Aggressive statin treatment, very low serum cholesterol levels and haemorrhagic stroke: is there an association?

Intracranial Bleeding After Percutaneous Coronary Intervention: Time-Dependent Incidence, Predictors, and Impact on Mortality

Background

Limited data are available on intracranial hemorrhage (ICH) in patients undergoing antithrombotic therapy after percutaneous coronary intervention (PCI).

Methods and Results

Using the Korean National Health Insurance Service database, we identified 219 274 patients without prior ICH and who underwent a first PCI procedure between 2007 and 2016 and analyzed nontraumatic ICH and all‐cause mortality. ICH after PCI occurred in 4171 patients during a median follow‐up of 5.6 years (overall incidence rate: 3.32 cases per 1000 person‐years). The incidence rate of ICH showed an early peak of 21.66 cases per 1000 person‐years within the first 30 days, followed by a sharp decrease to 3.68 cases per 1000 person‐years between 30 days and 1 year, and to <1 case per 1000 patient‐years from the second year until 10 years after PCI. The 1‐year mortality rate was 38.2% after ICH, with most deaths occurring within 30 days (n=999, mortality rate: 24.2%). No significant difference in mortality risk was observed between patients who had ICH within and after 1 year following PCI (adjusted hazard ratio, 1.04; 95% CI, 0.95–1.14; P=0.43). The predictors of post‐PCI ICH were age ≥75 years, hypertension, atrial fibrillation, end‐stage renal disease, history of stroke or transient ischemic attack, dementia, and use of vitamin K antagonists.

Conclusions

New ICH most frequently occurs in the early period after PCI and is associated with a high risk of early death, regardless of the occurrence time of ICH. Careful implementation of antithrombotic strategies is needed in patients at an increased risk for ICH, particularly in the peri‐PCI period.

LDL-C Levels Below 55 mg/dl and Risk of Hemorrhagic Stroke: A Meta-Analysis

OBJECTIVE

To evaluate the effect of very low levels of LDL-C (< 55 mg/dl) achieved with lipid-lowering therapy on hemorrhagic stroke incidence.

METHODS

We performed a meta-analysis including randomized trials that achieved LDL-C levels under 55 mg/dl in more intensive lipid-lowering arms, regardless of the lipid-lowering drug used. A fixed-effects model was used. This meta-analysis was performed according to PRISMA guidelines.

RESULTS

Eight eligible trials including 122.802 patients, were identified and considered eligible for the analyses. A total of 62.526 subjects were allocated to receive more intensive lipid-lowering therapy while 60.276 subjects were allocated to the respective control arms. There were no differences in the incidence of hemorrhagic stroke between the group that received a more intensive lipid-lowering therapy (achieved LDL-C level <55 mg/dl), and the group that received a less intense scheme (OR, 1.05; 95%CI, 0.85-1.31). The statistical heterogeneity was low (I2 = 2%). The sensitivity analysis showed that the results were robust.

CONCLUSIONS

The use of more intensive lipid-lowering therapy that achieved an LDL-C level lower than 55 mg/dl in patients with high cardiovascular risk, is not associated with an increased risk of hemorrhagic stroke. Considering the cardiovascular benefit and safety observed with the achievement of very low LDL-C values, the challenging lipid goals recommended by the new guidelines seem consistent.

Association between Serum Lipid and Hematoma Expansion after Spontaneous Intracerebral Hemorrhage in Chinese Patients

OBJECTIVES

Although several studies have shown that interventions to lower blood lipid concentration may reduce the risk of coronary arterial disease and ischemic stroke, the correlation between serum lipid levels and hemorrhagic stroke remains controversial. To clarify any possible association between serum lipid and hematoma expansion, we examined various serum lipid indices in patients with and without early hematoma expansion.

METHODS

Data of 572 intracerebral hemorrhage (ICH) patients from the cerebral small vessel disease cohort of Peking Union Medical College Hospital were retrospectively analyzed. Patients who finished the baseline brain computed tomography (CT) examination within 6 h post-ictus and the follow-up CT within 48 h after initial CT were included in the study. Hematoma expansion was delimited as an enlargement of hemorrhage volume over 33% or 12.5 mL between baseline and subsequent CT. Both uni- and multivariate logistic regression analyses were conducted to explore the association between early hematoma growth and various serum lipid indices, including triglycerides, total cholesterol (TC), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), non-HDL-C, ratios of LDL-C/HDL-C and LDL-C/TC, as well as other demographic and clinical features.

