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National Stroke Guidelines strongly recommend taking medication to lower LDL cholesterol to under 1.8 mmol/L (70 mg/dL).- Recommended for patients after stroke caused by a blood clot. - Helps to prevent another stroke and/or heart attack.  What’s important to know?
What’s the research behind this recommendation?There is moderately strong research behind this recommendation. One study (Amarenco et al. 2020) compared the effects of lowering LDL cholesterol to a low level (2.3–2.8 mmol/L, 90–110 mg/dL) versus a very low level (under 1.8 mmol/L, 90 mg/dL). It showed that a very low level of LDL cholesterol is better for preventing another stroke. Over 3½ years, another stroke or heart attack occurred in 1 in 9 patients with low LDL cholesterol, versus 1 in 11 patients with very low LDL cholesterol. In this study, a third of patients needed additional medication on top of statins to lower LDL cholesterol to a very low level. Another study (Baigent et al. 2010) looked at the combined results of 26 studies with 170,000 patients in total. There was a clear link between lowering LDL cholesterol and lowering the risk of stroke. On average, lowering LDL cholesterol by 1 mmol/L (38 mg/dL) lowered the risk of stroke by 20%. Additional information
Questions to ask your doctor
Learn moreAbout this recommendationStroke Foundation's guidelines provide recommendations for managing stroke according to the latest research. Being informed helps to ensure the best care and outcomes. This resource was co-designed with consumers to provide accessible and useful information for stroke survivors and carers. The information in this resource has been adapted from the Clinical Guidelines for Stroke Management. For more help
When are changes to diet and exercise routine enough to manage high cholesterol?Cholesterol levels in your body include:
You’ll receive a blood test known as a lipid panel to check your cholesterol levels. It will also include your triglyceride levels, which is another type of lipid (or fat) that’s found in your blood. Having high cholesterol means you have high levels of LDL or non-HDL cholesterol, or both. These are risk factors for cardiovascular (heart) disease. Having high triglyceride levels is also a risk factor for cardiovascular disease. Healthy diet and exercise are the first line in managing high cholesterol. However, management depends on the person. Some people are able to use lifestyle modifications to lower LDL levels and increase HDL levels. They may also able to lower triglyceride levels with diet and exercise. Others may struggle to manage high cholesterol with diet and exercise alone. This is especially true for people who have a strong family history of high cholesterol. When is medication typically required to manage high cholesterol?Medication is typically recommended when:
A doctor will calculate your cardiovascular disease risk score to show your risk for developing a heart attack or stroke over 10 years. If the score is greater than 5 percent, they’ll recommend a medication. You can calculate your cardiovascular disease risk score online using the American College of Cardiology’s risk estimator. Having a triglyceride level greater than 200 mg/dL also puts a person at higher risk for cardiovascular disease. A triglyceride level of greater than 885 mg/dL will prompt a doctor to prescribe a medication, because you would be at an additional increased risk for pancreatitis. Why aren’t lifestyle modifications enough to adequately lower cholesterol in some people?Some people have a very strong family history of high cholesterol, known as familial hypercholesterolemia. Lifestyle modifications may not be enough to lower their cholesterol levels. Additionally, some people need to lower their cholesterol levels because they are at high risk for future cardiovascular events. They should take cholesterol-lowering medications and not rely on lifestyle modifications alone. What are statins? Who are they for, and how do they work?Statins are a type of cholesterol medication used to lower bad cholesterol and lower risk for cardiovascular disease. They lower cholesterol by blocking your body’s ability to use an enzyme needed to make cholesterol. Statins are for anyone who has high cholesterol levels and who previously had a heart attack or stroke or who is at high risk for a cardiovascular event. What are PCSK9 inhibitors? Who are they for, and how do they work? (adsbygoogle = window.adsbygoogle || []).push({});PCSK9 inhibitors are a newer class of cholesterol-lowering medication. Two medications, alirocumab (Praluent) and evolocumab (Repatha), were approved for use by the Food and Drug Administration (FDA) in 2015. They are given by injection every 2 to 4 weeks to lower LDL (“bad”) cholesterol levels. PCSK9 is a protein in the liver that blocks it from getting rid of LDLs. PCSK9 inhibitors block PCSK9, which allows the liver to regain its ability to get rid of LDL. It can be taken on its own or along with a statin. If your LDL cholesterol levels aren’t responding well to a statin alone, a doctor may prescribe a PCSK9 inhibitor. What is siRNA? How does it treat high cholesterol, and who is it for?Small interfering RNA (siRNA) is the latest class of cholesterol-lowering medications aimed at blocking the production of PCSK9. It stops the translation of PCSK9 messenger RNA, which can lead to lower levels of PCSK9. As a result, siRNA can lower LDL levels. Inclisiran is the first drug in this class of medications. It’s been shown to cause a 30 to 46 percent decrease in LDL levels at 1 year. It hasn’t received FDA approval for consumer use in the United States, but it’s been approved in Europe. What other medications might my doctor recommend to treat my high cholesterol?Statins are usually recommended to treat high cholesterol. If you’re unable to tolerate statins, your doctor may recommend cholesterol-lowering medications, such as:
Your doctor may also prescribe one of these medications in addition to a statin if you have both high LDLs and high triglycerides (greater than 500 mg/dL). Are high cholesterol medications safe?Yes, high cholesterol medications are generally safe. Up to 3 percent of people may experience muscle aches on statins. This is known as a myopathy. Your doctor will ask you whether you’re experiencing muscle pains after you start a statin. Up to 5.5 percent of people may develop liver injury with statin use. Your doctor will also check for liver damage by testing liver enzymes with a blood test. If you show any signs of myopathy or liver damage, your doctor can lower the statin dose or prescribe a different cholesterol medication. There is also a small risk of increase in blood sugar levels on statins. In people with diabetes mellitus, the benefits of lowering LDL levels and reducing the risk for a heart attack or stroke with medication outweigh any risk. Will I need to stay on high cholesterol medications forever?Some people may be able to manage their cholesterol with diet, exercise, and weight management and can safely come off of cholesterol-lowering medications. Others may need to stay on cholesterol-lowering medications for the rest of their lives due to a strong family history for high cholesterol or because they have a high risk for cardiovascular disease. Even if you need to take a cholesterol-lowering medication, lifestyle strategies are still important. You should aim to:
Dr. Alana Biggers is an internal medicine physician. She graduated from the University of Illinois at Chicago. She is an assistant professor at the University of Illinois at Chicago College of Medicine, where she specializes in internal medicine. She also has a master’s of public health in chronic disease epidemiology. |
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