Low cholesterol levels increase mortality

Lowering serum cholesterol levels may actually increase the risk of death from stroke, recent research suggests.

This latest evidence demolishes the long held view of medicine that if lowering cholesterol can prevent coronary heart disease, it may also help prevent stroke.

The study, which took place in the acute stroke unit of an inner city general hospital, found that even after adjustment for known risk factors for stroke, higher serum cholesterol concentrations were associated with a better survival rate after stroke.

The study recommends that cholesterol lowering programmes should not be used as secondary prevention of acute stroke (BMJ, 1997, 314: 1584).

More evidence is accumulating about the poor performance of heparin in cases of stroke. The conclusions of the International Stroke Trial (IST) were that the routine early use of heparin in patients with acute ischemic stroke offers no clinical advantage for stroke patients. After 14 days of the anti thrombolitic therapy heparin was associated with more bleeding, more recurrent strokes and more deaths than low dose aspirin, heparin and aspirin combined or no treatment at all. At six months, neither heparin regimen offered any clinical advantage (Lancet, 1997, 349: 1569-81).

Researchers are working on production of a "super aspirin", which doesn't cause the severe gastrointestinal side effects associated with traditional aspirin. Two trials are currently underway to test the efficacy in preventing recurrent heart attacks of this new type of anti platelet, which acts as glycoprotein IIb/IIIa receptor antagonists. The main safety issue has yet to be resolved, though these super aspirins are so effective that if the patient begins to bleed severely there might be no way to stop him bleeding to death (Lancet, 1997; 349: 1409-10, 1422, 1429).

The aggressive management of patients after acute heart attack isn't doing any good, according to a new survey which compared the use of cardiac procedures and outcomes in both Canada and the US. Patients in the US receive more interventions, but do not live significantly longer (New Eng J Med, 1997; 336: 1500-5).