RESULTS

Out of 157 patients included in the analysis, hematoma growth occurred in 45 (28.7%). Only higher baseline systolic blood pressure was found to be correlated with an increased risk of hematoma growth based on both univariate (odds ratio [OR] 1.014, 95% confidence interval [CI]: 1.002-1.026, P = .024) and multivariate logistic regression analyses (OR 1.022, 95%CI: 1.008-1.037, P = .003). No associations were detected between the various serum lipid indices examined and other clinical features with a likelihood of early hematoma growth between groups or within various subgroups defined by different characteristics including age, gender, baseline Glasgow Coma Scale score, systolic blood pressure, intraventricular extension, and hematoma location.

CONCLUSIONS

No association between various indices of serum lipid and hematoma growth was identified among patients and subgroups with spontaneous ICH in the Chinese population; these findings may help to guide lipid management after ICH. However, further multi-centered, larger scale studies are expected to verify our results.

Long-term Safety and Efficacy of Achieving Very Low Levels of Low-Density Lipoprotein Cholesterol : A Prespecified Analysis of the IMPROVE-IT Trial

Importance

In the Improved Reduction of Outcomes: Vytorin Efficacy International Trial, intensive low-density lipoprotein cholesterol (LDL-C)-reducing therapy with ezetimibe/simvastatin compared with simvastatin alone was associated with a significant reduction in cardiovascular events in 18 144 patients after acute coronary syndrome. The safety of very low LDL-C levels over the long-term is unknown.

Objective

To assess the safety and clinical efficacy of achieving a very low (<30 mg/dL) level of LDL-C at 1 month using data from the Improved Reduction of Outcomes: Vytorin Efficacy International Trial.

Design, Setting, and Participants

This prespecified analysis compared outcomes in patients stratified by achieved LDL-C level at 1 month in the Improved Reduction of Outcomes: Vytorin Efficacy International Trial and adjusted for baseline characteristics during 6 years' median follow-up. Patients were enrolled from October 26, 2005, to July 8, 2010, and the data analysis was conducted from December 2014 to February 2017.

Main Outcomes and Measures

Safety end points included adverse events leading to drug discontinuation; adverse muscle, hepatobiliary, and neurocognitive events; and hemorrhagic stroke, heart failure, cancer, and noncardiovascular death. Efficacy events were as specified in the overall trial.

Results

Among the 15 281 patients included in the study, 11 645 (76.2%) were men and the median age was 63 years (interquartile range, 56.6-70.7 years). In these patients without an event in the first month, the achieved LDL-C values at 1 month were less than 30 mg/dL, 30 to 49 mg/dL, 50 to 69 mg/dL, and 70 mg/dL or greater in 6.4%, 31%, 36%, and 26% of patients, respectively. Patients with LDL-C values less than 30 mg/dL (median, 25 mg/dL; interquartile range, 21-27 mg/dL) at 1 month were more likely randomized to ezetimibe/simvastatin (85%), had lower baseline LDL-C values, and were more likely older, male, nonwhite, diabetic, overweight, statin naive, and presenting with a first myocardial infarction. After multivariate adjustment, there was no significant association between the achieved LDL-C level and any of the 9 prespecified safety events. The adjusted risk of the primary efficacy composite of cardiovascular death, major coronary events, or stroke was significantly lower in patients achieving an LDL-C level less than 30 mg/dL at 1 month (adjusted hazard ratio, 0.79; 95% CI, 0.69-0.91; P = .001) compared with 70 mg/dL or greater.

Conclusions and Relevance

Patients achieving an LDL-C level less than 30 mg/dL at 1 month had a similar safety profile (and numerically the lowest rate of cardiovascular events) over a 6-year period compared with patients achieving higher LDL-C concentrations. These data provide reassurance regarding the longer-term safety and efficacy of the continuation of intensive lipid-lowering therapy in very higher-risk patients resulting in very low LDL-C levels.

