To the Editor In his Viewpoint, Dr Thompson wrote, “Although statins reduce total stroke, they increase the risk of hemorrhagic stroke consistent with the observation that low cholesterol levels are associated with an increase in hemorrhagic stroke.”1 The statement could be misleading and requires clarification.
First, there are no data suggesting a statin-associated increased risk of hemorrhagic stroke among patients with no history of cerebrovascular disease. A meta-analysis of 10 trials involving a total of 83 205 patients without a history of stroke found a nonsignificant reduction in brain hemorrhage with statin treatment (relative risk [RR], 0.81; 95% CI, 0.60-1.08).2 Whether statin treatment increases the risk of brain hemorrhage among those with a history of stroke or transient ischemic attack is more controversial. The observations of increased brain bleeding risk in the Heart Protection Study and the Stroke Prevention by Aggressive Reduction in Cholesterol Levels (SPARCL) trial2 were based on post hoc exploratory analyses of small numbers of patients. Nevertheless, meta-analysis of data from these 2 trials suggests an increased risk (RR, 1.73; 95% CI, 1.19-2.50). In contrast, a meta-analysis3 including cohort and case-control studies and randomized trials found no increased risk of intracerebral hemorrhage associated with statins in patients with a prior stroke or transient ischemic attack (RR, 1.03; 95% CI, 0.82-1.30).
Goldstein LB. Adverse Effects of Statins. JAMA. 2017;317(10):1079. doi:10.1001/jama.2017.0142
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