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Marchina S, Yeatts SD, Foster LD, Janis S, Shoamanesh A, Khatri P, Bernstein K, Perlmutter A, Stever C, Heistand EC, Broderick JP, Greenberg SM, Leira EC, Rosand J, Lioutas VA, Salman RAS, Tirschwell D, Marti-Fabregas J, Selim M. Rationale and Design of the Statins Use in Intracerebral Hemorrhage Patients (SATURN) Trial. Cerebrovasc Dis 2024:000538195. [PMID: 38493765 PMCID: PMC11403066 DOI: 10.1159/000538195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 02/22/2024] [Indexed: 03/19/2024] Open
Abstract
INTRODUCTION The benefits and risks of HMG-CoA reductase inhibitor (statin) drugs in survivors of intracerebral hemorrhage (ICH) are unclear. Observational studies suggest an association between statin use and increased risk of lobar ICH, particularly in patients with apolipoprotein-E (APOE) ε2 and ε4 genotypes. There are no randomized controlled trials (RCTs) addressing the effects of statins after ICH leading to uncertainty as to whether statins should be used in patients with lobar ICH who are at high risk for ICH recurrence. The SATURN trial aims to evaluate the effects of continuation versus discontinuation of statin on the risk of ICH recurrence and ischemic major adverse cerebro-cardio-vascular events (MACCE) in patients with lobar ICH. Secondary aims include the assessment of whether the APOE genotype modifies the effects of statins on ICH recurrence, functional and cognitive outcomes and quality of life. METHODS The SATURN trial is a multi-center, pragmatic, prospective, randomized, open-label, Phase III clinical trial with blinded end-point assessment. A planned total of 1456 patients with lobar ICH will be recruited from 140 sites in the United States, Canada and Spain. Patients presenting within seven days of a spontaneous lobar ICH that occurred while taking a statin, will be randomized (1:1) to continuation (control) vs. discontinuation (intervention) of the same statin drug and dose that they were using at ICH onset. The primary outcome is the time to recurrent symptomatic ICH within a two-year follow-up period. The primary safety outcome is the occurrence of ischemic MACCE. CONCLUSION The results will help to determine the best strategy for statin use in survivors of lobar ICH and may help to identify if there is a subset of patients who would benefit from statins.
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Abstract
Hyperlipidemia is common in patients with intracerebral hemorrhage (ICH). Accumulating evidence indicates that patients with ICH are at risk for future hemorrhage recurrence, cardiovascular disease, and ischemic stroke and highlights the importance of secondary prevention of vascular events after ICH. Although the benefits of intensive treatment of hyperlipidemia for reducing ischemic cardiac and vascular events in patients with ischemic stroke are well established, the benefit versus harm in patients with ICH are less clear. Epidemiological studies suggest that hyperlipidemia is protective against ICH and that intensive lowering of lipids is associated with increased risk for ICH. Similarly, although currently available lipid-lowering treatments have been thoroughly studied in patients with ischemic cardiac and vascular disease, only few randomized trials of these therapies included a very small number of patients with history of ICH. Thus, limiting any definitive conclusions regarding the safety and net benefit of these treatments in ICH populations. Currently, there is no consensus regarding the optimal strategy for management of hyperlipidemia after ICH. In this article, we review relevant literature to outline the competing risks and benefits of lipid-lowering treatments in this vulnerable patient population. We suggest a treatment paradigm based on available data but note that data from dedicated randomized trials are needed to build the necessary evidence to guide optimal lipid-lowering strategy in patients with a history of ICH.
