Effect of previous statin therapy on severity and outcome in ischemic stroke patients: a population-based study

Prior statin use in acute ischemic stroke patients with mechanical thrombectomy: A prospective cohort study in China

BACKGROUND AND PURPOSE

Mechanical thrombectomy (MT) has been proven to be effective for selected patients with acute ischemic stroke (AIS). However, conflicting findings have suggested the association between prior statin use and outcomes in AIS patients with MT, with a particular lack of information in the Chinese population. Via a prospective cohort study, we explored the safety and efficacy of prior statin use in Chinese AIS patients with MT.

METHODS

We consecutively enrolled AIS patients treated with MT from the First Affiliated Hospital of Chengdu Medical College and Nanjing First Hospital between June 2015 and June 2022 who were under prior statin use or not. Safety and efficacy outcomes were prospectively followed. The primary outcomes were defined as 90-day favorable outcomes (mRS score 0-2). Secondary outcomes included successful recanalization (TICI≥2b), early neurological improvement (decrease of National Institutes of Health Stroke Scale (NIHSS) score ≥ 4 points at 24 h), symptomatic intracerebral hemorrhage (sICH), and death at 90 days.

RESULTS

We enrolled 334 patients in total, 50 of whom (15.0%) undertaken statins administration before AIS. 117 (35.0%) patients had favorable outcomes at 90 days, 288 (86.2%) patients had successful recanalization, 108 (32.3%) patients achieved early neurological improvement, 41 (12.3%) patients had sICH and 73 (21.9%) patients died within 90 days. The 90-day favorable outcomes were not significantly different (adjusted OR=0.853, 95% CI 0.449-1.620, P = 0.626) between prior statins use group and no statins use group. There was no significant difference in recanalization (adjusted OR=1.466, 95% CI 0.536-4.009, P = 0.456), early neurological improvement (adjusted OR=1.568, 95% CI 0.811-3.032, P = 0.181), sICH (adjusted OR=0.850, 95% CI 0.325-2.224, P = 0.741), ICH (adjusted OR=1.029, 95% CI 0.479-2.490, P = 0.942), and 90-day mortality (adjusted OR=0.381, 95% CI 0.091-1.586, P = 0.185) between the two groups.

CONCLUSIONS

Prior statin use may be safe for Chinese AIS patients with MT, but its efficacy warrants further research.

Do statins reduce the mortality rate in stroke patients treated with systemic thrombolysis in a 5-year

The present study investigated the association between pre-treatment with a cholesterol-lowering drug (statin) or new setting hereon and the effect on the mortality rate in patients with acute ischemic stroke who received intravenous systemic thrombolysis. During a 5-year period (starting in October 2008), 542 consecutive stroke patients who received intravenous systemic thrombolysis with recombinant tissue plasminogen activator (rt-PA) at the Department of Neurology, University Hospital Schleswig-Holstein, Campus Lübeck, Germany, were included. Patients were characterized according to statins. The primary endpoint was mortality; it was assessed twice: in hospital and 3 months after discharge. The secondary outcome was the rate of symptomatic intracerebral hemorrhage. Of the 542 stroke patients examined (mean age 72 ± 13 years; 51% women, mean National Institutes of Health Stroke Scale (NIHSS) score 11), 138 patients (25.5%) had been pre-treated with statin, while in 190 patients (35.1%) statin therapy was initiated during their stay in hospital, whereas 193 (35.6%) never received statins. Patients pre-treated with statin were older and more frequently had previous illnesses (arterial hypertension, diabetes mellitus and previous cerebral infarctions), but were comparably similarly affected by the stroke (NIHSS 11 vs. 11; P = 0.76) compared to patients who were not on statin treatment at the time of cerebral infarction. Patients pretreated with statin did not differ in 3-month mortality from those newly treated to a statin (7.6% vs. 8%; P = 0.9). Interestingly, the group of patients pretreated with statin showed a lower rate of in hospital mortality (6.6% vs. 17.0; P = 0.005) and 3-month mortality (10.7% vs. 23.7%; P = 0.005) than the group of patients who had no statin treatment at all. The same effect was seen for patients newly adjusted to a statin during the hospital stay compared to patients who did not receive statins (3-month mortality: 7.1% vs. 23.7%; P < 0.001). With a good functional outcome (mRS ≤ 2), 60% of patients were discharged, the majority (69.6%; P < 0.001) of whom received a statin at discharge. The rate of symptomatic intracerebral hemorrhages in the course of cranial computed tomography was independent of whether the patients were pretreated with a statin or not (8.8% vs. 8.7%, P = 0.96). Pre-treatment with statin as well as new adjustment could reveal positive effect on prognosis of intravenous thrombolyzed stroke patients. Further investigations are required. The study was approved by the Ethic Committee of the University of Lübeck (approval No. 4-147).

