Dr. Kohli On Statins Reducing Risk of Hemorrhagic Stroke

By Payal Kohli, MD, FACC - Last Updated: January 6, 2023

The use of statins, which have been shown to help prevent ischemic strokes, may also prevent deadly hemorrhagic stroke, particularly over a longer treatment duration, according to a recent study published in Neurology.

DocWire News Medical Lead Dr. Payal Kohli, spoke about this study, and why its findings back the benefits of using statins to prevent many cardiovascular diseases.

DocWire News: How many people in the U.S. suffer from stroke each year, and what are the risk factors?

Dr. Payal Kohli: There’s two different types of strokes that we worry about the most, and stroke is a form of cardiovascular disease because it’s usually a problem with the blood vessels. And so the first is the ischemic stroke, which means you have a blood clot in the blood vessels that’s preventing the blood from flowing. And that obviously, depending on the size of area involved of the tissue affected in the brain, can have significant morbidity and mortality. The other type of stroke is a hemorrhagic stroke. That’s a bleeding type of stroke. That’s where the blood vessel pops open and causes bleeding, and that can cause damage and lack of blood flow to tissues as well. Now, the ischemic strokes can convert into hemorrhagic strokes, and people who have one sometimes also have a risk factor for the other because a lot of the risk factors are the same. It’s things that really damage the walls of the blood vessels.

The most common being, of course, hypertension or high blood pressure because that can cause the blood vessels not only to get sticky, but also possibly rupture open and cause problems with inflammation in the walls of the blood vessels. High cholesterol is another risk factor because that’s what leads to those cholesterol deposits and those sticky blood vessels. Diabetes. Diabetes means excess sugar swimming around in our bloodstream, and that causes the walls of the blood vessels to have more inflammation. It can also change hormones and chemicals that are released that cause more inflammation. Obesity is another risk factor for stroke, particularly in women, but really in both genders. Smoking is a big one. It’s a huge risk factor as well because again, it affects the inflammation, the walls of the arteries.

And then other lifestyle factors as well, such as, in younger women especially, birth control use. So, in a young woman who uses birth control and smokes, that’s kind of the biggest risk that you can really have for having some of these types of strokes. So, a lot of modifiable risk factors that are within our control and things that we can really change with medication use.

A recent study published in Neurology found that statins can reduce the risk of hemorrhagic stroke – can you talk to us about this study?

Very interesting because there’s a lot of fear about statins out there in the scientific community and even potentially among some providers because there have been some observational studies, some research, that suggests that in people who may have had an ischemic stroke, giving them a statin could actually increase the risk downstream of a hemorrhagic stroke. We worry about lowering the LDL too much and how it affects bleeding, particularly in the brain, and all of those types of factors. As we know, statins are one of the most ubiquitous and widely used medications in, of course, in people who have stroke. It’s a Class 1 guideline indication, but also for prevention of strokes. So, this is a really important question, and this study essentially looked at a large number of people from Denmark, so 88,000 people, so really nice, long, large study. None of those people had a prior history of stroke.

So, this is that primary prevention. We’re sort of following people over time to see if they developed stroke. And then it followed people to see, based on whether or not they used statins and for how long they used statins, whether or not they ended up developing a hemorrhagic stroke, a bleeding type of stroke that occurred. And it found that if they used statins for any period of time, there was about a 16 to 17% lower chance of having a hemorrhagic stroke. We’ve known the data about ischemic stroke for a long time, but this was a really pleasant surprise. And in fact, if they use statins for longer, so if they used it for five or more years, they actually had a 33 to 38% reduction in those hemorrhagic strokes. And so to me, this is a very, very important sort of definitive answer to knowing that statins really do prevent strokes and many of us can start to feel more reassured about it.

Now, one thing to keep in mind about the study and some of its limitations are that it was a single country study, so it’s a specific population. So, how does that generalize to other races, other ethnicities, and other populations? That’s a little bit of a question mark. Also, the other thing to keep in mind is because of the design of the study, where they used it, I looked at prescription data and health records. Sometimes they couldn’t completely adjust for other factors, lifestyle factors and other risk factors for stroke, that could have been confounding the situation. In other words, using a statin may have been a marker of a more healthier lifestyle and not necessarily the statin itself that reduces the risk of stroke, but is just kind of associated with the lower risk of stroke. So, more information, of course, is needed. More studies are needed to know this for sure. But as somebody who writes statin prescriptions multiple times a day, I feel very reassured by this data, and this is something I can certainly talk to my patients about as well.

What are the key takeaways of this study?

The key takeaways I would say are that statins save lives. We have known for many decades now that the lower you get your LDL cholesterol, the less your chance of having a major adverse cardiovascular event, including cardiovascular death, myocardial infarction, and stroke. The fear about the adverse effects of statins, whether that comes to slightly higher hemoglobin A1C or some of the concerns that have been raised about hemorrhagic stroke, some of the other concerns about neurocognitive effects of statins, we have now seen a wealth of data coming out of many different types of studies, observational, randomized in others, that really reassure us about the safety of this medication on a population level and on an individual level. So, I feel like we should be now more empowered than ever to give our patients this life-saving therapy and to really tell them that not only are we reducing their risk of heart attack, a risk of a clotting stroke, but we’re actually now… Have data that suggests we’re also reducing their risk of a bleeding stroke.

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