After ischaemic stroke, halving LDL mattered beyond reaching 70 mg/dL

Design

Retrospective national cohort, time-varying Cox regression

Population

89,414 Korean adults after acute ischaemic stroke, mean follow-up 5.7 years

Primary outcome

Recurrent stroke, myocardial infarction or all-cause death

Effect

<70 mg/dL without ≥50% reduction: aHR 1.12 (1.06–1.18) vs both targets met

A retrospective cohort in Neurology (published 20 August) used the Korean national insurance database to follow 89,414 patients after acute ischaemic stroke for a mean of 5.7 years, with 136,427 serial LDL-cholesterol measurements. Patients were grouped by whether they reached an absolute LDL below 70 mg/dL and a relative reduction of 50% or more from baseline.

Against patients who achieved both, those below 70 mg/dL but without a 50% reduction had a higher risk of recurrent stroke, myocardial infarction or death (adjusted HR 1.12, 95% CI 1.06–1.18). Those who missed both had HR 1.28 (1.23–1.34). Only about 30% of patients reached the relative target at any point in follow-up. Results held across sex, age, baseline LDL and presumed cardioembolic source.

Stroke guidelines mostly set an absolute target, while cardiology guidelines ask for both. This supports adopting the cardiology approach after stroke: a patient whose LDL started at 90 and now sits at 68 has not been treated enough.

• Record the pre-treatment LDL at the stroke admission — the relative target depends on it
• Aim for both a 50% reduction and an absolute target at the first lipid review
• Start high-intensity statin; add ezetimibe early if the 50% reduction is not reached
• Recheck LDL 4–12 weeks after starting or changing therapy

Why it matters

It challenges treating stroke patients to an absolute number while ignoring where they started.

Don't overread it

This was observational — it shows an association with the relative reduction, not that intensifying therapy to reach it causes the benefit.

The statistics, in plain English

A hazard ratio of 1.12 means about 12% more events over time in the group that reached 70 mg/dL without halving LDL. The interval (1.06–1.18) is narrow because the cohort is large. But this is observational: patients who respond well to statins may differ in other ways.

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