Prestroke statin use enhances collateralization in acute ischemic stroke patients

BACKGROUND

Statin therapy has been shown to be effective in the prevention of ischemic stroke. In addition, recent studies have suggested that prior statin therapy could lower the initial stroke severity and improve stroke functional outcomes in the event of stroke. It was speculated that prestroke statin use may enhance collateral circulation and result in favorable functional outcomes.

OBJECTIVE

The aim of the study was to investigate the association of prestroke statin use with leptomeningeal collaterals and to determine the association of prestroke statin use with stroke severity and functional outcome in acute ischemic stroke patients.

METHODS

We prospectively and consecutively enrolled 239 acute ischemic stroke patients with acute infarction due to occlusion of the middle cerebral artery within 24 h in the neurology department of West China Hospital from May 2011 to April 2017. Computed tomographic angiography (CTA) imaging was performed for all patients to detect middle cerebral artery thrombus; regional leptomeningeal collateral score (rLMCS) was used to assess the degree of collateral circulation; the National Institutes of Health Stroke Scale (NIHSS) was used to measure stroke severity at admission; the modified Rankin scale (mRS) was used to measure outcome at 90 days; and premorbid medications were recorded. Univariate and multivariate analyses were performed.

RESULTS

Overall, 239 patients met the inclusion criteria. Fifty-four patients used statins, and 185 did not use statins before stroke onset. Prestroke statin use was independently associated with good collateral circulation (rLMCS > 10) (odds ratio [OR], 4.786; 95% confidence interval [CI], 1.195-19.171; P = 0.027). Prestroke statin use was not independently associated with lower stroke severity (NIHSS score≤14) (OR, 1.955; 95% CI, 0.657-5.816; p = 0.228), but prestroke statin use was independently associated with favorable outcome (mRS score≤2) (OR, 3.868; 95% CI, 1.325-11.289; P = 0.013).

CONCLUSIONS

Our findings suggest that prestroke statin use was associated with good leptomeningeal collaterals and clinical outcomes in acute ischemic stroke (AIS) patients presenting with occlusion of the middle cerebral artery. However, clinical studies should be conducted to verify this claim.

Cholesterol reducer and thrombolytic therapy in acute ischemic stroke patients

BACKGROUND

Specific clinical risk factors may contribute to improving or worsening neurological functions in acute ischemic stroke (AIS) patients pre-treated with a combined cholesterol reducer and recombinant tissue plasminogen activator (rtPA) therapy. In this study, clinical risk factors associated with good or poor presenting neurological symptoms in ischemic stroke patients with prior cholesterol reducer use, specifically a statin and rtPA therapy was investigated.

METHODS

Retrospective data for baseline clinical and demographic data for patients with AIS taking cholesterol reducers prior to rtPA treatment from January 2010 to June 2016 in a regional stroke center was analyzed. Improving (NIHSS score ≤ 7) or worsening (NIHSS score > 7) of neurologic functions were the determined measures of treatment outcome. Multivariate logistic regression models identified demographic and clinical factors associated with worsening or improving neurologic functions.

