Korean neurologists should keep an eye out on lipid-lowering therapies as a preventive measure to reduce secondary stroke, an expert said.
Lee Seung-hoon, director of the Korean Cerebrovascular Research Institute (KCRI) and a professor at neurology department at Seoul National University Hospital, said many neurologists were still unaware of the criteria for lipid reduction target in secondary stroke prevention.
He cited the result of KCRI’s recent survey on how physicians treated dyslipidemia as evidence.
The poll on 34 neurologists showed that 38 percent answered their target level of low-density lipoprotein cholesterol (LDL-C) for stroke prevention as “less than 100 mg/dL.” However, the right criteria of LDL-C level were “less than 70 mg/dL.”
Still, more than 91 percent of the respondents thought they were good at treating dyslipidemia for the prevention of the first and secondary stroke.
According to Lee, cardiopulmonary specialists actively lead clinical trials, make guidelines for lipid management, and discuss innovative ideas, whereas neurologists are passive about lipid control. “There is only one research called SPARCL which studied cholesterol in stroke patients. As local guideline was made based on this study, it was quite unclear,” he said.
The current guideline slightly mentions about controlling lipid by stating, “LDL-C is controlled below 100 mg/dL in atherosclerosis-induced stroke patients.” Atherosclerosis-induced stroke accounts for only one-third of all stroke cases.
There is no guideline for lipid management to prevent secondary stroke in the rest two-thirds of stroke cases, Lee noted.
The 2009 stroke guideline, offered on the website of the Korean Stroke Society, recommends setting the goal of cholesterol control in patients with coronary artery disease or symptomatic atherosclerotic ischemic stroke at below 100mg/dL.
“Neurologists are cautious about lowering cholesterol because many cohort studies and SPARCL trial concluded that low LDL-C could lead to intracranial hemorrhage (ISH),” Lee said.
Although it was true that the risk of hemorrhagic stroke was higher in patients with low LDL-C levels caused by nutritional problems, the issue was irrelevant to an artificial reduction of the cholesterol level in patients with high levels of LDL-C, Lee added. He emphasized that doctors should aggressively control lipid to prevent stroke, as the number of dyslipidemia patients was surging.
“Neurologists’ conservative stance about reducing cholesterol should be corrected through education about advanced lipid-controlling therapies and guidelines,” Lee said.
He also mentioned about PCSK9 inhibitor, a new lipid-lowering therapy.
“Thirty or 40 percent of stroke patients still have trouble reducing LDL-C below 70mg/dL, even after a combo therapy of maximum of statin and ezetimibe,” Lee said. “In these patients, PCSK9 inhibitor significantly helps to prevent secondary stroke, but its high price makes it difficult to use unless it becomes reimbursable.”