LOS ANGELES – Starting or maintaining acute stroke patients on a statin during their initial hospitalization was linked with a dramatic improvement in 1-year survival in a retrospective review of medical records for more than 12,000 U.S. patients.
Dr. Alexander C. Flint
Based on the finding, Kaiser Permanente of Northern California will issue a revised order set that will recommend to physicians that they start acute stroke patients on 80-mg simvastatin as soon as possible on the first day of their hospitalization, Dr. Alexander C. Flint said at the International Stroke Conference.
"Based on results from the SPARCL [Stroke Prevention by Aggressive Reduction in Cholesterol Levels] trial, pretty much everyone in the stroke community believes that patients who have had an ischemic stroke should be treated with high-dose statin to prevent a second stroke (N. Engl. J. Med. 2006;355:549-59). In our study, the question wasn’t whether to treat, but the timing. What our results say is that you should not wait until the patient is discharged or is an outpatient, but that you should start the statin on day 1," Dr. Flint said in an interview.
The data he reported showed that stroke patients who started on a statin during their acute-phase hospitalization had a 15% absolute reduced rate of death during the first year following their stroke, compared with patients who did not start on a statin and did not receive a statin prior to their stroke (Stroke 2011;42:e-42-110). After adjustment for several possible confounding factors, including age; sex; race and ethnicity; year of stroke; and comorbidities such as hypertension and diabetes, stroke patients who started on a statin while hospitalized had a statistically significant (45%) relatively lower risk of death during the subsequent year, compared with patients who did not receive a statin.
The study involved 12,689 patients who received care from Kaiser Permanente of Northern California and had an ischemic stroke during 2000-2007. The total included 3,749 patients who were on steady statin treatment for at least 3 months before their stroke, and 8,940 patients who were not receiving a statin at all before their stroke.* Of the 3,749 patients who were on a statin before their stroke, most (3,280, or 87%) continued to receive a statin during their hospitalization. And among the 8,940 who did not receive regular statin treatment before their stroke, 3,013 (34%) began statin treatment while hospitalized.
Patients who received a statin prior to their stroke but did not continue while hospitalized had a statistically significant 15% relative reduction in their mortality during the following year, compared with patients who never received a statin.
The key element for mortality protection appeared to be treatment while hospitalized. Relative mortality reduction compared with nonstatin users was 41% among patients who were on a statin both before their stroke and while hospitalized, and 45% among those who started on a statin while hospitalized, said Dr. Flint, a neurointensivist and stroke specialist at Kaiser Redwood City (Calif.). Patients who received a statin before their stroke but discontinued the drug once hospitalized had the worst outcomes, with a mortality rate that was 2.5-fold higher than that of patients who never received a statin.
Further analysis highlighted the importance of an early start to statin treatment in hospitalized patients, and also showed a dose-response relationship. Patients who received at least 60 mg of their statin daily either before hospitalization or both before and during hospitalization had a significantly lower mortality rate, compared with patients who took less than 60 mg/day. Dr. Flint noted that about 70% of patients received lovastatin, and about 20% received simvastatin.
Regarding timing, patients who either began on a statin for the first time or restarted their treatment on their first hospitalized day had a significantly lower 1-year mortality, compared with patients who did not start or restart their statin until their third day in hospital.
Dr. Flint also reported an additional analysis that had been run to determine whether patients’ survival prognosis drove their statin treatment instead of their statin treatment’s driving their survival. To do this, he looked at patterns of care at each of the 17 Kaiser Permanente of Northern California hospitals that were involved in the study. This "grouped treatment analysis" showed that although the survival prognosis of patients who were withdrawn from prior statin treatment while hospitalized played some role in the relationship, it was unable to explain all of the survival effect, indicating that statin treatment itself during hospitalization played a significant role in subsequent survival.
The strong impact that early statin treatment during stroke hospitalization has on long-term survival probably depends on the pleiotropic effects of statins. The timing makes it less likely that the effect of statins on lipid levels can explain the observed survival benefits, Dr. Flint said.