RESULTS

Adjusted multivariate analysis showed that in an AIS population with a combined rtPA and cholesterol reducer medication history, increasing age (OR = 1.032, 95% CI, 1.015-1.048, P < 0.001) and atrial fibrillation (OR = 1.859, 95% CI, 1.098-3.149, P = 0.021) demonstrated a likely association with worsening neurologic functions, while direct admission (OR = 0.411, 95% CI, 0.246-0.686, P = 0.001) and being Caucasian (OR = 0.496, 95% CI, 0.297-0.827, P = 0.007) showed an association with improving or progressing neurologic functions.

CONCLUSION

A prior cholesterol reducer, namely a statin, plus rtPA combination may be associated with worsening neurological function for elderly AIS patients with atrial fibrillation, while Caucasians directly admitted to a neurology unit are more likely to show an association with progress or improvements in neurologic functions. While combining statin with rtPA treatment may facilitate worsening neurologic functions in elderly AIS patients with atrial fibrillation, they should not be denied of this therapy. The decision to combine statin and rtPA for AIS patients with atrial fibrillation can be done after clinical stabilization following appropriate clinical management.

The Benefits and Risks of Statin Therapy in Ischemic Stroke: A Review of the Literature

Statins are effective cholesterol-lowering drugs for reducing the risks of mortality and morbidity of cardiovascular diseases. Increasing evidence has shown that statin use is associated with a significant beneficial effect in patients with ischemic stroke. Both pre-stroke and post-stroke statin use has been found to be beneficial in ischemic stroke. Furthermore, good adherence is associated with a better clinical outcome, and statin withdrawal is associated with a poor functional outcome in patients with ischemic stroke. High-intensity statin therapy is advocated for the treatment of ischemic stroke. However, there are concerns regarding the adverse effects associated with statin use in ischemic stroke such as intracranial hemorrhage. In this review, we summarize the beneficial effect of statin use in ischemic stroke and discuss the potential risks associated with statin therapy.

Long-Term Survival After Stroke According to Reperfusion Therapy, Cardiovascular Therapy and Gender

BACKGROUND

A wide variety of factors influence stroke prognosis, including age, stroke severity and comorbid conditions; but most current information about outcomes and safety is derived from patients at 3 - 12 months and mostly coming from the hospital activity. The aim of this study is to evaluate whether treatment strategies have a differential impact on long-survival after acute ischemic stroke among men versus women.

METHODS

Acute ischemic stroke patients identified from the population-based register between January 1, 2011 and December 31, 2012 were included, and they were classified into: 1) Acute ischemic stroke + intravenous thrombolysis (group I); 2) Acute ischemic stroke + mechanical thrombectomy with or without intravenous thrombolysis (group II); 3) Acute ischemic stroke + medical therapy alone (no reperfusion therapies) (group III). Follow-up went through up until December 2016. The probability of survival was estimated by the Kaplan-Meier method, and the hazard ratio was obtained by using the Cox proportional hazard regression models. Mortality was interpreted as overall mortality.

RESULTS

A total of 14,368 cases (men 50.1%), 77.1 ± 11.0 years old were included. There was higher survival among those treated with intravenous thrombolysis (P < 0.001); women treated with thrombectomy (P < 0.001); and women < 80 years old without reperfusion therapy. The most common medications were antiplatelets (52.8%), associated with lower survival (P < 0.001); and statins (46.5%), associated with higher survival. The regression model produced the following independent outcome variables associated to mortality: anticoagulant hazard ratio (HR) 1.53 (95% confidence interval (95% CI): 1.44 - 1.63, P < 0.001), diuretics HR 1.71 (95% CI: 1.63 - 1.79, P < 0.001), antiplatelet HR 1.49 (95% CI: 1.42 - 1.56, P < 0.001), statins HR 0.73 (95% CI: 0.70 - 0.77; P < 0.001), angiotensin II receptor antagonists HR 0.93 (95% CI: 0.89 - 0.98, P = 0.008) and reperfusion therapy HR 0.88 (95% CI: 0.81 - 0.97, P = 0.009).

