Interventions in the management of serum lipids for preventing stroke recurrence

 

Abstract

Background

Studies have shown that interventions which reduce total and low-density lipoprotein cholesterol levels also reduce coronary heart disease (CHD) and stroke events in those with a history of CHD. However, it is uncertain whether treatment to alter cholesterol levels can prevent recurrence of either stroke or subsequent cardiovascular events and whether differences in outcomes exist between classes of lipid-lowering therapy. This is an update of a Cochrane review first published in 2002.

Objectives

To investigate the effect of altering serum lipids pharmacologically for preventing subsequent cardiovascular disease and stroke recurrence in patients with a history of stroke.

Search methods

We searched the Cochrane Stroke Group Trials Register (last searched December 2008), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 3, 2008), MEDLINE (1966 to December 2008) and EMBASE (1980 to December 2008). We contacted pharmaceutical companies known to produce a lipid-lowering agent for information on relevant publications or unpublished work.

Selection criteria

Unconfounded randomised trials of participants aged 18 years and over with a history of stroke or transient ischaemic attack (TIA).

Data collection and analysis

Two review authors independently selected trials, assessed quality and extracted data.

Main results

We included eight studies involving approximately 10,000 participants. The active interventions were pravastatin, atorvastatin, simvastatin, clofibrate, and conjugated oestrogen. Fixed-effect analysis showed no overall effect on stroke recurrence but statin therapy alone had a marginal benefit in reducing subsequent cerebrovascular events in those with a previous history of stroke or TIA (odds ratio (OR) 0.88, 95% confidence interval (CI) 0.77 to 1.00). There was no evidence that such intervention reduced all-cause mortality or sudden death (OR 1.00, 95% CI 0.83 to 1.20). Three statin trials showed a reduction in subsequent serious vascular events (OR 0.74, 95% CI 0.67 to 0.82).

Authors' conclusions

There is evidence that statin therapy in patients with a history of ischaemic stroke or TIA significantly reduces subsequent major coronary events but only marginally reduces the risk of stroke recurrence. There is no clear evidence of beneficial effect from statins in those with previous haemorrhagic stroke and it is unclear whether statins should be started immediately post stroke or later. In view of this and the evidence of the benefit of statin therapy in those with a history of CHD, patients with ischaemic stroke or TIA, with or without a history of established CHD, should receive statins.

 

Plain language summary

Interventions in the management of serum lipids for preventing stroke recurrence

There is evidence of a reduction in subsequent serious vascular events from statin therapy in patients with a history of ischaemic stroke or transient ischaemic attack (TIA). Studies have shown that interventions for reducing either total serum cholesterol or low density lipoprotein cholesterol levels reduce the risk of coronary heart disease (CHD) and stroke events in people with a history of CHD. However, for stroke patients the relation between the level of serum cholesterol and cholesterol subfractions with the risk of future stroke or cardiovascular events is unclear. This review, which includes eight studies involving approximately 10,000 participants, shows statin therapy, but not other lipid-lowering measures, reduces the risk of subsequent major vascular events and a marginal benefit in decreasing stroke events, but not all-cause mortality in those with a history of ischaemic cerebrovascular disease.

 

摘要

背景

為了預防中風復發而對於血清脂質的介入治療

研究已顯示對於降低總膽固醇與低密度膽固醇(LDL)值的介入治療，在有冠心症(CHD)病史的病人中同時減少了冠心症與中風的事件。然而，關於哪一種改變膽固醇值的治療可以預防中風或是後續的心血管事件，以及在各種降血脂治療之間其預後是否存在差異，則尚未確定。這是Cochrane review在2002年首次發表之後的更新版本。

目標

研究在有中風病史的病人當中，以藥物改變血清脂質對於預防之後發生心血管疾病以及腦中風復發的效果。

搜尋策略

我們搜尋Cochrane Stroke Group Trials Register(及至2008年12月)、Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 3, 2008)、MEDLINE (自1966年至2008年12月)以及EMBASE (自1980年至2008年12月)。我們並聯絡所有已知生產降血脂藥物的藥商並要求其提供已發表或未發表的與此回顧相關之著作的資訊。

選擇標準

針對年紀在18歲及以上有中風或暫時性腦缺血(TIA)病史之對象的無干擾隨機試驗(unconfounded randomised trial)。

資料收集與分析

2位檢閱者各自選擇試驗、評估試驗品質並篩選資料。

主要結論

我們納入8個研究共計約有10,000位參與者。現有的介入治療有Pravastatin, atorvastatin, simvastatin, Clofibrate, 以及conjugated Oestrogen。固定效果分析(fixed effects analysis)顯示對於有中風或暫時性腦缺血(TIA)病史的病人，在中風的再發率上整體而言並無效益，但唯獨statin的治療在減少後續腦血管事件方面有些微的效益(OR 0.88, 95% CI 0.77 to 1.00)。並無證據顯示此種介入治療減少了所有原因死亡率(allcause mortality)或是猝死(OR 1.00, 95% CI 0.83 to 1.20)。三個statin的試驗顯示減少了後續的嚴重血管事件(OR 0.74, 95% CI 0.67 to 0.82)。

作者結論

在statin治療缺血性中風或TIA病史的病人方面有證據可顯著減少之後發生重大的冠狀動脈疾病事件，但在減少中風復發的風險上只有些微的效益。Statin對於先前有出血性中風的病人並沒有明顯有效益的證據，並且中風之後是否應該即刻給予或者晚一點再給statin，仍不清楚。基於此點，以及在冠心症病史的病人中statin治療效益的證據，缺血性中風或TIA的病人，不管有沒有確診過冠心症的病史，應該接受statin治療。

翻譯人

本摘要由奇美醫院陳軾正翻譯。

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

在statin治療有缺血性中風或TIA病史的病人方面有證據可減少之後嚴重的血管事件。研究已顯示介入治療以降低血清總膽固醇或是低密度膽固醇值，在有冠心症病史的病人中可減少冠心症與中風事件的風險。然而，對於中風病人來說，血清膽固醇與部份膽固醇，以及未來發生中風或心血管事件的風險，兩者之間的關係則不清楚。這篇納入了8個研究共有約10,000位參與者的回顧論文，顯示statin的治療，而非其他降低血脂的方法，減低了之後發生重大血管事件的風險，並在減少中風事件方面有些微的效益，但在有缺血性腦血管疾病病史的病人中其所有原因死亡率並不會減少。