Trial Registration

clinicaltrials.gov Identifier: NCT00202878.

Discovery of a ROCK inhibitor, FPND, which prevents cerebral hemorrhage through maintaining vascular integrity by interference with VE-cadherin

Hemorrhagic stroke occurs when a weakened vessel ruptures and bleeds into the surrounding brain, leading to high rates of death and disability worldwide. A series of complex pathophysiological cascades contribute to the risk of hemorrhagic stroke, and no therapies have proven effective to prevent hemorrhagic stroke. Stabilization of vascular integrity has been considered as a potential therapeutic target for hemorrhagic stroke. ROCKs, which belong to the serine/threonine protein kinase family and participate in the organization of actin cytoskeleton, have become attractive targets for the treatment of strokes. In this study, in vitro enzyme-based assays revealed that a new compound (FPND) with a novel scaffold identified by docking-based virtual screening could inhibit ROCK1 specifically at low micromolar concentration. Molecular modeling showed that FPND preferentially interacted with ROCK1, and the difference between the binding affinity of FPND toward ROCK1 and ROCK2 primarily resulted from non-polar contributions. Furthermore, FPND significantly prevented statin-induced cerebral hemorrhage in a zebrafish model. In addition, in vitro studies using the xCELLigence RTCA system, immunofluorescence and western blotting revealed that FPND prevented statin-induced cerebral hemorrhage by enhancing endothelial cell–cell junctions through inhibiting the ROCK-mediated VE-cadherin signaling pathway. As indicated by the extremely low toxicity of FPND against mice, it is safe and can potentially prevent vascular integrity loss-related diseases, such as hemorrhagic stroke.

Comparison of the efficacy and safety of intensive-dose and standard-dose statin treatment for stroke prevention: A meta-analysis

BACKGROUND

Previous study indicated that high-dose statin treatment might increase the risk of hemorrhagic stroke and adverse reactions. We aim to compare the efficacy and safety of intensive-dose and standard-dose statin treatment for preventing stroke in high-risk patients.

METHODS

A thorough search was performed of multiple databases for publications from 1990 to June 2015. We selected the randomized clinical trials comparing standard-dose statin with placebo and intensive-dose statin with standard-dose statin or placebo for the prevention of stroke events in patients. Duplicate independent data extraction and bias assessments were performed. Data were pooled using a fixed-effects model or a random-effects model if significant heterogeneity was present.

RESULTS

For the all stroke incidences, intensive-dose statin treatment compared with placebo treatment and standard-dose statin treatment compared with placebo treatment showed a significant 21% reduction in relative risk (RR) (RR 0.79, 95% confidence interval (CI) [0.71, 0.87], P < 0.00001) and an 18% reduction in RR (RR 0.82, 95% CI [0.73, 0.93], P = 0.002) in the subgroup without renal transplant recipients and patients undergoing regular hemodialysis separately. For the fatal stroke incidences, intensive-dose statin treatment compared with standard dose or placebo was effective reducing fatal stroke (RR 0.61, 95% CI [0.39, 0.96], P = 0.03) and the RR was 1.01 (95% CI [0.85, 1.20], P = 0.90) in standard-dose statin treatment compared with placebo.

CONCLUSION

The results of this meta-analysis suggest that intensive-dose statin treatment might be more favorable for reducing the incidences of all strokes than standard-dose statin treatment, especially for patients older than 65 years in reducing the incidences of all stroke incidences.

Incidence, Time Trends, and Predictors of Intracranial Hemorrhage During Long-Term Follow-up After Acute Myocardial Infarction

BACKGROUND

To address the lack of knowledge regarding the long-term risk of intracranial hemorrhage (ICH) after acute myocardial infarction (AMI), the aims of this study were to: (1) investigate the incidence, time trends, and predictors of ICH in a large population within 1 year of discharge after AMI; (2) investigate the comparative 1-year risk of ICH in AMI patients and a reference group; and (3) study the impact of previous ischemic stroke on ICH risk in patients treated with various antithrombotic therapies.

