What Proportion of Patients Admitted with Stroke or Transient Ischemic Attack May Be Suitable for Newer Cholesterol-Lowering Treatment?

• Published in: Journal of stroke and cerebrovascular diseases 2020-01, Vol.29 (1), p.104457-104457, Article 104457
• Main Authors: Alakbarzade, Vafa, Pereira, Anthony C.
• Format: Article
• Language: English
• Subjects: acute ischemic stroke; Adolescent; Adult; Aged; Aged, 80 and over; Anticholesteremic Agents - adverse effects; Anticholesteremic Agents - therapeutic use; Biomarkers - blood; Cholesterol, LDL - blood; Dyslipidemias - complications; Dyslipidemias - diagnosis; Dyslipidemias - drug therapy; Dyslipidemias - enzymology; Eligibility Determination; Female; Humans; Ischemic Attack, Transient - complications; Ischemic Attack, Transient - diagnosis; Ischemic Attack, Transient - therapy; low-density lipoprotein cholesterol; Male; Middle Aged; nonhigh-density lipoprotein cholesterol; Patient Admission; Patient Selection; PCSK9 inhibitors; Proprotein Convertase 9 - antagonists & inhibitors; Proprotein Convertase 9 - metabolism; Retrospective Studies; Risk Assessment; Risk Factors; Serine Proteinase Inhibitors - adverse effects; Serine Proteinase Inhibitors - therapeutic use; Stroke - complications; Stroke - diagnosis; Stroke - therapy; transient ischemic attack; Young Adult
• ISSN: 1052-3057; 1532-8511
• DOI: 10.1016/j.jstrokecerebrovasdis.2019.104457

Protein convertase subtilisin–kexin type 9 (PCSK9) inhibitors effectively clear low-density lipoprotein cholesterol (LDL-C) and non-high-density lipoprotein cholesterol (non-HDL-C). We evaluated stroke admissions potentially eligible for more intensive cholesterol treatment. Retrospective analysis of consecutive admissions to a hyperacute stroke unit over 5 months in 2017. Records were individually searched. Data were collected on diagnosis, risk factors, and stroke work-up. European Society of Cardiology and European Atherosclerosis Society guidelines for the management of dyslipidaemias were used for screening patients eligible for PCSK9 inhibitors. Of 650 patient admissions: 351 (54%) had acute ischemic stroke or transient ischemic attack (TIA), 80 (12%) hemorrhage, and 219 (34%) mimic syndromes. Patients with hemorrhage (n = 80), mimic syndromes (n = 219), and absent LDL-C, or non-HDL-C testing (n = 27) were subsequently excluded. 324 patients with acute ischemic stroke and TIA were further screened for PCSK9-inhibitor treatment eligibility. Forty-one (13%) patients with LDL-C greater than or equal to 1.8mmol/L (≥70 mg/dL) on maximal tolerated statin dose and with concomitant “very high vascular risk” were identified. “Very high vascular risk” was defined as a documented history of cardiovascular disease and/or peripheral arterial disease. Of 41 patients eligible for PCSK9 inhibitors, median age was 82 years (range 53-96); median vascular risk factors were 2 (range 1-5); 7 (17%) had TIA; 13 (31%) had history of preceding cerebrovascular events, 13 (31%) diabetes mellitus, 17 (42%) cardioembolic events, 9 (22%) lacunar syndrome, 11 (22%) symptomatic internal carotid artery stenosis (n = 9 were >70%), and 4 (10%) undetermined aetiology. Eighty-three percent patients eligible for PCSK9 inhibitors also had non-HDL-C values greater than or equal to 2.6 mmol/L. Up to 13% of unselected acute ischemic stroke or TIA patients admitted to a hyper-acute stroke unit were potentially suitable for more intensive cholesterol treatment. Our data may act as a useful guide for sample size selection in future stroke trials testing PCSK9 inhibitors.