Front Panel Painting “LIFE” By William T Chua MD

B.2. Secondary Stroke Prevention
The Stroke Prevention by Aggressive Reduction in Cholesterol Levels (SPARCL)
study was conducted among patients with previous stroke or TIA and mildly elevated
LDL but without CHD. The trial showed significant reduction in recurrent stroke by
16% with high dose atorvastatin 80 mg/day. A post hoc analysis showed an increase
in the number of hemorrhagic stroke but with no difference in the incidence of fatal
hemorrhagic stroke. Several factors are associated with this increased risk of
hemorrhagic stroke namely advancing age, hypertension, cigarette smoking, use of
antithrombotic medication, and lower blood glucose and among patients with a
diagnosis of hemorrhagic stroke. Nevertheless, the overall benefit of atorvastatin
was significant because any possible excess of hemorrhagic stroke is greatly
outweighed by the positive effect against ischemic strokes. Likewise, SPARCL
showed statins reduced cerebro-cardiovascular events in patients with or without
carotid stenosis group with the latter having the greater benefit.
C. Recommendations:
C.1. Primary Stroke Prevention
1) Therapeutic lifestyle changes are recommended as an essential modality in
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clinical management. These include smoking cessation, weight management,
regular physical activity and adequate BP monitoring and control. 12
2) For patients at any level of cardiovascular risk, especially those with established
atherosclerosis, a low-fat cholesterol diet is recommended for life.
3) High-risk hypertensive patients and those with CAD should be treated with
lifestyle measures and a statin, even with normal LDL levels (Class I-A). 13,14
4) Adults with diabetes, especially those with additional risks factors, should
receive statins to lower the risk of a first stroke (Class I-A). 13
5) Patients with coronary artery disease and low HDL may be treated with weight
reduction, increased physical activity, smoking cessation, and possibly niacin or
fibrates (Class IIa-B).
C.2. Secondary Stroke Prevention
(Adapted from NCEP-ATP III)
1) Patients with ischemic stroke or TIA with elevated cholesterol, comorbid
coronary artery disease, or evidence of an atherosclerotic origin should be
managed according to NCEP III guidelines, which include lifestyle
modification, dietary guidelines, and medication recommendations (Class I-A).
Statin agents are recommended, and the target goal for cholesterol lowering for
those with CHD or symptomatic atherosclerotic disease is an LDL-C of