METHODS AND RESULTS

Data about patients whose first AMI occurred between 1998 and 2010 were collected from the Swedish Register of Information and Knowledge about Swedish Heart-Intensive-Care Admissions (RIKS-HIA). Patients with an ICH after discharge were identified in the National Patient Register. Risk was compared against a matched reference population. Of 187 386 patients, 590 had an ICH within 1 year. The 1-year cumulative incidence (0.35%) was approximately twice that of the reference group, and it did not change significantly over time. Advanced age, previous ischemic or hemorrhagic stroke, and reduced glomerular filtration rate were associated with increased ICH risk, whereas female sex was associated with a decreased risk. Previous ischemic stroke did not increase risk of ICH associated with single or dual antiplatelet therapy, but increased risk with anticoagulant therapy.

CONCLUSION

The 1-year incidence of ICH after AMI remained stable, at ≈0.35%, over the study period. Advanced age, decreased renal function, and previous ischemic or hemorrhagic stroke are predictive of increased ICH risk.

Safety of statins: an update

Statins are widely used and have been proven to be effective in the prevention of atherosclerotic vascular disease events, primarily by reducing plasma low-density lipoprotein cholesterol concentrations. Although statins are generally well tolerated and present an excellent safety profile, adverse effects from muscle toxicity and liver enzyme abnormalities may occur in some patients. Myopathy and rhabdomyolysis are rare with statin monotherapy at the approved dose ranges, but the risk increases with use of higher doses, interacting drugs and genetic predisposition. Asymptomatic increases in liver transaminases with statin treatment do not seem to be associated with an increased risk of liver disease. Therefore, statin treatment can be safely used in patients with mild to moderately abnormal liver tests that are potentially attributable to nonalcoholic fatty liver disease and can improve liver tests and reduce cardiovascular morbidity in this group of patients. The risks of other unfavorable effects such as the slightly increased risk of new-onset diabetes and potentially increased risk of haemorrhagic stroke are much smaller than the cardiovascular benefits with the use of statins.

Risk factors, stroke prevention treatments, and prevalence of cerebral microbleeds in the Framingham Heart Study

BACKGROUND AND PURPOSE

Cerebral microbleeds (CMBs) are associated with increased risk of stroke and poor cognition. Vascular risk factors and medications used for stroke prevention may increase the risk of CMB. We examined the prevalence of CMB and the association of these risk factors with CMB, postulating that risk factors for cerebral amyloid angiopathy would be associated with lobar CMB and markers of hypertensive vasculopathy with deep CMB.

METHODS

We include 1965 Framingham Original and Offspring participants (age, 66.5±11.0 years; 54% women) and evaluated the age- and sex-specific prevalence of CMB. We related various vascular and genetic (apolipoprotein E [APOE]) risk factors and medication use to the presence of CMB overall and stratified by brain location (deep, lobar, or mixed).

RESULTS

CMBs were observed in 8.8% of participants, being mostly lobar (63%). CMB prevalence increased with age (P<0.0001) and was higher in men (P<0.001). Hypertension increased risk of any CMB, and in deep and mixed locations (P<0.05), and low total cholesterol and APOE ε4 increased risk of lobar CMB (P<0.05). Statin use increased risk of lobar and mixed location CMB (P<0.05). The latter association was not affected by adjustment for cholesterol levels or concomitant medication use.

CONCLUSIONS

We observed the expected association of hypertension with deep CMB and low cholesterol and APOE ε4 with lobar CMB. In addition, statin use was independently associated with CMB risk. This potential adverse effect of statin use needs to be examined in other cohorts.

Young-onset dementia

Young-onset dementia is a neurologic syndrome that affects behavior and cognition of patients younger than 65 years of age. Although frequently misdiagnosed, a systematic approach, reliant upon attainment of a detailed medical history, a collateral history, neuropsychological testing, laboratory studies, and neuroimaging, may facilitate earlier and more accurate diagnosis with subsequent intervention. The differential diagnosis of young-onset dementia is extensive and includes early-onset forms of adult neurodegenerative conditions including Alzheimer's disease, vascular dementia, frontotemporal dementia, Lewy body dementias, Huntington's disease, and prion disease. Late-onset forms of childhood neurodegenerative conditions may also present as young-onset dementia and include mitochondrial disorders, lysosomal storage disorders, and leukodystrophies. Potentially reversible etiologies including inflammatory disorders, infectious diseases, toxic/metabolic abnormalities, transient epileptic amnesia, obstructive sleep apnea, and normal pressure hydrocephalus also represent important differential diagnostic considerations in young-onset dementia. This review will present etiologies, diagnostic strategies, and options for management of young-onset dementia with comprehensive summary tables for clinical reference.

