Preface: The SPARCL trial made clinicians wary that high-dose statins may increase the risk of intracranial hemorrhage (ICH). This new observational study suggests that continued statin use after ICH appears to improve outcomes.
The SPARCL trial (Stroke Prevention through Aggressive Reduction of Cholesterol Levels) was a landmark study in the field of stroke prevention (N Engl J Med 2006; 355:549). In SPARCL, compared with those assigned to placebo, patients with transient ischemic attack or stroke taking 80 mg of atorvastatin had a subsequent 16% reduction in stroke and a reduction in ischemic stroke, but they also had an increase in hemorrhagic stroke. This led some clinicians to be wary about using statins in patients with intracerebral hemorrhage (ICH) or at high risk for ICH. Now, researchers have assessed the effects of in-hospital statin use on outcomes in 3481 patients with ICH in an integrated health system over a 10-year period.
Despite having higher rates of hypertension, coronary artery disease, atrial fibrillation, and congestive heart failure, inpatients who received statins were significantly more likely to survive 30 days after stroke onset compared with nonusers (82% vs. 61%; odds ratio adjusted for confounders except stroke severity, 4.25). Statin users also were significantly more likely to be transferred home or to inpatient rehabilitation (51% vs. 35%; adjusted odds ratio, 2.57). Patients with statin discontinuation during the hospital stay had a significantly higher unadjusted mortality rate than those who continued on statin therapy (58% vs. 19%). Adjustment for stroke severity and do-not-resuscitate status reduced these odds, but they remained statistically significant.
This large multicenter study provides a dose of reassurance that continuing statins after ICH may not only be safe but could also be beneficial. Clinicians might not have used statins in patients thought to have a poor prognosis at ICH diagnosis. Adjustment for code status may not have eliminated this bias completely. The study is also limited by its inclusion of various ICH etiologies. More-focused studies with specific ICH causes (e.g., hypertension, amyloid angiopathy) would be worthwhile.
Flint AC et al. Effect of statin use during hospitalization for intracerebral hemorrhage on mortality and discharge disposition. JAMA Neurol 2014 Sep 22; [e-pub ahead of print]. (https://dx.doi.org/10.1001/jamaneurol.2014.2124)