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Management of Dyslipidaemia for the Prevention of Stroke: Clinical Practice Recommendations from the Lipid Association of India

Author(s):

Raman Puri*, Vimal Mehta, S S Iyengar, Padma Srivastava, Jamal Yusuf, Akshaya Pradhan, Jeyaraj Durai Pandian, Vijay K Sharma, P N Renjen, A Muruganathan, K Mugundhan, A V Srinivasan, Sadanand Shetty, S N Narasingan, Devaki R Nair, Manish Bansal, D Prabhakar, Mukul Varma, Vimal K Paliwal, Aditya Kapoor, Saibal Mukhopadhyay, Rahul Mehrotra, Rashida Melinkari Patanwala, Rajeev Aggarwal, Kunal Mahajan, Soumitra Kumar, Neil Bardoloi, K K Pareek, P C Manoria, A K Pancholia, Rashmi Nanda, Nathan D Wong and P Barton Duell  

Abstract:


Stroke is the second most common cause of death worldwide. The rates of stroke are increasing in less affluent countries predominantly because of a high prevalence of modifiable risk factors. The Lipid Association of India (LAI) has provided a risk stratification algorithm for patients with ischaemic stroke and recommended low density lipoprotein cholesterol (LDL-C) goals for those in a very high risk group and extreme risk group (category A) of <50 mg/dl (1.3 mmol/l) while the LDL-C goal for extreme risk group (category B) is ≤30 mg/dl (0.8 mmol/l). High intensity statins are the first-line lipid lowering therapy. Non-statin therapy like ezetimibe and proprotein convertase subtilisin kexin type 9 (PCSK9) inhibitors may be added as an adjunct to statins in patients who do not achieve LDL-C goals statins alone. In acute ischaemic stroke, high intensity statin therapy improves neurological and functional outcomes regardless of thrombolytic therapy. Although conflicting data exist regarding increased risk of intracerebral haemorrhage (ICH) with statin use, the overall benefit risk ratio favors long-term statin therapy necessitating detailed discussion with the patient. Patients who have statins withdrawn while being on prior statin therapy at the time of acute ischaemic stroke have worse functional outcomes and increased mortality. LAI recommends that statins be continued in such patients. In patients presenting with ICH, statins should not be started in the acute phase but should be continued in patients who are already taking statins. ICH patients, once stable, need risk stratification for atherosclerotic cardiovascular disease (ASCVD).

Keywords:

Stroke, statin, ischaemic stroke, carotid stenosis, intracerebral haemorrhage, low density lipoprotein cholesterol

Affiliation:

Cardiac Care Centre, New Delhi, Department of Cardiology, G. B. Pant Institute of Postgraduate Medical Education and Research, New Delhi, Department of Cardiology, Manipal Hospital, Bangalore, Karnataka, Department of Neurology, Neurosciences Centre, AIIMS, New Delhi, Department of Cardiology, G. B. Pant Institute of Postgraduate Medical Education and Research, New Delhi, Department of Cardiology King George’s Medical University, Lucknow, U.P, Christian Medical College, Punjab, Yong Loo Lin School of Medicine, National University of Singapore and National University Hospital, Department of Neurology, Indraprastha Apollo Hospital, New Delhi, Consultant Internal Medicine, AG Hospital, Tirupur, Tamil Nadu, Department of Neurology, Govt, Stanley Medical College, Chennai, Department of Neurology, The Tamil Nadu,Dr MGR Medical University, Department of Cardiology, K.J Somaiya Super Speciality Institute Sion (East), Mumbai, The Tamil Nadu Dr MGR Medical University and Managing Director, SNN Specialities Clinic, Chennai, Tamil Nadu, Department of Lipidology and Chemical pathologist, Royal Free Hospital, London, Department of Cardiology, Medanta Hospital, Gurugram, Haryana, Department of Cardiology, Apollo Hospitals, Chennai, Tamil Nadu, Department of Neurology, Indraprastha Apollo Hospital, New Delhi, Department of Neurology, SGPGI, Lucknow, GPGI, Lucknow, Uttar Pradesh, Department of Cardiology, G. B. Pant Institute of Postgraduate Medical Education and Research, New Delhi, Non-Invasive Cardiology, Max Super Speciality Hospital, Saket, New Delhi, Department of Internal Medicine, Sahyadri Speciality Hospital, Pune, Jaswant Rai Speciality Hospital, Meerut, Uttar Pradesh, Department of Cardiology, Indra Gandhi Govt. Medical College and Hospital, Shimla, Department of Cardiology, Vivekananda Institute of Medical Sciences, Kolkata, Cardiology, Excel Care Hospital, Guwahati, Assam, Department of Medicine, S. N. Pareek Hospital, Dadabari, Kota, Rajasthan, Heart and Critical Care Hospital, Bhopal, Madhya Pradesh, Medicine and Preventive Cardiology, Arihant Hospital and Research Center, Indore, Madhya Pradesh, Consultant Physician and Lipidologist, Cardiac Care Centre, South Extension, New Delhi and Professor and Director University of California Irvine School of Medicine, Irvine, CA, Heart Disease Prevention Program, Division of Cardiology, University of California Irvine, Knight Cardiovascular Institute and Division of Endocrinology, Diabetes and Clinical Nutrition, Oregon Health and Science University, Portland, OR



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