Editor—The statement by Ebrahim et al, that “preventive strategies that include lowering blood cholesterol should not be tempered because of concerns about a possible increased risk of haemorrhagic stroke” is too general and does not acknowledge that their study population did not include patients with symptomatic vascular disease, the population most often aggressively treated with statins, with resultant low cholesterol concentrations.1
These patients frequently have cerebral vessels diseased with atherosclerosis, and evidence of silent cerebral infarcts.2 Indeed, the only randomised trial to evaluate an intensive statin treatment strategy in patients primarily with ischaemic stroke noted a higher incidence of haemorrhagic stroke among those who received the high dose statin.3 In another study there was a trend towards increased haemorrhagic stroke with statin use among those who had had a cerebrovascular event.4
Another limitation of their study is the lack of information on low density liproprotein cholesterol concentrations, the primary treatment target in guideline recommendations.5
Competing interests: None declared.
References
- 1.Ebrahim S, Sung J, Song YM, Ferrer RL, Lwalor DA, Davey Smith G. Serum cholesterol, haemorrhagic stroke, ischaemic stroke, and myocardial infarction: Korean national health system prospective cohort study. BMJ 2006;333: 22-7. (1 July.) [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Uekita K, Hasebe N, Funayama N, Aoyama H, Kuroda K, Aizawa H, et al. Cervical and intracranial atherosclerosis and silent brain infarction in Japanese patients with coronary artery disease. Cerebrovasc Dis 2003;16: 61-8 [DOI] [PubMed] [Google Scholar]
- 3.Welch M, et al. The stroke prevention by aggressive reduction in cholesterol levels (SPARCL) study. 15th European stroke conference, 16-19 May 2006, Brussels.
- 4.Collins R, Heart Protection Study Collaborative Group. Effects of cholesterol-lowering with simvastatin on stroke and other major vascular events in 20536 people with cerebrovascular disease or other high-risk conditions. Lancet 2004;363: 757-67. [DOI] [PubMed] [Google Scholar]
- 5.Executive Summary of the third report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol In Adults (Adult Treatment Panel III). JAMA 2001;285: 2486-97. [DOI] [PubMed] [Google Scholar]