Women Have Particular Stroke Risk Factors, Outcomes
By Will Boggs MD
February 14, 2018
NEW YORK (Reuters Health) - Women face different risk factors for stroke and experience worse outcomes after stroke, compared with men, according to four related articles in a focused update online February 8 in the journal Stroke.
In one report, Dr. Kathryn M. Rexrode from Brigham and Women's Hospital, in Boston, and colleagues summarize stroke risk factors unique to women, including endogenous hormone levels, exogenous hormone therapy, pregnancy, parity, and ages at menarche and menopause.
“The degree to which women are more likely than men to experience stroke as their first manifestation of cardiovascular disease is not well appreciated," Dr. Rexrode told Reuters Health by email “We wanted to delve into why - what factors might disproportionately affect women.”
Her team identified nine clearly established female-specific stroke risk factors: early age at menarche (<10 years); early age at menopause (<45); low endogenous levels of dehydroepiandrosterone (DHEAS); postmenopausal treatment with oral estrogens; use of combined oral contraceptives; exogenous estrogen use in transgender women; pregnancy; gestational diabetes; and hypertension in pregnancy or preeclampsia.
“The fact that these risk factors unique to women have not been formally studied in clinical risk prediction models, to see whether they would improve our estimation of risk in women, is surprising and an area for future research,” Dr. Rexrode said. “I also think that women themselves do not fully appreciate the risk of early menopause or a history of pregnancy complications. We need to do a better job of educating patients and findings ways to mitigate their risk.”
In another report, Dr. Lynda D. Lisabeth from University of Michigan, Ann Arbor, and colleagues examined sex differences in patient-reported outcome measures (PROMs) in the first 12 months after stroke.
Consistent evidence from nearly two dozen studies showed that women have more activity limitations, worse health-related quality of life, and a higher prevalence of post-stroke depression, compared with men.
“There are a few key points here,” Dr. Lisabeth told Reuters Health by email. “First, it is important to note that while women's advanced age, greater stroke severity, and poorer pre-stroke health contribute to their worse outcomes, they do not fully explain all of the sex differences that we see pointing to the need for more research.”
“Second,” she said, “assessing multiple outcome domains in women beyond the more commonly assessed function/disability outcomes is important. We found that women were more likely to report depressive symptoms and poorer quality of life, which can impact recovery and secondary stroke prevention efforts, so these outcomes are also important to assess.”
“We need studies that specifically explore what factors explain why women have worse outcomes, so we can begin to move towards interventions,” Dr. Lisabeth said. “Much more research is needed to consider cognitive and mental health outcomes and participation restrictions, which are important patient-centered outcomes that have received little attention in women with stroke.”
In the third report, Dr. Mollie McDermott from University of Michigan, Ann Arbor, and colleagues discuss another unique risk factor for stroke among women: preeclampsia.
Data from various studies suggest a greater than 40-fold increased risk for ischemic stroke and greater than 10-fold increased risk for hemorrhagic stroke among pregnant women with preeclampsia/eclampsia, compared with other pregnant women.
The risk of stroke remains elevated in later years, so that women with preeclampsia have a long-term risk of stroke about 80% higher than that of women without preeclampsia.
These authors note "a need to increase awareness among women with this condition and their providers, so they can make risk factor modifications and lifestyle changes needed to reduce their risk of stroke.”
In the final report, Dr. Tracy E. Madsen from Alpert Medical School of Brown University, Providence, Rhode Island, and colleagues focus on conventional stroke risk factors in women.
According to recent evidence, diabetes, metabolic syndrome, atrial fibrillation, and migraine carry greater ischemic stroke risks for women, compared with men, whereas the association between dyslipidemia and stroke may be slightly lower among women.
Differences are more complex for hypertension. The association with ischemic stroke appears to be similar between women and men in younger age groups, but it may be higher in women than men among older people.
Cognitive impairment is more common in women, perhaps because they live longer than men, but there are few data on the association between cognitive impairment and stroke risk.
Likely contributors to the disparity in stroke risks associated with these conditions are ongoing disparities in addressing dyslipidemia, atrial fibrillation, and other key stroke risk factors.
Dr. Madsen told Reuters Health by email, "Physicians across specialties need to be aware that there are key sex and gender differences when it comes to stroke prevention. Physicians should take special care to counsel women about their stroke risk and to ensure their risk factors are being controlled optimally.”
“It is also important to be aware that stroke prevention may not look exactly the same for women as it does for men,” she said. “For example, women with migraine histories that take estrogen-containing birth control or smoke cigarettes are at much increased risk of stroke. These risks should help guide the conversations we have with patients on smoking cessation and when choosing types of birth control.”
“We are really just scratching the surface when it comes to finding out about sex and gender differences in stroke risk factors and prevention,” Dr. Madsen said. “We have a lot left to learn, and though we don't have many sex-specific guidelines at this point, we may see stroke prevention change significantly as we learn more about sex differences.”
Dr. Sonia S. Anand from McMaster University, Hamilton, Ontario, Canada, who coauthored an editorial related to these reports, told Reuters Health by email, "As we emphasize in the editorial, prevention of stroke in women should be considered across the lifecourse: in pregnancy, with the use of exogenous oral contraceptives, when considering hormone replacement therapy, and in the older population with respect to treatment of common risk factors and treatment of atrial fibrillation with oral anticoagulants.”
“Although we have a lot of research already to inform our screening and treatment decisions, we need to put this into action!” she said. “We need to establish health systems to maximize the screening and treatment of at risk women, especially those from high-risk groups.”
“Sex differences in stroke burden are most influenced by differences in cardiovascular risk factor burden; thus, the greatest gains in stroke prevention will come from increased screening and treatment of these primary risk factors in women early in life, especially in the obese, during pregnancy, and those from high-risk ethnoracial groups,” the editorial, coauthored by Dr. Eric Kaplovitch from McMaster University, concludes.
SOURCES: bit.ly/2nX8JFg, bit.ly/2Eeag4G, bit.ly/2C8KtVI, bit.ly/2sk1dd1 and bit.ly/2EuGPKT
Stroke 2018.
Reuters Health Information © 2018
Cite this article: Women Have Particular Stroke Risk Factors, Outcomes - Medscape - Feb 13, 2018.
