Making sense of the low LDL – high hemorrhagic stroke risk in women

Strokes that result from bleeding into the brain — known as hemorrhagic strokes — are much less common than ones that result from blood flow being cut off to brain tissue (ischemic strokes).

Bleeding/hemorrhagic strokes are also more difficult to treat and therefore more likely to be deadly.

Sounds pretty scary.

But things got even scarier this past spring when news of a study came out warning of a two-fold increase in the risk of bleeding stroke in women with LDL cholesterol levels below 70 mg/dL.

Related: 11 stroke signals no woman should ignore

Very low triglyceride levels (below 74 mg/dL) were also associated with higher risk. The study that showed this association was notable for its size since it included over 27,000 women over age 45 that were followed for an average of 19 years.

Not surprisingly, these findings generated a lot of press coverage, raising concerns among many patients who are purposefully trying to lower their LDL.

Noteworthy is the fact that published cholesterol treatment guidelines actually advise getting LDL to below 70 mg/dL if heart disease is present.

How concerned should you be?

So, what should you do with this information? First, it’s important to put it into context because there’s always more to the story than the headlines reveal:

  1. Over the 19 years of the study, only 0.8 percent of women with very low LDL experienced a hemorrhagic stroke, compared to 0.4 percent of women with higher LDL readings. So, the rate of events might have doubled with low LDL values, but practically speaking the chance of experiencing a bleeding stroke is still remote, regardless of cholesterol level. And just in case you’re wondering, for triglycerides, 0.6 percent of women with levels below 74 mg/dL experienced a stroke, compared to 0.4 percent of those with higher levels.
  2. The researchers only looked at the very first cholesterol profile obtained at the beginning of the study. And we don’t know what happened to those profiles over time. If some of the women with higher LDL levels ended up with lower readings during the 19 years of follow-up (because they were placed on statins, for example), the whole premise of the analysis could have been made moot.
  3. Women with migraine headache with aura, and women with a past history of high blood pressure with pregnancy (preeclampsia) have also been shown to have increased risk for hemorrhagic stroke and these risk factors were not accounted for in comparing the groups.

Second, it’s the cumulative risk of all events that matters, so don’t forget the bigger picture. Especially since multiple other large studies have shown improved overall outcomes with lower LDL readings.

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So, what am I telling my patients now?

The same thing I’ve been telling them all along…

That people who live long well do so because they live well — and achieving perfect numbers without achieving a better lifestyle is an incomplete solution.

That one study, regardless of how many people were enrolled, doesn’t change the fundamentals.

That the risk of a bleeding stroke is very low regardless of cholesterol levels.

And that, based upon mountains of evidence, LDL under 70 mg/dL is still a reasonable goal for those individuals who have established heart disease.

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Dr. Elizabeth Klodas MD, FACC

By Dr. Elizabeth Klodas MD, FACC

"Diet is a major driver of high cholesterol, but instead of changing the food, we prescribe medications. This never seemed logical to me.” Dr. Klodas has dedicated her career to preventive cardiology. Trained at Mayo Clinic and Johns Hopkins, she is the founder and Chief Medical Officer for Step One Foods. Dr. Klodas is a nationally sought out speaker and has an active role at the American College of Cardiology. Her clinical interests include prevention of heart disease and non-invasive cardiac imaging and she has published dozens of scientific articles throughout her career. Dr. Klodas has been featured on CNN Health for her mission to change how heart disease is treated. An independent study performed at leading medical institutions affirmed the ability of Step One Foods to deliver measurable and meaningful cholesterol-reduction benefits in the real world. The results of the trial were presented at the 2018 American Heart Association’s Scientific Sessions. Dr. Klodas has also authored a book for patients, "Slay the Giant: The Power of Prevention in Defeating Heart Disease," and served as founding Editor-in-Chief of the patient education effort of the American College of Cardiology. In addition to her practice and her duties at Step One Foods, she also serves as medical editor for webMD.