Protecting the Brain and the Heart

Novel anticoagulants (NOACs) are the recent therapeutic breakthrough in the prophylaxis of stroke in patients with nonvalvular atrial fibrillation (NVAF). Patients with NVAF seem to have a high atherosclerotic burden, but it has not yet been established whether these agents also protect against cardiovascular disease (CVD). Different NOACs could have cardioprotective properties of different importance, but data come only from indirect comparisons. Patients with NVAF are at risk of stroke when there is concomitant atherosclerosis that also necessitates optimal treatment to reduce CVD risk. Combining antiplatelets with anticoagulants is a common clinical scenario and not always justified by current data and guidelines, putting patients at unnecessary bleeding risk. This review provides current knowledge about the cardioprotective properties of NOACs, the clinical importance of the link between CVD and NVAF, and the pitfalls of combining antiplatelet therapy with warfarin or NOACs.

Dyslipidaemia in patients with established cardiovascular disease in Sub-Saharan Africa: a systematic review and meta-analysis

Dyslipidaemia has been recognized as a major risk factor for cardiovascular diseases. Our objectives were to conduct a systematic review and meta-analysis of published studies to determine the prevalence of dyslipidaemia among hospitalized adult patients with cardiovascular disease in sub-Saharan Africa and to compare between the various cardiovascular disease types. We searched Internet-based search tools and other sources for studies on dyslipidaemia or hypercholesterolaemia among hospitalized adult patients with established cardiovascular disease in sub-Saharan Africa, from 1985 to May 2011. Established cardiovascular disease was defined as ischaemic heart disease, heart failure, stroke or chronic kidney disease. We then assessed for between-study heterogeneity and carried out sensitivity analyses. Study quality was assessed using Downs and Black Checklist and publication bias was considered present when positive in both Egger's and Begg's tests. Restricted analyses were then performed on data from studies on ischaemic heart disease, heart failure and stroke separately. A total of 451 studies were screened and eventually 16 studies were included with a total of 2584 persons. The overall estimate of dyslipidaemia was 38.38% (95% confidence intervals = 26.75-50.0; I(2 )= 96.878; p < 0.001). The prevalence was highest among those with ischaemic heart disease (49.64%) than among those with stroke (26.53%) or heart failure (15.4%; p-values for all comparisons<0.001). Prevalence of dyslipidaemia in subjects with cardiovascular disease including ischaemic heart disease, stroke and heart failure in sub-Saharan Africa was high and similar to what was obtained in Western Europe and North America; highest in subjects with ischaemic heart disease, followed by those with stroke and heart failure.

Epidemiology and prevention of stroke: a worldwide perspective

This paper reviews how epidemiological studies during the last 5 years have advanced our knowledge in addressing the global stroke epidemic. The specific objectives were to review the current evidence supporting management of ten major modifiable risk factors for prevention of stroke: hypertension, current smoking, diabetes, obesity, poor diet, physical inactivity, atrial fibrillation, excessive alcohol consumption, abnormal lipid profile and psychosocial stress/depression.