CONCLUSIONS

Men and women have different prognoses after revascularization treatment for acute ischemic stroke. Under 80 years old the women appear to have a better outcome than men when treated with thrombolysis therapy and/or catheter-based thrombectomy. The chronic cardiovascular pharmacotherapy must be evaluated whether they should be included as factors in the decision to reperfusion.

Hyperlipidemia is associated with lower risk of poststroke mortality independent of statin use: A population-based study

Background Although statin therapy is associated with reduced stroke and mortality risk, some studies report that higher lipid levels are associated with improved outcomes following ischemic stroke. Aims We examined the association of hyperlipidemia (HLD) combined with statin therapy on all-cause mortality in stroke patients. Methods All stroke patients in the Greater Cincinnati Northern Kentucky region of ∼1.3 million were identified using ICD-9 discharge codes in 2005 and 2010. Stroke patients with and without HLD were categorized based on their reported statin use at baseline or discharge into three groups: no-HLD/no-statins, HLD/no-statins, and HLD/on-statins. Cox proportional hazards model was used to estimate the risk of mortality at 30 days, 1 year, and 3 years poststroke. Results Overall, 77% (2953) of the 3813 ischemic stroke patients were diagnosed with HLD and 72% ( n = 2123) of those patients were on statin medications. The mean age was 70.0 ± 14.6 years, 56% were women, and 21% were black. In adjusted analyses, the HLD/no-statins group showed 35% (adjusted hazard ratio (aHR) = 0.65, 95% CI: 0.46-0.92), 27% (aHR = 0.73, 95% CI: 0.59-0.90), and 17% (aHR = 0.83, 95% CI: 0.70-0.97) reduced risk of mortality at 30 days, 1 year, and 3 years, respectively, poststroke, compared with no-HLD/no-statins group. The HLD/on-statins group showed an additional 17% significant survival benefit at 3 years poststroke compared with HLD/no-statins group. Conclusions A diagnosis of HLD in ischemic stroke patients is associated with reduced short- and long-term mortality, irrespective of statin use. Statin therapy is associated with significant, additional long-term survival benefit.

Influence of Statin Pretreatment on Initial Neurological Severity and Short-Term Functional Outcome in Acute Ischemic Stroke Patients: The Fukuoka Stroke Registry

Background: Statins have neuroprotective effects against ischemic stroke. However, associations between pre-stroke statin treatment and initial stroke severity and between the treatment and functional outcome remain controversial. This study aimed at determining these associations in ischemic stroke patients. Methods: Among patients registered in the Fukuoka Stroke Registry from June 2007 to October 2014, 3,848 patients with ischemic stroke within 24 h of onset, who had been functionally independent before onset, were enrolled in this study. Ischemic stroke was classified as cardioembolic or non-cardioembolic infarction. Primary and secondary study outcomes were mild neurological symptoms defined as a National Institutes of Health Stroke Scale score of ≤4 on admission and favorable functional outcome defined as a modified Rankin Scale score of ≤2 at discharge, respectively. Multivariable logistic regression models were used to quantify associations between pre-stroke statin treatment and study outcomes. Results: Of all 3,848 participants, 697 (18.1%) were taking statins prior to the stroke. The frequency of mild neurological symptoms was significantly higher in patients with pre-stroke statin treatment (64.1%) than in those without the treatment (58.3%, p < 0.01). Multivariable analysis showed that pre-stroke statin treatment was significantly associated with mild neurological symptoms (OR 1.31; 95% CI 1.04-1.65; p < 0.01). Sensitivity analysis in patients with dyslipidemia (n = 1,998) also showed the same trend between pre-stroke statin treatment and mild neurological symptoms (multivariable-adjusted OR 1.26; 95% CI 0.99-1.62; p = 0.06). In contrast, the frequency of favorable functional outcome was not different between patients with (67.0%) and without (65.3%) the treatment (p = 0.40). Multivariable analysis also showed no significant association between pre-stroke statin treatment and favorable functional outcome (OR 1.21; 95% CI 0.91-1.60; p = 0.19). Continuation of statin treatment, however, was significantly associated with favorable functional outcome among patients with pre-stroke statin treatment (multivariable-adjusted OR 2.17; 95% CI 1.16-4.00; p = 0.02). Conclusions: Pre-stroke statin treatment in ischemic stroke patients was significantly associated with mild neurological symptoms within 24 h of onset. Pre-stroke statin treatment per se did not significantly influence the short-term functional outcome; however, continuation of statin treatment during the acute stage of stroke seems to relate with favorable functional outcome for patients with pre-stroke statin treatment.

