Lipid lowering therapy, low-density lipoprotein level and risk of intracerebral hemorrhage – a meta-analysis
O'Donnell, Martin J.
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Judge, Conor, Ruttledge, Sarah, Costello, Maria, Murphy, Robert, Loughlin, Elaine, Alvarez-Iglesias, Alberto, Ferguson, John, Gorey, Sarah, Nolan, Aoife, Canavan, Michelle, O'Halloran, Martin, O'Donnell, Martin J. (2019). Lipid Lowering Therapy, Low-Density Lipoprotein Level and Risk of Intracerebral Hemorrhage – A Meta-Analysis. Journal of Stroke and Cerebrovascular Diseases, 28(6), 1703-1709. doi: https://doi.org/10.1016/j.jstrokecerebrovasdis.2019.02.018
The association of lipid lowering therapy and intracerebral hemorrhage risk is controversial. We performed a cumulative meta-analysis of lipid lowering trials that reported intracerebral hemorrhage. Statin, fibrate, ezetimibe, PCSK9, and CETP trials were included. We explored whether the association of lipid lowering therapy and risk of intracerebral hemorrhage may vary by baseline low-density lipoprotein (LDL) level, mean change in LDL or baseline cardiovascular risk of population. Among 39 trials (287,651 participants), lipid lowering therapy was not associated with a statistically significant increased risk of intracerebral hemorrhage (ICH) in primary and secondary prevention trials combined (odds ratio [OR], 1.12; 95% confidence interval [CI], .98-1.28). Lipid lowering was associated with an increased risk of ICH in secondary prevention trials (OR, 1.18; 95% CI, 1.00-1.38), but not in primary prevention trials (OR, 1.01; 95% CI, .78-1.30), but the test for interaction was not significant (P for interaction¿=¿.31). Meta-regression of baseline LDL or difference in LDL reduction between active and control did not explain significant heterogeneity between studies for ICH risk. Of 1000 individuals treated for 1 year for secondary prevention, we estimated 9.17 (95% CI, 5.78-12.66) fewer ischemic strokes and .48 (95% CI, .06-1.02) more ICH, and a net reduction of 8.69 in all stroke per 1000 person-years. The benefits of lipid lowering therapy in prevention of ischemic stroke greatly exceed the risk of ICH. Concern about ICH should not discourage stroke clinicians from prescribing lipid lowering therapy for secondary prevention of ischemic stroke.
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