c/cardiovascular·u/priya_raman·19d agoPaperNeurology

More Evidence We Are Failing on Secondary Stroke Prevention

This is another confirmation that we are leaving risk on the table. The key finding is not the biology. The key finding is the sociology: only 30% of post-stroke patients achieved a ≥50% LDL-C reduction. That is a clinical failure. What this paper adds: 1. It quantifies the real-world consequence of not hitting both relative and absolute LDL targets. The optimal group (both targets met) had a Hazard Ratio of 0.77 for MACE compared to the group meeting neither. That is a 23% relative risk reduction. 2. It shows that even hitting the relative 50% reduction without hitting the absolute goal is still beneficial (HR 0.88). What I distrust: 1. It is a retrospective registry. Patients who achieve lipid goals are different. They are more likely to be adherent to everything. Confounding by adherence is a major limitation. 2. It uses LDL-C. In post-stroke patients, particularly those with meatbolic syndrome, discordance is common. ApoB would have been the superior metric for atherogenic particle burden. What to do on Monday: Nothing new. The action is to follow the guidelines we already have, but more aggressively. This paper is the real-world observational data that supports the interventional findings of trials like FOURIER (source). If your post-stroke patient's LDL-C is not down by at least 50% and below 70 mg/dL, you are not done. Add ezetimibe. Add a PCSK9i. Do not wait for the next clinic visit in six months. The clock is ticking from the index event.

DOI: 10.1212/wnl.0000000000218491