Achieving a ≥50% reduction in LDL-C from baseline was independently associated with a lower risk of secondary cardiovascular events in ischemic stroke patients, regardless of whether an absolute LDL-C goal (<70 mg/dL) was attained.
Key Findings
Results
Patients with ischemic stroke who failed to achieve a ≥50% LDL-C reduction from baseline had significantly higher risk of the composite outcome even when they achieved the absolute LDL-C goal of <70 mg/dL.
The adjusted hazard ratio for those achieving <70 mg/dL but <50% reduction compared to the optimal group (both goals met) was 1.12 [95% CI 1.06–1.18].
The adjusted hazard ratio for those achieving ≥70 mg/dL and <50% reduction was 1.28 [95% CI 1.23–1.34].
The primary outcome was a composite of recurrent stroke, myocardial infarction, and all-cause death.
Analysis used time-varying Cox regression to account for changing LDL-C status over follow-up.
Results
Only approximately 30% of ischemic stroke patients achieved a ≥50% LDL-C reduction from baseline throughout the follow-up period.
The proportion achieving ≥50% LDL-C reduction remained at approximately 30% throughout the follow-up period.
This indicates a substantial proportion of patients consistently failed to achieve the relative LDL-C reduction goal.
136,427 post-stroke LDL-C measurements were analyzed across 89,414 patients.
Methods
The study cohort consisted of 89,414 patients admitted for acute ischemic stroke between 2014 and 2022, followed for a mean of 5.72 years.
Data were sourced from the Korean National Health Insurance Database in South Korea.
Mean follow-up was 5.72 ± 2.40 years.
LDL-C status over time was derived from serial national health examinations following the index stroke.
This was a retrospective cohort study design.
Results
The independent prognostic benefit of achieving ≥50% LDL-C reduction was consistent across multiple prespecified subgroups.
Subgroup analyses were stratified by sex, age, baseline LDL-C level, and the presence of a presumed cardioembolic source.
Results were described as 'consistent across subgroups,' suggesting no significant effect modification.
This consistency supports the generalizability of the relative LDL-C reduction goal across diverse ischemic stroke patient populations.
Methods
Patients were categorized into four groups based on attainment of absolute (<70 mg/dL) and relative (≥50% reduction) LDL-C goals, with the group achieving both goals serving as the reference.
The four groups were: (1) <70 mg/dL and ≥50% reduction (optimal/reference), (2) <70 mg/dL and <50% reduction, (3) ≥70 mg/dL and ≥50% reduction, and (4) ≥70 mg/dL and <50% reduction.
Current secondary atherosclerotic cardiovascular disease prevention guidelines recommend both goals, but stroke-specific guidelines primarily emphasize only the absolute LDL-C goal.
The study design specifically tested whether relative LDL-C reduction provides prognostic benefit independent of absolute LDL-C goal attainment.
Conclusions
The authors concluded that more intensive and multifaceted lipid-lowering strategies focusing on both absolute and relative LDL-C reduction may lead to improved long-term outcomes in ischemic stroke patients.
The study found that achieving a ≥50% LDL-C reduction was independently associated with lower cardiovascular risk beyond what is captured by absolute LDL-C targets alone.
The authors noted that 'a substantial proportion of patients with ischemic stroke fail to achieve optimal LDL-C reduction.'
The findings suggest stroke-specific guidelines, which currently focus primarily on absolute LDL-C goals, may benefit from also incorporating relative reduction targets.
What This Means
This research suggests that for people who have had an ischemic stroke (a stroke caused by a blocked blood vessel), reducing LDL cholesterol—often called 'bad' cholesterol—by at least half from their pre-treatment levels is important for preventing future heart attacks, strokes, and death, even beyond simply getting LDL below a specific number like 70 mg/dL. The study followed nearly 90,000 stroke patients in South Korea for an average of nearly 6 years and found that patients who achieved both a 50% or greater reduction AND got below 70 mg/dL had the best outcomes. Patients who got their LDL below 70 mg/dL but did not achieve the 50% relative reduction still had a 12% higher risk of bad outcomes compared to those who met both goals.
A key practical finding is that only about 30% of stroke patients were achieving this 50% relative LDL reduction at any given point during follow-up, meaning the majority of patients were not reaching this target. This gap persisted throughout the years of follow-up, suggesting that current lipid-lowering treatment after stroke is often insufficient in many patients.
This research matters because current stroke prevention guidelines tend to focus mainly on getting LDL cholesterol below an absolute number, but this study suggests that how much a person's LDL is reduced from their own starting point also matters independently. This implies that clinicians and patients may need to consider both goals—the absolute target level and the relative reduction from baseline—when managing cholesterol after a stroke, and that more aggressive or multifaceted lipid-lowering approaches may be needed to optimize long-term outcomes.
Baik M, Jeon J, Yoo J, Kim J. (2026). Effect of a ≥50% Reduction in Low-Density Lipoprotein Cholesterol From Baseline in Patients With Ischemic Stroke.. Neurology. https://doi.org/10.1212/WNL.0000000000218491