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Affiliation(s)
- Ashkan Shoamanesh
- McMaster University / Population Health Research Institute, Dept. of Medicine, Hamilton, ON, CA
| | - Magdy Selim
- Beth Israel Deaconess Medical Center / Harvard Medical School, Dept. of Neurology, Stroke Division, Boston, MA
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González-Henares MA, Clua-Espuny JL, Lorman-Carbo B, Fernández-Saez J, Queralt-Tomas L, Muria-Subirats E, Ballesta-Ors J, Gil-Guillen JV. Risk of Long-Term Mortality for Complex Chronic Patients with Intracerebral Hemorrhage: A Population-Based e-Cohort Observational Study. Adv Ther 2020; 37:833-846. [PMID: 31879838 DOI: 10.1007/s12325-019-01206-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Over recent years there has been growing evidence of increased risk of mortality associated with hemorrhagic stroke among older patients. The main objective of this study is to propose and validate a prognostic life table for complex chronic patients after an intracerebral hemorrhage (ICH) episode in primary care settings. METHODS This was a multicenter and retrospective study (April 1, 2006-December 31, 2016) of a cohort from the general population presenting an episode of ICH from which a predictive model of mortality was obtained using a Cox proportional hazards regression model. In addition, Kaplan-Meier survival curves, the log-rank test, receiver operating characteristic (ROC) curves, and area under the ROC curve (AUC) were used to evaluate the ability to stratify patients according to vital prognosis. We proceeded to external validation of the model through prospective monitoring (January 1, 2013-December 31, 2017) of the population of complex chronic patients with an episode of ICH. RESULTS A total of 3594 people aged ≥ 65 years were identified as complex chronic patients (women 55.9%; mean age, 86.1 ± 8.4 years) of whom 161 suffered hemorrhagic stroke during the study period (January 1, 2013-December 31, 2017). The primary outcome was death from any cause within 5 years of follow-up after an ICH episode. The independent prognostic factors of mortality were age > 80 years (HR 1.048, 95% CI 1.021-1.076, p < 0.001) and HAS-BLED score (HR 1.369, 95% CI 1.057-1.774, p = 0.017). Compared to the general population, the incidence density/1000 person per year (15 vs 0.22) was significantly higher with a significantly lower annual lethality rate (17% vs 49.2%); and both the prognostic factors and the risk of stratified mortality showed different epidemiological patterns. The internal validation of the model was optimal (log-rank < 0.0001) in the general population, but its external validation was not significant in the complex chronic patient population (log-rank p = 0.104). CONCLUSIONS The ICH-AP is a clinical scale that can improve the prognostic prediction of mortality in primary care after an episode of ICH in the general population, but it was not significant in its external validation in a population of complex chronic patients. TRIAL REGISTRATION ClinicalTrials.gov ID: NCT03247049.
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Affiliation(s)
- Maria Antonia González-Henares
- EAP-Alcanar-St Carlos de la Rápita, Catalonian Health Institute, SAP Terres de l'Ebre, Health Department, Generalitat de Catalunya, CAP St Carles de la Rápita, 43540, Sant Carles de la Ràpita, Spain
- Department of Research, ICS Terres de l'Ebre, Research Institute University Primary Care (IDIAP) Jordi Gol, Barcelona, Spain
| | - Jose Luis Clua-Espuny
- Department of Research, ICS Terres de l'Ebre, Research Institute University Primary Care (IDIAP) Jordi Gol, Barcelona, Spain.
- EAP-Tortosa 1-Est Catalonian Health Institute, SAP Terres de l'Ebre, Health Department, Generalitat de Catalunya, CAP Temple, Plaça Carrilet, s/núm, 43500, Tortosa, Spain.
| | - Blanca Lorman-Carbo
- UUDD Tortosa-Terres de l'Ebre, Catalonian Health Institute, SAP Terres de l'Ebre, Health Department, Generalitat de Catalunya, CAP Temple, 43500, Tortosa, Spain
| | - Jose Fernández-Saez
- Unitat de Suport a la Recerca Terres de l'Ebre, Institut Universitari d'Investigació en Atenció Primària (IDIAP) Jordi Gol, Grupo de investigación de Salud Pública, Universidad de Alicante, Alicante, Spain
| | - Lluisa Queralt-Tomas
- EAP-Tortosa-Oest, Catalonian Health Institute, SAP Terres de l'Ebre, Health Department, Generalitat de Catalunya, CAP Xerta, 43592, Xerta, Spain
| | - Eulalia Muria-Subirats
- UUDD Tortosa-Terres de l'Ebre, Catalonian Health Institute, SAP Terres de l'Ebre, Health Department, Generalitat de Catalunya, CAP Temple, 43500, Tortosa, Spain
| | - Juan Ballesta-Ors
- UUDD Tortosa-Terres de l'Ebre, Catalonian Health Institute, SAP Terres de l'Ebre, Health Department, Generalitat de Catalunya, CAP Temple, 43500, Tortosa, Spain
| | - Jose Vicente Gil-Guillen
