Should people with history of hemorrhagic stroke avoid statins?

DEAR DR. ROACH: I am a 63-year-old man taking 20 mg of rosuvastatin a day, and my blood showed that my total cholesterol level was 136 mg/dL; my HDL was 47 mg/dL; and my LDL was 70 mg/dL. I was then given 10 mg of ezetimibe, and my LDL reduced to 43 mg/dL. I read that low cholesterol can cause a bleed in the brain, and because the total cholesterol level was below the normal range, I was concerned.

I also developed cramps in my hand, and I stopped taking ezetimibe. To my surprise, the muscle cramps stopped. When I went back to the doctor, I was told that the lower cholesterol levels are, the better. If low cholesterol can cause a brain hemorrhage, how low is too low? Did I do the right thing in stopping ezetimibe? — A.W.

ANSWER: Statin drugs like rosuvastatin reduce the risk of heart attack and overall stroke in people who are at a high risk to develop them. Unfortunately, they have downsides to them as well. It is not low cholesterol that increases the risk for a stroke due to bleeding in the brain (a hemorrhagic stroke); it is the statin. We believe this because a different type of medication, the PCSK9 inhibitors (which are given by injection), does not increase the risk of a hemorrhagic stroke, despite the fact that they lower LDL cholesterol more powerfully than statins.

The overall risk of hemorrhagic stroke in people taking statins (compared to a control group that wasn’t on statins) is low: 0.06%. Compared alongside the expected benefit in reduction of death, heart attack and overall stroke rate, the downside is small for most people who are at an increased risk. Certainly, in a person with a history of a heart attack, a thrombotic stroke or an embolic stroke, the benefit greatly outweighs the risk.

However, in a person with a history of a hemorrhagic stroke who has a greatly increased risk of having another one, statins need much more careful consideration. They may still be the best choice in a person with multiple other risks. A person with a history of hemorrhagic stroke who is at a low risk for heart disease or other strokes should avoid statins. Some people may benefit from a PCSK9 inhibitor, which reduces heart disease risk without increasing hemorrhagic stroke risk.

Finally, ezetimibe works by blocking absorption of cholesterol in the intestine. It has a low risk of muscle aches, but can cause joint aches. I wonder if your hand problem was a joint problem, since most people with muscle aches due to cholesterol medicine notice them in larger muscles like the legs, arms and back.

I don’t have enough information to tell you what the optimal treatment is; though, in hindsight, stopping the ezetimibe, which stopped your side effect, was a smart idea. Only your doctor, who can go over your individual risk for heart disease and stroke based on lots of information I don’t have, can inform you of the relative merits of statins or other treatments to reduce heart disease and stroke risk.

Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to [email protected] or send mail to 628 Virginia Dr., Orlando, FL 32803.

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