Serum Levels of LDL Cholesterol Are Found to Be Higher Among Many Stroke Patients

Many patients hospitalized with ischemic stroke or transient ischemic attack (TIA) have serum levels of LDL cholesterol that are greater than what is recommended as healthy by the National Cholesterol Education Program Adult Treatment Panel (NCEP-ATPIII), including patients with known dyslipidemia and those who are taking lipid-lowering agents, reported researchers in the February 27 Neurology.

Eric E. Smith, MD, MPH, FRCPC, and colleagues from the Department of Neurology and Stroke Service at Massachusetts General Hospital in Boston analyzed data from 1,212 consecutive admissions for ischemic stroke or TIA over a 30-month period; 76% were for first-ever stroke or TIA, they reported. The 589 patients with previously diagnosed dyslipidemia, 75% of whom were taking lipid-lowering agents, were more likely to be older, to be of nonwhite race, and to have vascular risk factors besides smoking.

Lipids were measured in 1,040 patients upon hospital admission, in 84% of patients with previously diagnosed dyslipidemia and in 88% of patients without. In a multivariate analysis, failure to have had lipid levels meas­ured was associated with in-hospital mortality (odds ratio [OR], 4.17), history of stroke (OR, 1.68), and history of myocardial infarction (OR, 1.54), reported the authors. Goals for LDL cholesterol were set prior to admission, and they were set in only 441 patients at the NCEP-ATPIII–recommended level of less than 100 mg/dL; 359 had a preadmission LDL cholesterol goal of less than 130 mg/dL, and 240 had a goal set at less than 160 mg/dL.

Two hundred eighty-four patients (27%) failed to meet their LDL cholesterol goal at admission; these represent “a population in which there was a failure of primary or secondary stroke prevention,” stated Dr. Smith and colleagues. Patients with coronary heart disease equivalents and the strictest LDL cholesterol target were observed to be the most likely to fail, followed by those with intermediate risk and lipid target. Only 6% of those with low risk and a lenient target failed to reach their goal.

Of patients admitted with LDL cholesterol levels greater than their goal, 213 (75%) were not taking lipid-lowering agents. Based on NCEP-ATPIII guidelines, 57% of those patients should have had lipid-lowering agent use initiated, while optional initiation would have been recommended for another 36%, and lifestyle modification would have been recommended in 7%.

“Because statins are the most commonly prescribed lipid-lowering drugs and have been associated with decreased stroke risk, it is probable that, had NCEP-ATPIII guidelines been followed, then at least some stroke or TIA events would never have happened,” speculated the authors. They recommended that LDL cholesterol be measured routinely in all ischemic stroke and TIA patients as a secondary prevention initiative.

Suggested Reading
Smith EE, Abdullah AR, Amirfarzan H, Schwamm LH. Serum lipid profile on admission for ischemic stroke. Neurology. 2007;68:660-665.

Stents May Benefit Patients With Severe Stenosis

Successful stent placement for severe stenosis may not present a higher subsequent stroke risk than does moderate stenosis, reported Wei-Jian Jiang, MD, and colleagues, in the February 6 Neurology. Severe stenosis was not shown to be a high-risk feature for primary or secondary end points, including lesion-related ischemic stroke and symptomatic brain or subarachnoid hemorrhage, within 30 days or during a follow-up period after 30 days.

The investigators studied 213 patients ages 20 to 79 undergoing elective stenting who collectively had 220 symptomatic intracranial atherosclerotic stenoses. They found 126 stenoses among 121 patients; at least 70% of those were severe stenosis. They also found 94 stenoses among 92 patients that were 50% to 69% moderate stenoses. Within 30 days, there were six primary events (4.8%) and three secondary events (2.4%) in the severe stenosis group. During a mean follow-up period of 26 months after 30 days, stent placement was found to be successful in 105 patients with 110 lesions in the severe stenosis group, while stents had failed in 11 patients. There were four (3.3%) definite lesion-related ischemic strokes (three among patients with successful stents and one among patients with failed stents) and two (1.7%) definite non–lesion-related ischemic strokes.

Within 30 days in the moderate stenosis group, there were four (4.3%) primary events and six (6.4%) secondary end points. The average follow-up time after 30 days was 27.6 months for the moderate stenosis group, in which 90 patients exhibited 92 lesions. A total of 85 patients with 87 lesions had a successful stent outcome, while stents had failed in five patients. There were three (3.3%) definite lesion-related ischemic strokes, all in patients with successful stent placement, and one (1.1%) definite non–lesion-related ischemic stroke.

The cumulative probability of primary end points was 7.2% at one year and 8.2% at two years in the severe stenosis group, and 5.3% at one year and 8.3% at two years in the moderate stenosis group. In addition, rates for primary and secondary end points within 30 days in the severe stenosis group were 4.8% and 2.4%, respectively, compared with 4.3% and 6.4%, respectively, in the moderate stenosis group. “The similar outcomes in the two groups may mean that elective stenting has eliminated the degree of stenosis as a predictor of outcome,” Dr. Jiang and colleagues noted. “These results imply that compared with the results of medical treatment, the procedure-related primary or secondary endpoint rate of elective stenting may be acceptable for patients with severe stenosis but may not be for patients with moderate stenosis.”