- Universidad Miguel Hernández, Cátedra Medicina de Familia, Carretera Alicante-Elche s/num, 03202, Elche, Spain
- Clinical Evidence Based Medicine and Emotional Department, Miguel Hernández University, Family and Community Specialty, Elche, Spain
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Biocatalyzed Synthesis of Statins: A Sustainable Strategy for the Preparation of Valuable Drugs. Catalysts 2019. [DOI: 10.3390/catal9030260] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Statins, inhibitors of 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase, are the largest selling class of drugs prescribed for the pharmacological treatment of hypercholesterolemia and dyslipidaemia. Statins also possess other therapeutic effects, called pleiotropic, because the blockade of the conversion of HMG-CoA to (R)-mevalonate produces a concomitant inhibition of the biosynthesis of numerous isoprenoid metabolites (e.g., geranylgeranyl pyrophosphate (GGPP) or farnesyl pyrophosphate (FPP)). Thus, the prenylation of several cell signalling proteins (small GTPase family members: Ras, Rac, and Rho) is hampered, so that these molecular switches, controlling multiple pathways and cell functions (maintenance of cell shape, motility, factor secretion, differentiation, and proliferation) are regulated, leading to beneficial effects in cardiovascular health, regulation of the immune system, anti-inflammatory and immunosuppressive properties, prevention and treatment of sepsis, treatment of autoimmune diseases, osteoporosis, kidney and neurological disorders, or even in cancer therapy. Thus, there is a growing interest in developing more sustainable protocols for preparation of statins, and the introduction of biocatalyzed steps into the synthetic pathways is highly advantageous—synthetic routes are conducted under mild reaction conditions, at ambient temperature, and can use water as a reaction medium in many cases. Furthermore, their high selectivity avoids the need for functional group activation and protection/deprotection steps usually required in traditional organic synthesis. Therefore, biocatalysis provides shorter processes, produces less waste, and reduces manufacturing costs and environmental impact. In this review, we will comment on the pleiotropic effects of statins and will illustrate some biotransformations nowadays implemented for statin synthesis.
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Judge C, Ruttledge S, Costello M, Murphy R, Loughlin E, Alvarez-Iglesias A, Ferguson J, Gorey S, Nolan A, Canavan M, O'Halloran M, O'Donnell MJ. Lipid Lowering Therapy, Low-Density Lipoprotein Level and Risk of Intracerebral Hemorrhage - A Meta-Analysis. J Stroke Cerebrovasc Dis 2019; 28:1703-1709. [PMID: 30878368 DOI: 10.1016/j.jstrokecerebrovasdis.2019.02.018] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 02/11/2019] [Accepted: 02/14/2019] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND The association of lipid lowering therapy and intracerebral hemorrhage risk is controversial. METHODS We performed a cumulative meta-analysis of lipid lowering trials that reported intracerebral hemorrhage. Statin, fibrate, ezetimibe, PCSK9, and CETP trials were included. We explored whether the association of lipid lowering therapy and risk of intracerebral hemorrhage may vary by baseline low-density lipoprotein (LDL) level, mean change in LDL or baseline cardiovascular risk of population. RESULTS Among 39 trials (287,651 participants), lipid lowering therapy was not associated with a statistically significant increased risk of intracerebral hemorrhage (ICH) in primary and secondary prevention trials combined (odds ratio [OR], 1.12; 95% confidence interval [CI], .98-1.28). Lipid lowering was associated with an increased risk of ICH in secondary prevention trials (OR, 1.18; 95% CI, 1.00-1.38), but not in primary prevention trials (OR, 1.01; 95% CI, .78-1.30), but the test for interaction was not significant (P for interaction = .31). Meta-regression of baseline LDL or difference in LDL reduction between active and control did not explain significant heterogeneity between studies for ICH risk. Of 1000 individuals treated for 1 year for secondary prevention, we estimated 9.17 (95% CI, 5.78-12.66) fewer ischemic strokes and .48 (95% CI, .06-1.02) more ICH, and a net reduction of 8.69 in all stroke per 1000 person-years. CONCLUSIONS The benefits of lipid lowering therapy in prevention of ischemic stroke greatly exceed the risk of ICH. Concern about ICH should not discourage stroke clinicians from prescribing lipid lowering therapy for secondary prevention of ischemic stroke.
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Affiliation(s)
- Conor Judge
- HRB-Clinical Research Facility, NUI Galway, Galway, Ireland; Translational Medical Device Lab, NUI Galway, Galway, Ireland; Wellcome Trust - HRB Irish Clinical Academic Training, Ireland.
