Statins come to rescue of patients with acute large vessel occlusion

Initiating statin therapy immediately after onset of large vessel occlusion (LVO) in acute ischaemic stroke patients proves beneficial, leading to better functional outcome and lower mortality at 90 days, according to data from the RESCUE*‐Japan Registry 2.

“Our study is the first to attest the effectiveness of statin administration in patients with acute LVO and clearly demonstrated reduced disability at 90 days,” the investigators said. “Although ours was not a randomized clinical trial, the findings should be considered robust because of the large sample size, consecutive patient enrollment, and extensive multivariable adjustment.”

RESCUE included 2,399 consecutive patients (mean age, 75.9 years; 55 percent men) with acute LVO who were admitted to multiple centres across Japan within 24 hours of onset. In total, 447 patients (19.1 percent) received statins, including atorvastatin (10 mg/d), rosuvastatin (5 mg/d), pitavastatin (2 mg/d), pravastatin (10 mg/d), simvastatin (5 mg/d), and fluvastatin (30 mg/d).

Compared with patients not given the cholesterol-lowering drug, those who were tended to have atherothrombotic cerebral infarctions (34.2 percent vs 12.1 percent; p<0.0001), younger age (73.4 vs 76.5 years; p<0.0001), and lower median National Institutes of Health Stroke Scale on admission (14 vs 17; p<0.0001). [J Am Heart Assoc 2020;doi:10.1161/JAHA.120.017472]

Ninety-day outcomes were more favourable in the statin than the control group. It not only had better physical function (modified Rankin scale [mRS] score, 0–2: 45 percent vs 34.6 percent; p<0.0001) but also lower deaths (4.7 percent vs 12.5 percent; p<0.0001).

Multivariable logistic regression analysis confirmed that statin was associated with greater odds of having a 1‐scale lower mRS score (odds ratio [OR], 1.29, 95 percent confidence interval [CI], 1.04–1.37; p=0.02) and lower likelihood of dying (OR, 0.36, 95 percent CI, 0.21–0.62; p=0.02) at 90 days.

Statins were consistently beneficial in the subgroups of patients who received endovascular therapy and achieved thrombolysis in cerebral infarction ≥2b (OR for lower mRS score, 1.09, 95 percent CI, 0.81–1.47; p=0.56).

“Although most LVOs were attributable to cardioembolism and not atherosclerosis, our study suggests that statins should be administered in patients with acute LVO as early as possible irrespective of revascularization such as recombinant tissue plasminogen activator (rt‐PA) or endovascular therapy (EVT),” the investigators said.

Statins exert cholesterol‐lowering–dependent effects (eg, antiatherosclerosis) and –independent effects (eg, anti‐inflammation, antioxidation, and modulation of nitric oxide products), both of which have been shown to be neuroprotective. [Eur Heart J 2002;23:1908-1921]

“Thus, the effects of statin administration on acute ischaemic strokes should be considered mainly independent of cholesterol lowering,” the investigators pointed out.

Nevertheless, uncertainties remain regarding the doses of statins and how long they should be continued to achieve stabilized functional outcomes, they said. “These [points] should be investigated in future studies.”

*Recovery by Endovascular Salvage for Cerebral Ultra‐Acute Embolism