Relationship between pre-stroke cardiovascular medication use and stroke severity

INTRODUCTION

Stroke is a major health problem with important morbidity and mortality. Various risk factors and cardiovascular medication groups are known to have an influence on stroke incidence, but less is known about the relation between medication use and stroke severity.

AIM

To determine if relationships exist between the pre-stroke cardiovascular medication use and stroke severity.

METHODS

A retrospective study was conducted on a database with anonymized data of 1974 patients with a suspected stroke, admitted to the Universitair Ziekenhuis (UZ) Brussel. Stroke severity was quantified using the National Institute of Health Stroke Scale (NIHSS). Cardiovascular medication groups were first included in a multivariable linear regression model. Second, to obtain clinically interpretable results, all variables that were retained in the final linear regression model were introduced in a cumulative odds ordinal logistic regression model with proportional odds.

RESULTS

Angiotensin II receptor blockers (ARBs), statins, and antiarrhythmics were significantly associated with stroke severity at the 10 % α level in a multivariable linear regression model, suggesting a possible effect of these medication groups on stroke severity. Only pre-stroke statin use showed a significant relationship with the NIHSS score in the ordinal logistic regression model with an adjusted odds ratio of 0.740 (95 % CI 0.580-0.944; p = 0.015).

CONCLUSION

Pre-stroke use of statins is significantly associated with lower stroke severity. No significant relationship was detected between pre-stroke use of other medication groups and stroke severity, defined by the NIHSS score.

Impact of Metformin on the Severity and Outcomes of Acute Ischemic Stroke in Patients with Type 2 Diabetes Mellitus

BACKGROUND

Diabetes mellitus (DM) is a major risk factor for cardiovascular disease. Metformin therapy reportedly decreases the risk of stroke, but the associations between metformin treatment and neurological severity or patient prognosis have not been investigated in clinical studies. This study evaluated the effects of metformin on stroke severity and outcomes in acute ischemic stroke patients with type 2 DM.

METHODS

We examined 355 stroke patients with type 2 DM without severe renal impairment or prestroke impairment of activities of daily living who were admitted to Kyushu Medical Center between April 2010 and September 2014. Neurological severity was assessed according to the National Institutes of Health Stroke Scale (NIHSS) score on admission. Mild neurological severity was defined as an NIHSS score lower than 3 on admission, and favorable functional outcome was defined as a modified Rankin Scale score of 2 or lower at discharge.

RESULTS

On logistic regression analysis with adjustments for multiple confounding factors, pretreatment with metformin was independently associated with mild neurological symptoms (odds ratio [OR], 2.12; 95% confidence interval [CI], 1.09-4.10; P = .026). In contrast, functional outcomes showed no significant associations. Nevertheless, a benefit of prior metformin use was observed in patients with a prior history of stroke (OR, 11.3; P = .046) and in patients after excluding those with mild stroke severity (OR, 5.64; P = .042).

CONCLUSIONS

Administration of metformin in DM patients prior to stroke onset may be associated with reduced neurological severity and improved acute-phase therapy outcomes.

