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LOW LDL CHOLESTEROL, STATINS, AND BRAIN HEMORRHAGE: SHOULD WE WORRY?

LOW LDL CHOLESTEROL, STATINS, AND BRAIN HEMORRHAGE: SHOULD WE WORRY? To the Editor: Bang et al. found that lower lowdensity lipoprotein (LDL) cholesterol levels with or without statin treatment were strongly and independently related to a higher risk of symptomatic hemorrhagic transformation after recanalization therapy.1 These findings, added to those of the industry-driven Stroke Prevention with Aggressive Reduction in Cholesterol (SPARCL) trial,2 should question the widely believed assumption of beneficial effects of statin therapy in the prevention of stroke. In the SPARCL trial,2 it was reported that, as compared with placebo, the use of high-dose statin in patients who had a stroke or TIA reduced the risk of nonfatal stroke from 11.8% to 10.4% over a period of 5 years, but it did so without improving survival (five more deaths in the statin arm), and with 66% increase in the relative risk of hemorrhagic stroke among the patients receiving high-dose atorvastatin. To our knowledge, no statin trial has demonstrated a net reduction in all-cause mortality when studying primary or secondary prevention of stroke. What is the point of decreasing the number of events without decreasing overall mortality, when considering that statin therapy might increase the risk of hemorrhagic infarction, and when the harm caused by the side effects of statins is considered? It is possible that the numbers of side effects are much larger in clinical practice where the drugs may be given to most patients usually excluded in randomized trials, in which ingenious criteria used for selecting the test individuals and generous limits for what is considered as normal laboratory results are usually used.3 Furthermore, in the accompanying editorial,4 Goldstein (from the Steering Committee for the SPARCL study), highlighting the beneficial effects of statins in reducing vascular events, discussed the global beneficial action of statins in the prevention of stroke. However, he did not mention any other statin-related side effects. We do not share Goldstein’s optimism and think that concerns about efficacy and safety of statins remain.