Lipid Paradox in Statin-Naïve Acute Ischemic Stroke But Not Hemorrhagic Stroke

Kai-Hung Cheng, Jr-Rung Lin, Craig S. Anderson, Wen-Ter Lai, Tsong-Hai Lee, the SRICHS Group, Tsong-Hai Lee, Yeu-Jhy Chang, Chien-Hung Chang, Hsiu-Chuan Wu, Kuo-Lun Huang, Ting-Yu Chang, Chi-Hung Liu, Chih-Kuang Cheng, Te-Fa Chiu, Chi-Ren Huang, Ho-Fai Wong, Cheng-Hong Toh, Tsung-I Peng, Wen-Yi Huang, Yu-Yi Chien, Kong Chung, Hsiang-Yun Lo, Yao-Liang Chen, Jiann-Der Lee, Meng Lee, Yen-Chu Huang, Shao-Wen Chou, Cheng-Ting Hsiao, Yuan-Hsiung Tsai, Chia-Wei Liou, Ku-Chou Chang, Hung-Sheng Lin, Teng-Yeow Tan, Ru-Huei Fu, Wei Hsi Chen, Chia-Te Kung, Wei-Che Lin

Background: Low lipid level is associated with better cardiovascular outcome. However, lipid paradox indicating low lipid level having worse outcomes could be seen under acute injury in some diseases. The present study was designed to clarify the prognostic significance of acute-phase lipid levels within 1 day after admission for stroke on mortality in first-ever statin-naïve acute ischemic stroke (IS) and hemorrhagic stroke (HS). Methods: This observational study was conducted using the data collected from Stroke Registry In Chang-Gung Healthcare System (SRICHS) between 2009 and 2012. Patients with recurrent stroke, onset of symptoms >1 day, and history of the use of lipid-lowering agents prior to index stroke were excluded. Stroke was classified into IS and hypertension-related HS. The primary outcomes were 30-day and 1-year mortality identified by linkage to national death registry for date and cause of death. Receiver operating characteristic (ROC) curve analysis and multivariate Cox proportional hazard models were used to examine the association of lipid profiles on admission with mortality. Results: Among the 18,268 admitted stroke patients, 3,746 IS and 465 HS patients were eligible for analysis. In IS, total cholesterol (TC) <163.5 mg/dL, triglyceride (TG) <94.5 mg/dL, low-density lipoprotein (LDL) <100 mg/dL, non-high-density lipoprotein cholesterol (non-HDL-C) <130.5 mg/dL, and TC/HDL ratio <4.06 had significantly higher risk for 30-day/1-year mortality with hazard ratio (HR) of 2.05/1.37, 1.65/1.31, 1.68/1.38, 1.80/1.41, and 1.58/1.38, respectively, compared with high TC, TG, LDL, non-HDL-C, and TC/HDL ratio (p < 0.01 in all cases). In HS, lipid profiles were not associated with mortality, except HDL for 30-day mortality (p = 0.025) and high uric acid (UA) concentrations for 30-day and 1-year mortality (p = 0.002 and 0.012, respectively). High fasting glucose and high National Institute of Health Stroke Scale (NIHSS) score at admission were associated with higher 30-day and 1-year mortality in both IS and HS and low blood pressure only in IS (p < 0.05). Synergic effects on mortality were found when low lipids were incorporated with high fasting glucose, low blood pressure, and high NIHSS score in IS (p < 0.05). Conclusions: Lipid paradox showing low acute-phase lipid levels with high mortality could be seen in statin-naïve acute IS but not in HS. The mortality in IS was increased when low lipids were incorporated with high fasting glucose, low blood pressure, and high NIHSS score.