Statins in Acute Ischemic Stroke: A Systematic Review

BACKGROUND AND PURPOSE

Statins have pleiotropic effects of potential neuroprotection. However, because of lack of large randomized clinical trials, current guidelines do not provide specific recommendations on statin initiation in acute ischemic stroke (AIS). The current study aims to systematically review the statin effect in AIS.

METHODS

From literature review, we identified articles exploring prestroke and immediate post-stroke statin effect on imaging surrogate markers, initial stroke severity, functional outcome, and short-term mortality in human AIS. We summarized descriptive overview. In addition, for subjects with available data from publications, we conducted meta-analysis to provide pooled estimates.

RESULTS

In total, we identified 70 relevant articles including 6 meta-analyses. Surrogate imaging marker studies suggested that statin might enhance collaterals and reperfusion. Our updated meta-analysis indicated that prestroke statin use was associated with milder initial stroke severity (odds ratio [OR] [95% confidence interval], 1.24 [1.05-1.48]; P=0.013), good functional outcome (1.50 [1.29-1.75]; P<0.001), and lower mortality (0.42 [0.21-0.82]; P=0.0108). In-hospital statin use was associated with good functional outcome (1.31 [1.12-1.53]; P=0.001), and lower mortality (0.41 [0.29-0.58]; P<0.001). In contrast, statin withdrawal was associated with poor functional outcome (1.83 [1.01-3.30]; P=0.045). In patients treated with thrombolysis, statin was associated with good functional outcome (1.44 [1.10-1.89]; P=0.001), despite an increased risk of symptomatic hemorrhagic transformation (1.63 [1.04-2.56]; P=0.035).

CONCLUSIONS

The current study findings support the use of statin in AIS. However, the findings were mostly driven by observational studies at risk of bias, and thereby large randomized clinical trials would provide confirmatory evidence.

Effect of pre-stroke statin use on stroke severity and early functional recovery: a retrospective cohort study

BACKGROUND

Experimental studies suggest that pre-stroke statin treatment has a dual effect of neuroprotection during ischemia and neurorestoration after ischemic injury. The aim of this study was to evaluate the effect of pre-stroke statin use on initial stroke severity and early clinical outcome.

METHODS

We used a prospective database enrolling patients with acute ischemic stroke from 12 hospitals in Korea between April 2008 and January 2012. Primary endpoint was the initial stroke severity as measured by the National Institutes of Health Stroke Scale (NIHSS) score. Secondary endpoints were good outcome (modified Rankin Scale [mRS], 0-2) and overall mRS distribution at discharge. Multivariable regression model and propensity score (PS) matching were used for statistical analyses.

RESULTS

Among the 8340 patients included in this study, 964 patients (11.6%) were pre-stroke statin users. The initial NIHSS score (mean [95% CI]) was lower among pre-stroke statin users vs. non-users in multivariable analysis (5.7 [5.2-6.3] versus 6.4 [5.9-6.9], p = 0.002) and PS analysis (5.2 [4.7-5.7] versus 5.7 [5.4-6.0], p = 0.043). Pre-stroke statin use was associated with increased achievement of mRS 0-2 outcome (multivariable analysis: OR [95% CI], 1.55 [1.25-1.92], p < 0.001; PS matching: OR [95% CI], 1.47 [1.16-1.88]; p = 0.002) and favorable shift on the overall mRS distribution (multivariable analysis: OR [95% CI], 1.29 [1.12-1.51], p = 0.001; PS matching: OR [95% CI], 1.31 [1.11-1.54]; p = 0.001).

CONCLUSIONS

Pre-stroke statin use was independently associated with lesser stroke severity at presentation and better early functional recovery in patients with acute ischemic stroke.