Design and rationale of the LAPLACE-TIMI 57 trial: a phase II, double-blind, placebo-controlled study of the efficacy and tolerability of a monoclonal antibody inhibitor of PCSK9 in subjects with hypercholesterolemia on background statin therapy

Lowering low-density lipoprotein cholesterol (LDL-C) is a cornerstone for the prevention of atherosclerotic heart disease, improving clinical outcomes and reducing vascular mortality in patients with hypercholesterolemia. The clinical benefits of LDL-C reduction appear to extend even to patients starting with LDL-C as low as 60-80 mg/dL prior to initiating therapy. Statins are the first-line agents for treating hypercholesterolemia and are effective in reducing LDL-C, but many patients are unable to achieve their optimal lipid targets despite intensive statin therapy. Therefore, there has been a strong impetus for the development of novel pharmacologic agents designed to lower LDL-C further in patients already on statin therapy. Genetic mutations resulting in altered cholesterol homeostasis provide valuable information regarding novel approaches for treating hypercholesterolemia. To that end, mutations in proprotein convertase subtilisin/kexin type 9 (PCSK9) were linked to altered levels of LDL-C, illustrating this protein's role in lipid metabolism. PCSK9 promotes degradation of the LDL receptor, preventing its transport back to the cell surface and thereby increasing circulating LDL-C. Conversely, inhibition of PCSK9 can profoundly decrease circulating LDL-C, and thus is an attractive new target for LDL-C-lowering therapy. AMG 145 is a fully human monoclonal immunoglobulin G2 antibody that binds specifically to human PCSK9 and inhibits its interaction with the low-density lipoprotein receptor. In this manuscript, we describe the rationale and design of LDL-C Assessment with PCSK9 Monoclonal Antibody Inhibition Combined With Statin Therapy-Thrombolysis In Myocardial Infarction 57 (LAPLACE-TIMI 57; NCT01380730), a 12-week, randomized, double-blind, dose-ranging, placebo-controlled study designed to assess the safety and efficacy of AMG 145 when added to statin therapy in patients with hypercholesterolemia.

[Cerebral amyloid angiopathy is difficult to diagnose in the intensive care unit]

Cerebral amyloid angiopathy is a common cause of intracerebral haemorrhage in elderly patients. The diagnosis of cerebral amyloid angiopathy is based on the Boston criteria combining clinical and radiological criteria with no other cause of intracerebral haemorrhage. We describe the case of a 60-year-old female admitted to the intensive care unit for agitation and spatial disorientation. She had multiple intracerebral haematomas on brain CT scan. Typical cerebral microbleeds using MRI and the absence of other cause of intracerebral haemorrhage argued in favour of the diagnosis of cerebral amyloid angiopathy. The patient outcome was favourable with a discharge from the intensive care unit on day 16.

Reperfusion Strategies for Acute Ischemic Stroke

Stroke remains a major cause of morbidity and mortality worldwide. Despite preventive measures, effective management strategies are needed to reduce the morbidity and mortality associated with this devastating condition. While the management of hemorrhagic stroke is mostly limited to supportive care, reperfusion strategies in ischemic stroke have been developed and continue to evolve. Conceptually, the pathophysiology of ischemic stroke is similar to that of acute myocardial infarction and the objective of management is similar (ie, to rapidly restore normal flow to reduce permanent damage). It is, therefore, not surprising that the management of acute ischemic stroke includes intravenous (IV) thrombolysis, the only Food and Drug Administration (FDA)-approved strategy at this point. In addition, there are a myriad of emerging endovascular interventional techniques. We review the current literature and discuss some of the technical aspects of endovascular therapy in the setting of acute ischemic stroke.

Cerebral amyloid angiopathy: a systematic review

Cerebral amyloid angiopathy (CAA) is a disorder characterized by amyloid deposition in the walls of leptomeningeal and cortical arteries, arterioles, and less often capillaries and veins of the central nervous system. CAA occurs mostly as a sporadic condition in the elderly, its incidence associating with advancing age. All sporadic CAA cases are due to deposition of amyloid-β, originating from proteolytic cleavage of the Amyloid Precursor Protein. Hereditary forms of CAA are generally familial (and therefore rare in the general population), more severe and earlier in onset. CAA-related lobar intracerebral hemorrhage is the most well-studied clinical condition associated with brain amyloid deposition. Despite ever increasing understanding of CAA pathogenesis and availability of reliable clinical and diagnostic tools, preventive and therapeutic options remain very limited. Further research efforts are required in order to identify biological targets for novel CAA treatment strategies. We present a systematic review of existing evidence regarding the epidemiology, genetics, pathogenesis, diagnosis and clinical management of CAA.