| | | | - Maria Costello
- HRB-Clinical Research Facility, NUI Galway, Galway, Ireland
| | - Robert Murphy
- HRB-Clinical Research Facility, NUI Galway, Galway, Ireland
| | | | | | - John Ferguson
- HRB-Clinical Research Facility, NUI Galway, Galway, Ireland
| | - Sarah Gorey
- HRB-Clinical Research Facility, NUI Galway, Galway, Ireland
| | - Aoife Nolan
- HRB-Clinical Research Facility, NUI Galway, Galway, Ireland
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Chung CM, Lin MS, Liu CH, Lee TH, Chang ST, Yang TY, Pan KL, Lin YS. Discontinuing or continuing statin following intracerebral hemorrhage from the view of a national cohort study. Atherosclerosis 2018; 278:15-22. [PMID: 30236866 DOI: 10.1016/j.atherosclerosis.2018.08.049] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2018] [Revised: 07/19/2018] [Accepted: 08/30/2018] [Indexed: 01/17/2023]
Abstract
BACKGROUND AND AIMS Statins improve clinical outcomes in patients with ischemic stroke but there is no evidence of the effect of continuing long-term statin therapy in patients with intracerebral hemorrhage (ICH). The aim of this study was to evaluate the impact of continuing statin after ICH. METHODS Data on patients with ICH was retrieved from the National Health Insurance Research Database of Taiwan. The final population was separated into two groups according to those who continued and those who discontinued statin treatment. All-cause mortality and cardiovascular outcomes were analyzed after a 3 year follow-up after propensity score matching (PSM). RESULTS Of the 114,101 patients with ICH, who were initially enrolled, 2468 patients with dyslipidemia and ICH were included. After PSM, the benefit of statin therapy on mortality appeared from 1 year to the end of the 3-year follow-up period after discharge (statin group versus non-statin group: 4.9% vs.12.3% at 1 year (hazard ratio [HR], 0.38; 95% confidence interval [CI], 0.26-0.57) and 12.9% vs. 25.3% at the end of the 3 year follow-up period (HR, 0.45; 95% CI, 0.35-0.58). Compared with the patients using lipophilic statins, those using hydrophilic statins had a significantly lower incidence of all-cause mortality (HR = 0.65, 95% CI = 0.43-0.99). There were no differences between those prescribed moderate-intensity statins and those prescribed high-intensity statins in terms of stroke and all-cause mortality (HR = 0.76; 95% CI = 0.40-1.46). CONCLUSIONS There was a lower risk of all-cause mortality following ICH in patients who continued statin treatment compared with those without statin treatment, especially in those treated with hydrophilic statins.
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Affiliation(s)
- Chang-Min Chung
- School of Traditional Chinese Medicine, College of Medicine, Chang Gung University, Taoyuan County, Taiwan; Division of Cardiology, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Ming-Shyan Lin
- Division of Cardiology, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Chi-Hung Liu
- Stroke Center and Department of Neurology, Chang Gung Memorial Hospital, Linkou Medical Center, Taiwan
| | - Tsong-Hai Lee
- Stroke Center and Department of Neurology, Chang Gung Memorial Hospital, Linkou Medical Center, Taiwan
| | - Shih-Tai Chang
- School of Traditional Chinese Medicine, College of Medicine, Chang Gung University, Taoyuan County, Taiwan; Division of Cardiology, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Teng-Yao Yang
- Division of Cardiology, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Kuo-Li Pan
- School of Traditional Chinese Medicine, College of Medicine, Chang Gung University, Taoyuan County, Taiwan; Division of Cardiology, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Yu-Sheng Lin
- Division of Cardiology, Chang Gung Memorial Hospital, Chiayi, Taiwan.
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Tai SY, Lin FC, Lee CY, Chang CJ, Wu MT, Chien CY. Statin use after intracerebral hemorrhage: a 10-year nationwide cohort study. Brain Behav 2016; 6:e00487. [PMID: 27247857 PMCID: PMC4867570 DOI: 10.1002/brb3.487] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2016] [Revised: 03/28/2016] [Accepted: 04/08/2016] [Indexed: 11/06/2022] Open
Abstract
INTRODUCTION Although statin therapy is beneficial to patients with ischemic stroke, statin use, and intracerebral hemorrhage (ICH) remain a concern. ICH survivors commonly have comorbid cardiovascular risk factors that would otherwise warrant cholesterol-lowering medication, thus emphasizing the importance of assessing the characteristics of statin therapy in this population. METHODS We performed a cohort study by using 10 years of data collected from the National Health Insurance Research Database in Taiwan. We enrolled 726 patients admitted for newly diagnosed ICH from January 1, 2001 to December 31, 2010. The patients were categorized into high- (92), moderate- (545), and low-intensity (89) statin groups, and into hydrophilic (295) and lipophilic (431) statin groups. The composite outcomes included all-cause mortality, recurrent ICH, ischemic stroke, transient ischemic attack, and acute coronary events. RESULTS The patients in the low-intensity group did not differ significantly from the patients in the high-intensity group in risk of all-cause mortality (adjusted hazard ratio [aHR] = 0.65, 95% confidence interval [CI] = 0.28-1.55) and recurrent ICH (aHR = 0.66, 95% CI = 0.30-1.44). In contrast, the patients in the hydrophilic group had a significantly lower risk of recurrent ICH than did those in the lipophilic group (aHR = 0.69, 95% CI = 0.48-0.99). We determined no significant differences in other composite endpoints between hydrophilic and lipophilic statin use. CONCLUSION Hydrophilic statin therapy is associated with a reduced risk of recurrent ICH in post-ICH patients. The intensity of statin use had no significant effect on recurrent ICH or other components of the composite outcome. Additional studies are required to clarify the biological mechanisms underlying these observations.