Suggested Reading
Jiang WJ, Xu XT, Du B, et al. Comparison of elective stenting of severe vs moderate intracranial atherosclerotic stenosis. Neurology. 2007;68:420-426.

Alzheimer’s Disease Progression Varies With Concurrent Drug Use

The drugs taken by some Alzheimer’s disease patients may result in an increased rate of disease progression, reported researchers in the March Journal of Neurology, Neurosurgery, and Psychiatry. A decreased rate of deterioration was also observed with use of other drugs, like those licensed for dementia and those used to lower blood pressure and cholesterol, when compared with decline in those for whom the medications were not prescribed.

John Ellul, DM, on the Department of Neurology faculty at the University of Patras in Greece, and colleagues recruited a cohort of 224 white probable–Alzheimer’s disease patients 65 and older; disease severity did not affect recruitment. Seventy-three percent were women, and mean age was 82.3. At baseline, the Global Deterioration Scale was administered to all participants, and information on current drug regimens was collected. Thirty-nine percent of patients were taking drugs for dementia (acetylcholinesterase-inhibiting drugs or N-methyl-D-aspartate [NMDA] antagonists in 86 of 87 patients), 24% were taking antidepressant drugs, 15% were taking antipsychotic drugs, and 13% were taking benzodiazepine or benzodiazepine-related drugs.

Twelve-month follow-up revealed that participants taking antipsychotics or sedatives were more likely to have an increased rate of deterioration compared with those not taking either type of drug (odds ratio [OR], 2.74 and 2.77, respectively) and those taking no drugs (ORs, 2.25 in those taking either type of drug and 3.86 for those taking both). The authors also noted that the older generation of antipsychotics tended to be more strongly associated with an increased rate of deterioration, though the difference was not statistically significant.

Risk of rapid deterioration was significantly lower in patients taking other drugs; compared with those not taking any of the listed drugs, ORs were reported as 0.49 in patients taking acetylcholinesterase inhibitors or NMDA antagonists, 0.31 in those taking drugs that affect the renin-angiotensin system, and 0.12 in those taking statins. “However, patients who were taking two or more of these type[s] of drugs did not show an additive protective effect,” noted Dr. Ellul and colleagues.

The authors acknowledged that the findings of the study do not prove causality, nor were 12-month compliance or the dosages of the drugs taken into account. While prescription of these classes of drugs may be unavoidable at times, they said clinicians need to be aware that antipsychotics and benzodiazepines, especially in combination, may hasten patient deterioration.

Suggested Reading
Ellul J, Archer N, Foy CML, et al. The effects of commonly prescribed drugs in patients with Alzheimer’s disease on the rate of deterioration. J Neurol Neurosurg Psychiatry. 2007;78:233-239.

Employment Status and Age May Predict Depression in Headache Patients

Headache patients referred for specialist consultation who meet certain clinical and demographic criteria may be at higher risk for depression, according to findings published in the February 13 Neurology. Employment status, age under 50, severe headache impact as gauged by the Headache Impact Test–6, and a diagnosis of transformed migraine were all factors strongly associated with depression in the cohort examined by Susan E. Jelinski, PhD, and colleagues.

The investigators studied 712 headache patients referred for specialist consultation. Excluding headache associated with head trauma or cervical spine disorder, the majority of patients in all headache categories did not have moderate to severe depression as defined by the Beck Depression Inventory; 189 patients (27%) were diagnosed with moderate to severe depression. At the time of initial consultation with a headache specialist, 17% of patients with epi­sodic migraine and 36% of patients with transformed migraine had depression.

The two factors most strongly associated with depression were being on disability or welfare and suffering from severe headache impact. Moreover, patients younger than 30 with headache had a more than twofold increase in depression risk compared with those older than 50. Unemployment and a diagnosis of transformed migraine were also strongly associated with depression. Additional factors independently associated with depression included age between 30 and 49, being widowed, separated, or divorced, severe disability as measured by the Migraine Disability Questionnaire, and a diagnosis of headache associated with head trauma or with cervical spine disorder.

“The possibility of a concomitant depression should be strongly considered in patients with headache with any of these characteristics,” Dr. Jelinksi and colleagues stated. Patients with transformed migraine, both with and without medication overuse, are particularly prone to depression, they pointed out.

“Although the study is limited by inherent selection bias, by its cross-sectional nature, and by a lack of control for clustering of observations within sites, this study reminds us that the care of patients with headache should include standardized depression screening,” noted Linda S. Williams, MD, and Matthew J. Bair, MD, MS, in an accompanying editorial. “This study underscores the fact that patients with headache, especially chronic debilitating headache, frequently have co-existing major depressive disorder. Neglecting depression assessment and subsequent treatment may thus negatively impact the response to headache treatments.”                        

Suggested Reading
Jelinski SE, Magnusson JE, Becker WJ. Factors associated with depression in patients referred to headache specialists. Neurology. 2007;68:489-495.
Williams LS, Bair MJ. Predictors of depression in patients referred to headache specialists. Neurology. 2007;68:477.

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