Patient-Oriented Evidence That Matters

Small Reduction in Cardiovascular Outcome After Ischemic Stroke with Lower LDL Target, but also Harms; No Change in All-Cause Mortality


Am Fam Physician. 2020 Aug 15;102(4):247-248.

Clinical Question

Does a lower low-density lipoprotein (LDL) target following ischemic stroke reduce the likelihood of major adverse cardiovascular events?

Bottom Line

A lower LDL target slightly reduced the likelihood of a broad composite outcome (number needed to treat [NNT] = 43 over 3.5 years), largely by reducing nonfatal strokes (NNT = 77; statistical significance not reported). The benefit was seen only in patients whose index event was a stroke; risk may be increased in those with transient ischemic attack (TIA). (Level of Evidence = 1b)


The study identified adults with a recent ischemic stroke or TIA of at least 10 minutes duration in France or South Korea who had a modified Rankin score of 0 to 3 (functionally independent or largely so). All patients underwent imaging and had stenosis of a cerebral artery or known coronary artery disease. They also had an LDL level greater than 100 mg per dL (2.59 mmol per L) if not taking a statin or greater than 70 mg per dL (1.81 mmol per L) if already taking a statin. The 2,860 patients were then randomized to an LDL target of 70 mg per dL or an LDL target of 90 to 110 mg per dL (2.33 to 2.85 mmol per L) using any type or dose of statin preferred by their physicians (plus ezetimibe [Zetia], if needed). The total number of patients recruited was less than the authors' stated target of 3,786. The included patients were followed for a median of 5.3 years in France but only 2.0 years in South Korea. The mean age of participants was 67 years, 67% were men, 64% had hypertension, and their baseline LDL level was 135 mg per dL (3.50 mmol per L) with approximately one-half already taking a statin. Groups were balanced, and analysis was by intention to treat. The patients hit their mean LDL targets: 65 mg per dL (1.68 mmol per L) in the low target group and 96 mg per dL (2.49 mmol per L) in the higher target group. The authors had a broad primary composite outcome of cardiovascular death, nonfatal stroke, acute coronary syndrome,

POEMs (patient-oriented evidence that matters) are provided by Essential Evidence Plus, a point-of-care clinical decision support system published by Wiley-Blackwell. For more information, see http://www.essentialevidenceplus.com. Copyright Wiley-Blackwell. Used with permission.

For definitions of levels of evidence used in POEMs, see http://www.essentialevidenceplus.com/product/ebm_loe.cfm?show=oxford.

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This series is coordinated by Sumi Sexton, MD, editor-in-chief.

A collection of POEMs published in AFP is available at https://www.aafp.org/afp/poems.



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