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Affiliation(s)
- Shu-Yu Tai
- Department of Family Medicine School of Medicine College of Medicine Kaohsiung Medical University Kaohsiung Taiwan; Department of Family Medicine Kaohsiung Medical University Hospital Kaohsiung Medical University Kaohsiung Taiwan; Department of Family Medicine Kaohsiung Municipal Ta-Tung Hospital Kaohsiung Medical University Hospital Kaohsiung Medical University Kaohsiung Taiwan
| | - Feng-Cheng Lin
- Department of Neurology Kaohsiung Medical University Hospital Kaohsiung Taiwan; Department of Neurology Pingtung Hospital Ministry of Health and Welfare Pingtung Taiwan
| | - Chung-Yin Lee
- Department of Family Medicine Kaohsiung Medical University Hospital Kaohsiung Medical University Kaohsiung Taiwan
| | - Chai-Jan Chang
- Department of Family Medicine School of Medicine College of Medicine Kaohsiung Medical University Kaohsiung Taiwan; Department of Family Medicine Kaohsiung Medical University Hospital Kaohsiung Medical University Kaohsiung Taiwan; Department of Family Medicine Kaohsiung Municipal Hsiao-Kang Hospital Kaohsiung Medical University Kaohsiung Taiwan
| | - Ming-Tsang Wu
- Department of Family Medicine School of Medicine College of Medicine Kaohsiung Medical University Kaohsiung Taiwan; Department of Public Health Kaohsiung Medical University Kaohsiung Taiwan; Center of Environmental and Occupational Medicine Kaohsiung Municipal Hsiao-Kang Hospital Kaohsiung Medical University Kaohsiung Taiwan
| | - Chen-Yu Chien
- Department of Otorhinolaryngology School of Medicine College of Medicine Kaohsiung Medical University Kaohsiung Taiwan; Department of Otorhinolaryngology Kaohsiung Medical University Hospital Kaohsiung Medical University Kaohsiung Taiwan; Department of Otorhinolaryngology Kaohsiung Municipal Hsiao-Kang Hospital Kaohsiung Medical University Kaohsiung Taiwan
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Statins in neurological disorders: An overview and update. Pharmacol Res 2014; 88:74-83. [DOI: 10.1016/j.phrs.2014.06.007] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2014] [Revised: 06/11/2014] [Accepted: 06/11/2014] [Indexed: 01/16/2023]
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Pan YS, Jing J, Wang YL, Zhao XQ, Song B, Wang WJ, Wang D, Liu GF, Liu LP, Wang CX, Wang YJ. Use of statin during hospitalization improves the outcome after intracerebral hemorrhage. CNS Neurosci Ther 2014; 20:548-55. [PMID: 24750990 DOI: 10.1111/cns.12274] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2014] [Revised: 03/25/2014] [Accepted: 03/26/2014] [Indexed: 11/30/2022] Open
Abstract
AIMS To examine the relationship between statin use in Chinese patients with intracerebral hemorrhage (ICH) during their hospitalization and the outcomes. METHODS Data were collected from the China National Stroke Registry. Good functional outcome was defined by a modified Rankin Scale score between 0-2. Functional outcome and rate of mortality at 3 months and 1 year were compared between ICH patients on statin and those without it during their hospitalization. Odds ratios (ORs) with 95% confidence intervals (CI) were calculated using the multivariable logistic regression model adjusted for baseline risk factors. RESULTS Among 3218 consecutive ICH patients from 2007 to 2008, 220 (6.8%) were on statin during their hospitalization. Compared with those without statin, patients on statin were younger, had more stroke risk factors but lower stroke severity. ICH patients on statin had better functional outcome at 3 months (OR 2.24, 95% CI 1.49-3.36) and at 1 year (OR 2.04, 95% CI 1.37-3.06). They also had lower rate of mortality at 3 months (OR 0.44, 95% CI 0.22-0.87) and 1 year (OR 0.49, 95% CI 0.27-0.86). CONCLUSIONS In-hospital statin use in ICH patients is associated with better functional outcome and lower mortality at 3 months and 1 year.
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Affiliation(s)
- Yue-Song Pan
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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