Use of statins for the secondary prevention of stroke: are we respecting the scientific evidences?

https://doi.org/10.1016/j.jstrokecerebrovasdis.2020.104912Get rights and content

Abstract

Background: Stroke accounts for approximately as 5.0% of disability-adjusted years of life and 10.0% of all deaths worldwide. Secondary stroke prevention in surviving individuals, which includes the use of statins, reduces atherothrombotic stroke recurrence, complications and mortality. The present study aimed to characterize the Brazilian population with stroke history and estimate the prevalence of statin use as secondary prevention.

Methods: This is a population-based cross-sectional study conducted in Brazilian urban areas. A total of 41.433 individuals were interviewed, representing 171 million of Brazilians, based on post-stratification weights. We included only participants aged 20 years or older who answered "yes" to the following question: "Did any doctor ever tell you that you had a stroke?” The main outcome was the prevalence of statin use among individuals who answered affirmatively. To identify the factors associated with stroke occurrence, the participants were categorized according to clinical and sociodemographic characteristics.

Results: Only 24.2% (95% CI 19.9 – 29.1) of those who reported history of stroke regardless of other conditions also reported statin use. However, the results indicated that 52.9% (95% CI 43.6 – 62.0) of individuals who reported a previous diagnosis of dyslipidemia stated the use of statins. Regarding patients who reported stroke and did not report dyslipidemia history, only 9.1% (95% CI 5.9 - 13.8) referred to use statins.

Conclusion: This study showed a low prevalence of statin use by individuals with a history of stroke in Brazil. Actions involving the organization of services and training of professionals may positively impact the rates of stroke recurrence.

Introduction

Stroke, defined as an acute episode of focal dysfunction of the brain, retina, or spinal cord lasting for more than 24 hours, is characterized by the death of cells in a part of the brain due to reduced blood flow in that region. 1 Stroke data published by the American Heart Association indicated that approximately 800,000 people have stroke per year in the United States, of which 87% are ischemic and it is responsible for 5.0% of disability-adjusted years of life and 10.0% of all deaths worldwide are caused by this medical emergency.2,3

Despite the reduction in stroke incidence in developed countries in recent years, the incidence in low- and middle-income countries continues to increase.4,5 In Brazil, 8.7% of deaths between 2004 and 2014 were consequences of strokes, making it the second major vascular complication leading to death, a finding comparable to that in other countries.6

The recurrence rate is responsible for 30% of all notifications in the US.2 Therefore, to reduce mortality and the complications and to increase life expectancy and quality of life, patients should adopt secondary stroke prevention practices including as the correct use of prescribed medications such as statins.7, 8, 9, 10

Considering accident transient ischemic attack and ischemic stroke of atherosclerotic origin, statins are indicated for all individuals who do not present contraindications for their use. In these cases, the target is a low-density lipoprotein (LDL)-cholesterol concentration < 70 mg/dL.11 More recent evidence suggests that even lower values (LDL-cholesterol ≤ 30 mg/dL) could be more effective as secondary prophylaxis.12 Although the benefits of secondary prophylaxis have not been clearly demonstrated in relation to hemorrhagic stroke, there is no evidence to contraindicate its use.13,14

A study in Japan reported that statin use significantly reduced the risk of mortality after stroke, with 4-year risks of 11.8% and 21.7%, respectively, in patients who did and did not use statins.15 Kumbhani et al.7 analyzed international data from 37,000 patients, reporting that non-adherence to secondary prophylaxis in individuals with atherothrombotic disease was associated with unfavorable long-term clinical outcomes, including mortality.

Population-based studies to characterize the profile of statin use in populations affected by stroke are important to guide health policies to promote improvement of related indicators. Thus, the present study aimed to characterize the Brazilian population with stroke history and estimate the prevalence of statin use as secondary prevention in this population.

Section snippets

Methods

This study analyzed data from the National Survey on the Access, Use, and Promotion of Rational Use of Medicines (PNAUM, Pesquisa Nacional sobre Acesso, Utilização e Promoção do Uso Racional de Medicamentos no Brasil), a population-based cross-sectional study conducted in the urban areas of five Brazilian regions (North, Northeast, Center-West, Southeast, and South). The data were collected face-to-face, at home, between September 2013 and February 2014.

The study population comprised

Ethical Aspects

PNAUM was approved by National Research Ethics Comission – Protocol 18947013.6.0000.0008) and Research Ethics Committee of the Federal University of Rio Grande do Sul – Protocol 19997. All interviews were conducted after the respondents or their legal representatives (in the case of incapable persons) had read and signed the informed consent, with assurance of confidentiality and anonymity.

Results

We interviewed a total of 32,348 individuals aged 20 years or older, representing approximately 120 million Brazilians living in urban areas. In this population, the self-reported prevalence of at least one stroke was 1.7% (95%CI 1.5–1.8). The sociodemographic characteristics are shown in Table 1.

Age, number of chronic diseases, and smoking were associated with stroke history. The prevalence of stroke was higher among those aged 65 years or older (6.3%, 95%CI 5.5–7.1), reached 12.3% (95%CI

Discussion

As 30% of diagnosed stroke are recurrent events, international studies and guidelines recommend the control of risk factors and indicate prophylactic pharmacological therapy to prevent stroke recurrence.17, 18, 19, 20 There is evidence that a 40 mg/dL reduction in LDL-cholesterol reduces the risk of strokes by 25%.21 Smoking, age 65 years or older, and multiple chronic morbidities (three or more) are reportedly associated with a history of stroke.

World Health Organization (WHO) data indicate a

Declarations of Competing Interest

None

Acknowledgments

To the Brazilian Ministry of Health for the commission, funding and technical support of the National Survey on Access, Use and Promotion of Rational Use of Medicines.

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      Citation Excerpt :

      Stroke is responsible for an estimated 5% of disability-adjusted years of life and 10% of mortalities worldwide (Benjamin et al., 2019; Rodrigues et al., 2020).

    The study was performed at School of Medicine, Federal University of Rio Grande do Sul and School of Pharmaceutical Sciences of Ribeirão Preto, University of São Paulo.

    Grant Support: Brazilian Ministry of Health through the Secretariat of Science, Technology and Strategic Inputs – SCTIE (Process 25000.111834/2).

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