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This editorial refers to ‘Plasma lipids predict myocardial infarction, but not stroke, in patients with established cerebrovascular disease’† by A. Patel et al., on page 1910 The meta-analysis of over 90 000 patients included in statin tria ls shows a significant 21% reduction of stroke with no heterogeneity between trials and no increase in haemorrhagic stroke.1 Because the link between total cholesterol and incident stroke has never been clearly established in epidemiological studies,2 it is surprising to see, in the meta-analysis, that the larger the between-group LDL level difference the greater the stroke risk reduction.1 Indeed, we calculated that LDL reduction could explain 35–80% of the benefit of statins on stroke risk reduction, leaving room for other non-lipid lowering effects of statins, the so-called pleiotropic effects, but the main effect is through LDL reduction.1 New results from randomized trials since this meta-analysis, have confirmed that LDL lowering decreased the risk of stroke in diabetics with ‘normal’ LDL cholesterol at baseline3 and in patients with coronary artery disease4 (CAD), with 48 and 25% reduction in stroke incidence, respectively. In the Treat to New Target trial, the benefit was observed in the group of patients with a mean LDL cholesterol of 70 mg/dL when compared with the group of patients with a mean LDL level of 1.02 mg/dL.4 Hence, the lack of a relationship between cholesterol and stroke in epidemiologic studies2 is paradoxical because the association between carotid atherosclerosis and blood cholesterol has been well established in other … *Corresponding author. Tel: +33 1 4025 8725; fax: +33 1 4025 7198. E-mail address : pierre.amarenco{at}bch.ap-hop-paris.fr

european heart journal

Lipid lowering and recurrent stroke: another stroke paradox?The opinions expressed in this article are not necessarily those of the Editors of the European Heart Journal or of the European Society of Cardiology.