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Simvastatin and Stroke

Summary and Comment |
June 24, 2004

Simvastatin and Stroke

  1. Philip B. Gorelick, MD, MPH, FACP

Simvastatin has been shown to reduce cardiovascular risk in people with cerebrovascular disease, but it doesn't reduce these patients' stroke risk.

  1. Philip B. Gorelick, MD, MPH, FACP

Does simvastatin reduce the risk for stroke and other major vascular events in people with cerebrovascular disease (CVD) or other high-risk conditions? In the Heart Protection Study (HPS), 3280 adults with CVD and 17,256 adults with other occlusive arterial disease or diabetes mellitus were randomized to receive either 40 mg of simvastatin daily or matching placebo for 5 years.

The overall results favored simvastatin therapy: Compared with placebo, there was a 25% lower first stroke occurrence (P<0.0001), primarily attributable to fewer ischemic strokes (P<0.0001), with no apparent difference in hemorrhagic strokes (P=0.8). TIAs and need for carotid endarterectomy or angioplasty were also less common with simvastatin use (P=0.02 and P=0.0003, respectively). However, among patients with a history of CVD, stratified analyses showed no significant differences in overall stroke, ischemic stroke, or severe or fatal stroke rates and showed more hemorrhagic strokes with simvastatin (21 vs. 11 events). Although the study was partially manufacturer-funded, the research was conducted and reported independently of the funding sources.

Comment

  1. Philip B. Gorelick, MD, MPH, FACP

Statins have been labeled "miracle drugs," as they have surpassed other agents in the reduction of myocardial infarction (MI), stroke, and mortality (Pandey D and Gorelick PB. Should statin agents be administered to all stroke patients? Arch Neurol 2004 [editorial]; in press). Based on the HPS findings, the FDA approved the use of simvastatin for people at high risk for coronary events because of existing coronary heart disease (CHD), diabetes, peripheral vascular disease, or history of stroke or other CVD to reduce mortality by reducing CHD deaths, MI, stroke, and need for revascularization procedures.

The Third Report of the National Cholesterol Education Program recommends lipid lowering for those with CHD risk equivalents, including symptomatic carotid artery disease (www.nhlbi.nih.gov/guidelines/cholesterol/). However, the HPS results did not show a significant stroke reduction among people with prior CVD. We await the results of the Stroke Prevention by Aggressive Reduction in Cholesterol Levels (SPARCL) study (the design of which was described in Cerebrovasc Dis 2003; 16:389) -- an atorvastatin treatment trial to prevent recurrent stroke among people without a history of CHD. Nonetheless, there remain many stroke patients with CHD or diabetes who qualify for statin therapy.

Reviewed Articles

Citation(s):

Dr. Gorelick is John S. Garvin Professor and Head, Department of Neurology and Rehabilitation, University of Illinois College of Medicine at Chicago.

Dr. Gorelick is John S. Garvin Professor and Head, Department of Neurology and Rehabilitation, University of Illinois College of Medicine at Chicago.

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