Lumping 'Apples and Oranges'?
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 hemorrhagic stroke” is too
general and does not acknowledge that their study population did not
include symptomatic vascular disease patients, the population most often
aggressively statin-treated, with resultant low cholesterol levels. These
patients frequently have cerebral vessels diseased with atherosclerosis,
and evidence of silent cerebral infarcts. Indeed, the only randomized
trial to evaluate an intensive statin treatment strategy in primarily
ischemic stroke patients noted a higher incidence of hemorrhagic stroke
among those who received the high dose statin, and in another study
there was a trend towards increased hemorrhagic stroke with statin use
among those who had a prior cerebrovascular event. Another limitation
of their study is the lack of information on low density liproprotein
cholesterol levels, the primary treatment target in guideline
1. Ebrahim S, et al. Serum cholesterol, haemorrhagic stroke,
ischaemic stroke, and myocardial infarction: Korean national health system
prospective cohort study. BMJ. 2006
2. Uekita K, Hasebe N, Funayama N, et al. Cervical and intracranial
atherosclerosis and silent brain infarction in Japanese patients with
coronary artery disease. Cerebrovasc Dis. 2003;16:61-8
3. Welch M et al. The Stroke Prevention by Aggressive Reduction in
Cholesterol Levels (SPARCL) Study. 15th European Stroke Conference; May 16
-19, 2006; Brussels, Belgium.
4. Collins R, et al; 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 Mar 6;363:757-67.
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).
Competing interests: No competing interests