Should statins be used when someone has had a stroke?

A decision analysis just published in the Archives of Neurology offers cautionary evidence that statins should be avoided for people who have suffered an intracerebral hemorrhage (bleeding in the brain). The authors first observe:

"Statins are widely prescribed for primary and secondary prevention of ischemic cardiac and cerebrovascular disease...results from a recent clinical trial suggested increased risk of intracerebral hemorrhage (ICH) associated with statin use. For patients with baseline elevated risk of ICH, it is not known whether this potential adverse effect offsets the cardiovascular and cerebrovascular benefits."

They used life expectancy measured as as an outcome measure, examining how it varied according to a range of clinical parameters location of hemorrhage, ischemic heart and brain risks, and the magnitude of ICH risk that could be associated with statin use. What did their data show?

"Avoiding statins was favored over a wide range of values for many clinical parameters, particularly in survivors of lobar ICH who are at highest risk of ICH recurrence. In survivors of lobar ICH without prior cardiovascular events, avoiding statins yielded a life expectancy gain of 2.2 quality-adjusted life-years compared with statin use...In patients with lobar ICH who had prior cardiovascular events, the annual recurrence risk of myocardial infarction would have to exceed 90% to favor statin therapy. Avoiding statin therapy was also favored, although by a smaller margin, in both primary and secondary prevention settings for survivors of deep ICH."

Thus the authors conclude:

"Avoiding statins should be considered for patients with a history of ICH, particularly those cases with a lobar location."

In an editorial published in the same issue, its author states that despite the many questions that remain:

"The data are, however, generally consistent with the conclusion of the decision analysis—the risk of statin therapy likely outweighs any potential benefit in patients with (at least recent) brain hemorrhage and should generally be avoided in this setting. Until and unless there are data to the contrary, or warranted by specific clinical circumstances, the use of statins in patients with hemorrhagic stroke should be guided by the maxim of nonmaleficence— Primum non nocere."