortality.

The findings therefore support the idea that intensive cholesterol reduction with statins does not increase stroke risk, says J David Spence (Western University, London, Canada), author of an editorial accompanying the study in Neurology.

"This is important because the misplaced fear of ICH has caused many physicians to limit lowering of LDL cholesterol, even though intensive lowering of LDL markedly reduces the risk of both stroke and myocardial infarction, particularly in patients with large artery disease."

He adds that the belief that cholesterol is not a major stroke risk factor is a "relic" from the days when blood pressure was poorly controlled and so dominated stroke risk profiles.

Didier Leys (University Hospital of Lille, France) and colleagues studied 1847 patients, drawn from various prospective stroke thrombolysis registries. This makes their study twice as large as all previous studies on the subject combined, they say.

On multivariate analysis, patients with HDL cholesterol or triglyceride levels above the median had about half the risk for dying of those with lower levels. High HDL cholesterol levels were also weakly associated with an increased odds for an excellent outcome (modified Rankin Scale 0-1).

But risk for symptomatic ICH was not the mediating factor; no lipid measure was associated with ICH, as defined by either the European Cooperative Acute Stroke Study or the National Institute for Neurological Disorders and Stroke.

Neither total nor LDL cholesterol levels were associated with outcomes.

The researchers suggest that the apparent impact of low triglyceride and HDL cholesterol levels on patient outcomes may be a "nonspecific effect" related to patients' baseline nutritional status.

"This is in line with the higher mortality found in very slim patients in general, and the increased mortality rate in stroke patients with malnutrition," say Leys et al. But they caution: "This hypothesis remains speculative and could not be evaluated by a marker of malnutrition such as albumin level or body mass index because of the post hoc design of our study."

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