Cholesterol – The Lower the Better?

Odnos razine serumskoga kolesterola i rizika za moždani udar složen je, oprečan i prisutan u širokom rasponu serumskih razina ukupnoga kolesterola, LDL-a i HDL-a. Različite tvari različitog mehanizma djelovanja, ali s istim ciljem snižavanja razine serumskog LDL-a, statini, ezetimib i PCSK9 inhibitori snizuju incidenciju ishemijskoga moždanog udara, što izravno upućuje na uzročno-posljedičnu povezanost snižavanja serumske razine LDL-a i sprječavanja nastanka moždanog udara. Upozorenja o mogućemu povećanom riziku za hemoragijski moždani udar na temelju rezultata SPARCL istraživanja i statistički neznačajno povećanje rizika naznačeno u rezultatima IMPROVE-IT, FOURIER i Cholesterol Treatment Trialist metaanalize moguće upućuju kako bi značajno snižavanje LDL-C-a moglo uzrokovati hemoragijski moždani udar u posebno ranjivoj podskupini bolesnika, osobito u žena i bolesnika s loše reguliranom arterijskom hipertenzijom. S obzirom na to da je hemoragijski moždani udar u usporedbi s ishemijskim moždanim udarom rijedak, zabrinutost zbog mogućega povećanog rizika za hemoragijski moždani udar ne smije zasjeniti dobrobit od primjene lijekova za snižavanje LDL-C-a i boljeg ishoda vaskularnih bolesti u bolesnika liječenih ovom terapijom. Nužno je utvrditi stratifikaciju različitih kategorija bolesnika s obzirom na rizične čimbenike, kao i s obzirom na spol i životnu dob, te primijeniti individualan pristup i personalizaciju liječenja, kako u primarnoj tako i u sekundarnoj prevenciji moždanog udara.The correlation between serum cholesterol levels to stroke risk is complex and contradictory, and exists in a whole scope of serum levels of total cholesterol, LDL and HDL. Different substances with different action mechanisms, but with a shared goal of lowering serum LDL levels, statins, ezetimibe and PCSK9 inhibitors, reduce the incidence of IS (ischemic stroke), which directly suggests a cause-and-effect link between lowering serum LDL levels and preventing stroke. Warnings of a possible increased risk of hemorrhagic stroke (HS) based on the results of the SPARCL study and a statistically insignificant increase in risk indicated in the IMPROVE-IT and FOURIER results, as well as Cholesterol Treatment Trialist meta-analyses may suggest that a significant reduction in LDL-C could cause HS in a particularly vulnerable subgroup of patients, especially in women and patients with poorly regulated arterial hypertension. As HS is rare compared to IS, concerns about potential increased risk of HS should not overshadow the benefits of LDL-C-lowering drugs and better vascular effects in patients treated with this therapy. It is necessary to determine the stratification of different patient categories in terms of risk factors as well as gender and age, and apply an individual approach and personalised treatment in both primary and secondary prevention of stroke