From the APHP, Department of Neurology and Stroke center, Bichat Hospital, INSERM LVTS-U1148, DHU FIRE, University of Paris, France (P.A., J.L., H.C.).
Asan Medical Center, Seoul, South Korea (J.S.K.).
Stroke. 2020 Apr;51(4):1231-1239. doi: 10.1161/STROKEAHA.119.028718. Epub 2020 Feb 20.
Background and Purpose- The TST trial (Treat Stroke to Target) evaluated the benefit of targeting a LDL (low-density lipoprotein) cholesterol of <70 mg/dL to reduce the risk of cardiovascular events in 2860 patients with ischemic stroke with atherosclerotic stenosis of cerebral vasculature or aortic arch plaque >4 mm, in a French and Korean population. The follow-up lasted a median of 5.3 years in French patients (similar to the median follow-up time in the SPARCL trial [Stroke Prevention by Aggressive Reduction in Cholesterol Level]) and 2.0 years in Korean patients. Exposure duration to statin is a well-known driver for cardiovascular risk reduction. We report here the TST results in the French cohort. Methods- One thousand seventy-three French patients were assigned to <70 mg/dL (1.8 mmol/L) and 1075 to 100±10 mg/dL (90-110 mg/dL, 2.3-2.8 mmol/L). To achieve these goals, investigators used the statin and dosage of their choice and added ezetimibe on top if needed. The primary outcome was the composite of ischemic stroke, myocardial infarction, new symptoms requiring urgent coronary or carotid revascularization and vascular death. Results- After a median follow-up of 5.3 years, the achieved LDL cholesterol was 66 (1.69 mmol/L) and 96 mg/dL (2.46 mmol/L) on average, respectively. The primary end point occurred in 9.6% and 12.9% of patients, respectively (HR, 0.74 [95% CI, 0.57-0.94]; =0.019). Cerebral infarction or urgent carotid revascularization following transient ischemic attack was reduced by 27% (=0.046). Cerebral infarction or intracranial hemorrhage was reduced by 28% (=0.023). The primary outcome or intracranial hemorrhage was reduced by 25% (=0.021). Intracranial hemorrhages occurred in 13 and 11 patients, respectively (HR, 1.17 [95% CI, 0.53-2.62]; =0.70). Conclusions- After an ischemic stroke of documented atherosclerotic origin, targeting a LDL cholesterol of <70 mg/dL during 5.3 years avoided 1 subsequent major vascular event in 4 (number needed to treat of 30) and no increase in intracranial hemorrhage. Registration- URL: https://www.clinicaltrials.gov; Unique identifier: NCT01252875.
背景与目的- TST 试验（靶向治疗以达到目标）评估了将低密度脂蛋白（LDL）胆固醇降低至<70mg/dL 的益处，以降低 2860 名患有脑血管粥样硬化狭窄或主动脉弓斑块>4mm 的缺血性中风患者的心血管事件风险，该研究在法国和韩国人群中进行。法国患者的中位随访时间为 5.3 年（与 SPARCL 试验[通过积极降低胆固醇水平预防中风]的中位随访时间相似），韩国患者的中位随访时间为 2.0 年。他汀类药物暴露时间是降低心血管风险的一个重要因素。我们在此报告 TST 试验在法国队列中的结果。方法- 1073 名法国患者被分配至<70mg/dL（1.8mmol/L），1075 名患者被分配至 100±10mg/dL（90-110mg/dL，2.3-2.8mmol/L）。为了达到这些目标，研究人员使用了他们选择的他汀类药物和剂量，如果需要，还额外添加了依折麦布。主要终点是缺血性中风、心肌梗死、新出现的需要紧急冠状动脉或颈动脉血运重建的症状以及血管性死亡的复合事件。结果- 中位随访 5.3 年后，平均 LDL 胆固醇分别达到 66（1.69mmol/L）和 96mg/dL（2.46mmol/L）。主要终点分别发生在 9.6%和 12.9%的患者中（HR，0.74[95%CI，0.57-0.94]；=0.019）。短暂性脑缺血发作后发生的脑梗死或紧急颈动脉血运重建减少了 27%（=0.046）。脑梗死或颅内出血减少了 28%（=0.023）。主要终点或颅内出血减少了 25%（=0.021）。颅内出血分别发生在 13 名和 11 名患者中（HR，1.17[95%CI，0.53-2.62]；=0.70）。结论- 在有明确动脉粥样硬化起源的缺血性中风后，5.3 年内 LDL 胆固醇<70mg/dL 的目标值可避免 4 例后续主要血管事件（需要治疗的人数为 30），并且不会增加颅内出血。注册- URL：https://www.clinicaltrials.gov；唯一标识符：NCT01252875。