The many roles of statins in ischemic stroke

Stroke is the third leading cause of human death. Endothelial dysfunction, thrombogenesis, inflammatory and oxidative stress damage, and angiogenesis play an important role in cerebral ischemic pathogenesis and represent a target for prevention and treatment. Statins have been found to improve endothelial function, modulate thrombogenesis, attenuate inflammatory and oxidative stress damage, and facilitate angiogenesis far beyond lowering cholesterol levels. Statins have also been proved to significantly decrease cardiovascular risk and to improve clinical outcome. Could statins be the new candidate agent for the prevention and therapy in ischemic stroke? In recent years, a vast expansion in the understanding of the pathophysiology of ischemic stroke and the pleiotropic effects of statins has occurred and clinical trials involving statins for the prevention and treatment of ischemic stroke have begun. These facts force us to revisit ischemic stroke and consider new strategies for prevention and treatment. Here, we survey the important developments in the non-lipid dependent pleiotropic effects and clinical effects of statins in ischemic stroke.

Analysis of vitamin D levels in patients with and without statin-associated myalgia - a systematic review and meta-analysis of 7 studies with 2420 patients

INTRODUCTION

Vitamin D (vit D) deficiency may be associated with an increased risk of statin-related symptomatic myalgia in statin-treated patients. The aim of this meta-analysis was to substantiate the role of serum vitamin D levels in statin-associated myalgia.

METHODS

The search included PUBMED, Cochrane Library, Scopus, and EMBASE from January 1, 1987 to April 1, 2014 to identify studies that investigated the impact of vit D levels in statin-treated subjects with and without myalgia. Two independent reviewers extracted data on study characteristics, methods and outcomes. Quantitative data synthesis was performed using a fixed-effect model.

RESULTS

The electronic search yielded 437 articles; of those 20 were scrutinized as full texts and 13 studies were considered unsuitable. The final analysis included 7 studies with 2420 statin-treated patients divided into subgroups of patients with (n=666 [27.5%]) or without (n=1754) myalgia. Plasma vit D concentrations in the symptomatic and asymptomatic subgroups were 28.4±13.80ng/mL and 34.86±11.63ng/mL, respectively. The combination of data from individual observational studies showed that vit D plasma concentrations were significantly lower in patients with statin-associated myalgia compared with patients not manifesting this side effect (weighted mean difference -9.41ng/mL; 95% confidence interval: -10.17 to -8.64; p<0.00001).

CONCLUSIONS

This meta-analysis provides evidence that low vit D levels are associated with myalgia in patients on statin therapy. Randomized controlled trials are necessary to establish whether vitamin D supplementation reduces the risk for statin-associated myalgia.

Association of vitamin D and incident statin induced myalgia--a retrospective cohort study

BACKGROUND AND OBJECTIVES

Evidence is conflicting with regards to the role of vitamin D in statin induced myalgia (SIM). Studies so far have assessed cross-sectional association and were limited by study sample selected predominantly from cardiology clinics. In this retrospective cohort study we assessed the association between vitamin D and SIM and attempted to establish a serum vitamin D cutoff to identify patients at risk for developing SIM.

METHODS

Medical charts of 5526 consecutive patients from a primary care practice in Scranton, Pennsylvania from 2005-2012 were reviewed. Vitamin D level (25-hydroxy cholecalciferol) at statin initiation was considered "Exposure level". Vitamin D levels were categorized into quartiles (≤ 10, 11-20, 21-30, >30 ng/ml). SIM was identified by patient report.

RESULTS

1160 out of 5526 patients were treated with statins. The mean age was 55.9 years. 276 (24%) developed SIM. Unadjusted 7-yr cumulative incidences of SIM for quartiles 1-4 of vitamin D were 32.3, 21.5, 18.3 and 14.6% respectively. The lowest quartile of vitamin D was independently associated with 1.21 times the hazard of the fourth quartile for developing SIM (95% CI: 1.09, 1.33; P-trend  = 0.001). Vitamin D cut-off ≤15 ng/ml, showed a positive predictive value, negative predictive value, likelihood ratio (LR) + and LR- of 81, 90, 5.1 and 0.1, respectively for predicting SIM.

CONCLUSIONS

Low vitamin D level at statin initiation is associated with SIM, levels ≤15 ng/ml have a high predictive accuracy for SIM. Randomized controlled trials are needed to validate our results.