The following recommendations apply to most people. They do not apply to people with lipid disorders, such as familial hypercholesterolaemia.

• A statin should be started:
• As soon as possible for people with a transient ischaemic attack (TIA).
• 48 hours after the event for people with an acute stroke.
• People with an acute stroke or TIA who are already receiving statins should continue their statin treatment.
• Seek specialist advice before initiating a statin in people with a history of haemorrhagic stroke, particularly those with inadequately controlled hypertension.
• Before starting treatment:
• Consider whether treatment is appropriate, taking into account comorbidities and life expectancy.
• Perform baseline blood tests (see the section on Tests before drug treatment in the CKS topic on Lipid modification - CVD prevention).
• Investigate for (and if found, manage) any conditions, such as diabetes, that are suggested by the baseline tests.
• If dyslipidaemia is present, investigate for, and manage, secondary causes.
• Consider higher-intensity statin therapy if the total cholesterol level does not decrease to below 4 mmol/L or the low-density lipoprotein cholesterol level does not decrease to below 2 mmol/L.
• Optimize, as far as possible, the management of comorbidities and implementation of lifestyle interventions.
• For more information (including options when simvastatin is not suitable), see the CKS topic on Lipid modification - CVD prevention and the appropriate sections in the CKS topic on Diabetes type 2.

• The above recommendations for lipid modifications reflect stroke guidelines issued by the National Institute for Health and Clinical Excellence (NICE) and the Royal College of Physicians Intercollegiate Stroke Working Party (RCP ICSWP) [Intercollegiate Stroke Working Party, 2008; National Collaborating Centre for Chronic Conditions, 2008]. These are in line with NICE guidance on lipid modification for secondary prevention of cardiovascular disease [NICE, 2008a].
• Prescribing statins in people with an acute stroke:
• Evidence reviewed by the NICE Guideline Development Group found that statin withdrawal is associated with worse clinical outcome after ischaemic stroke than when premorbid statin treatment is continued. They found no evidence regarding the safety and efficacy of initiating lipid-lowering statin therapy for people with an acute stroke.
• The consensus of the NICE Guideline Development roup was [National Collaborating Centre for Chronic Conditions, 2008]:
• There is no evidence for initiating statins in acute stroke, but there is evidence to support continuing statin treatment in those who were taking statins before the stroke.
• It would be safe to start statins after 48 hours. There is benefit from initiation of statins after the acute phase of stroke in vascular risk reduction.
• Prescribing statins for people who have had a haemorrhagic stroke:
• The RCP ICSWP recommended that statins should be prescribed with caution, if at all, in people who have had a haemorrhagic stroke, particularly if they have inadequately controlled hypertension [Intercollegiate Stroke Working Party, 2008]:
• The manufacturer of atorvastatin warns that, for people with prior haemorrhagic stroke or lacunar infarct, the balance of risks and benefits of atorvastatin 80 mg is uncertain and the potential risk of haemorrhagic stroke should be considered carefully before initiating treatment [Pfizer Ltd, 2007].
• One meta-analysis found the evidence for statins causing haemorrhagic stroke to be uncertain [Law and Rudnicka, 2006]. Cohort studies showed an association while randomized trials were uninformative because the confidence intervals on the summary estimate were too wide. However, the authors concluded that the possible risk is greatly outweighed by the protective effect against thromboembolic stroke and coronary artery disease.
• A more recent study found that the risk of haemorrhagic stroke was increased in people who were taking atorvastatin: hazard ratio 1.68, 95% CI 1.09 to 2.59; p = 0.02 [Goldstein et al, 2008].
• CKS therefore recommends seeking specialist advice before prescribing a statin for people who have had a haemorrhagic stroke, particularly if they have uncontrolled high blood pressure.