In patients with statin-associated side effects that are not severe, it is recommended to reassess and to rechallenge to achieve a maximal LDL-C lowering by modified dosing regimen, an alternate statin or in combination with nonstatin therapy. I B-R Recommendation unchanged from 2018 Cholesterol Guidelines. In patients at increased ASCVD risk with severe statin-associated muscle symptoms or recurrent statin-associated muscle symptoms despite appropriate statin rechallenge, it is reasonable to use RCT-proven nonstatin therapy that is likely to provide net clinical benefit.384 386 IIa B-R Recommendation unchanged from 2018 Cholesterol Guidelines. 6.8.4. Timing COR LOE New, Revised, or Unchanged Among patients already taking statins at the time of onset of ischemic stroke, continuation of statin therapy during the acute period is reasonable. IIa B-R Recommendation and COR unchanged from 2013 AIS Guidelines. LOE amended to conform with ACC/AHA 2015 Recommendation Classification System. For patients with AIS who qualify for statin treatment, in-hospital initiation of statin therapy is reasonable. IIa C-LD New recommendation. Statins have an established role in secondary stroke prevention and harbor promise in improving index stroke A retrospective cohort study that assessed 3-month treatment adherence rates after in-hospital initiation of statins in patients with ischemic stroke showed a high rate of adherence to statin therapy 3 months after hospital discharge.387 A meta-analysis of primarily observational studies found that in-hospital statin use was associated with good functional outcomes.388 Withdrawal of statins after ischemic stroke was associated with poor functional outcomes. There are limited published randomized trials examining the role of early statin use in AIS patients. FASTER (Fast Assessment of Stroke and Transient Ischemic Attack to Prevent Early Recurrence) evaluated simvastatin 40 mg versus placebo in patients with a TIA or minor stroke within Because of slow enrollment, this trial was terminated early. 