Atrial fibrillation‐related stroke in women: Evidence and inequalities in epidemiology, mechanisms, clinical presentation, and management

Abstract

BackgroundAtrial fibrillation (AF) is the most common clinical arrhythmia and one of the major causes of stroke, heart failure, sudden death, and cardiovascular morbidity. Despite substantial advances in (interventional) rhythm control treatment during the last decade, anticoagulation for stroke prevention remains a major component of AF treatment.HypothesisThere are important sex‐specific differences in AF‐related stroke, resulting from sex‐specific mechanisms and therapeutic differences.MethodsThis review summarizes available data on sex differences in risk assessment and prevention of stroke and highlights current knowledge gaps in AF‐related stroke mechanisms, prevention and management that warrant further research.ResultsIncreased thrombotic risk in women is multifactorial, involving hormonal changes after menopause, structural, endocrine and lifestyle/social factors and their interactions. It is clear from randomized studies that women benefit from anticoagulant treatment and that their bleeding risk is similar to men. Women should therefore receive equivalent treatment to men, based on the validated criteria for anticoagulation therapy. However, women are not represented equally in the large randomized studies and sex‐related information in many fields is lacking.ConclusionsFemale sex is an established risk factor for stroke in AF patients. The evidence for sex‐specific differences in stroke risk assessment and stroke prevention is accumulating. However, the underlying biological mechanisms remain incompletely understood and further studies are required in order to decrease AF‐related morbidity and mortality.

ArrhythmoGenoPharmacoTherapy

“…Thus, pharmacological therapies of cardiac arrhythmias should be focused on the most relevant underlying mechanism of arrhythmias, where it's known, and interventions may be antiarrhythmic by suppressing the initiating arrhythmogenic mechanism. Atrial fibrillation (AF) is caused by various mechanisms and one of the most common cardiac rhythm disturbances (Chua et al, 2019;Sutanto et al, 2019) associated with increased risk of heart failure, stroke (Kostopoulou et al, 2019), and death. More than dozens of genetic loci have been associated with AF, but the current review does not attempt to focus on these genetic mechanisms (Kalsto et al, 2019) and clinical management (Sutanto et al, 2019) of AF in detail.…”

Racial and ethnic disparities in coronary, vascular, structural, and congenital heart disease

“…In the Global Burden of Disease Study (2010), age‐adjusted prevalence (per 100.000 population) of AF was 596.2 in men versus 373.1 in women; and incidence (per 100.000 population) was 77.5 in men versus 59.5 in women 108 . However, women had a higher risk of AF‐associated stroke and mortality compared with men 108,109 . Compared with men, women are less likely to receive OAC at all levels of the CHA2DS2VASc score 110 .…”

Untitled

“…The women aged < 65 years with 'lone' AF have a low annual risk for stroke; therefore, the current European and American guidelines do not recommend anticoagulation therapy for this group [12,13]. In a meta-analysis of 30 studies with 4371714 participants, Edim CA and al.…”

“…found AF to be a significant risk factor for death and cardiovascular disease, more important in women than in men [14]. When AF associates with stroke, cardiac events, and heart failure, all causes mortality, is more pronounced in women than men [8,13], suggesting that women and men experience risk factors for cardiovascular disease differently [8,15]. It is unclear what could cause these differences.…”