Lower cholesterol targets after stroke may reduce subsequent major vascular events

Targeting a low-density lipoprotein (LDL) cholesterol level <70 mg/dL following an ischaemic stroke of atherosclerotic origin helps to avoid one in four subsequent major vascular events without increasing the risk of intracranial haemorrhage over about 5 years of follow-up, according to data from the Treat Stroke to Target (TST) trial.

TST randomly assigned 2,148 ischaemic stroke patients with atherosclerotic stenosis of cerebral vasculature or aortic arch plaque >4 mm to a target LDL cholesterol of <70 mg/dL (1.8 mmol/L; n=1,073) or 100±10 mg/dL (2.3–2.8 mmol/L; n=1,075). All patients received intense or moderate dose of statin with or without ezetimibe.

There were no significant between-group differences in age (mean, 67 years) and baseline LDL cholesterol (mean, 137 mg/dL). The primary outcome was the composite of ischaemic stroke, myocardial infarction, new symptoms requiring urgent coronary or carotid revascularization, and vascular death.

After a median follow-up of 5.3 years, the achieved LDL cholesterol was 66 mg/dL in the lower-target group and 96 mg/dL in the higher-target group. A lower LDL cholesterol target resulted in fewer composite outcome events (9.6 percent vs 12.9 percent; hazard ratio [HR], 0.74, 95 percent confidence interval [CI], 0.57–0.94; p=0.019).

Additionally, a target LDL cholesterol of <70 vs 100±10 mg/dL cut the risks of cerebral infarction or urgent carotid revascularization following transient ischaemic attack by 27 percent (p=0.046), cerebral infarction or intracranial haemorrhage by 28 percent (p=0.023), and the primary outcome or intracranial haemorrhage by 25 percent (p=0.021).

Safety outcome did not significantly differ between the lower- and higher-target groups, with intracranial haemorrhage occurring in 13 and 11 patients, respectively (HR, 1.17, 95 percent CI, 0.53–2.62; p=0.70).