Statins after haemorrhagic stroke

 

We have been consistently asked why statins are to be avoided after haemorrhagic stroke.

 The 2012 RCP Stroke Guideline states:

 Treatment with statin therapy should be avoided and only used with caution, if

required for other indications, in individuals with a recent primary intracerebral

haemorrhage.’

 

The reason for this is that back in 2003 a seminal meta-analyis by Law and Wald
click here showed an increase in haemorrhagic stroke risk with statins.

 Overall there was a 15% decrease in thromboembolic stroke and a 19% increase in haemorrhagic stroke (including sub-arachnoid hemorrhage and intracerebral haemorrhage). The reasons for this were unclear, and the authors stated there were too few haemorrhagic strokes to be certain it was a real effect.  However since then two subsequent RCTs  NEJM 2006   Neurology 2008 also showed a very small increased risk of haemorrhagic stroke with statins

However, other RCTs have not shown an increased risk and the recent primary prevention Cochrane meta-analysis did not show an increased risk. The most reassuring data however comes from a meta-analysis of all RCTs which have reported stroke as an outcome Stroke meta-analysis 2012 In this study of 95,000 patients statin therapy was not associated with significant increase in ICH. A significant reduction in all stroke and all-cause mortality was observed with statin therapy.

 So what should we as GPs do?

There has been a question mark that statins may increase intracerebral haemorrhage, so in patients who have had a recent haemorrhagic stroke the RCP guidance seems prudent and sensible. However, more recent data is reassuring and given that the benefits of statins are so clear in established vascular disease then in patients with co-morbidity (e.g. previous haemorrhagic stroke and established ischaemic heart disease) individualised decisions will need to be made between you, your patient and the specialist. The most important thing, of course, for both types of stroke is good BP control <130/80.