Guidelines for the Prevention of Stroke in Women

Abstract

1545Purpose-The aim of this statement is to summarize data on stroke risk factors that are unique to and more common in women than men and to expand on the data provided in prior stroke guidelines and cardiovascular prevention guidelines for women. This guideline focuses on the risk factors unique to women, such as reproductive factors, and those that are more common in women, including migraine with aura, obesity, metabolic syndrome, and atrial fibrillation. Results-We provide current evidence, research gaps, and recommendations on risk of stroke related to preeclampsia, oral contraceptives, menopause, and hormone replacement, as well as those risk factors more common in women, such as obesity/metabolic syndrome, atrial fibrillation, and migraine with aura. Conclusions-To more accurately reflect the risk of stroke in women across the lifespan, as well as the clear gaps in current risk scores, we believe a female-specific stroke risk score is warranted. (Stroke. 2014;45:1545-1588.)

Field Synopsis of the Role of Sex in Stroke Prediction Models

“…The importance of sex‐specific risk assessment in primary stroke prevention is emphasized in both the 2014 American Heart Association/American Stroke Association primary prevention guidelines,55 and those specific to women 20. The relevance of sex‐specific risk in primary prevention is supported by our observation that sex was included in 69% of the population sample–stroke models.…”

“…Conversely, our finding that all 4 models estimate lower risk of death after ischemic stroke for women than otherwise similar men was surprising given the inconsistency of the literature, which has frequently reported worse prognoses in women (particularly in populations untreated with thrombolysis) 17, 68, 69, 70. Finally, it is notable that about half of the models predicting stroke in a population sample were sex stratified (thereby allowing the effects of risk factors to vary among men and women), in keeping with evidence that sex modifies the effect of some risk factors on stroke risk 20, 71…”

“…The literature has shown sex differences in the risk of incident stroke,13, 15, 16 likelihood of favorable outcomes after a stroke,13 and responses to thrombolysis treatment 17, 18, 19. The importance of sex‐specific risk in clinical management of stroke was underscored in the first American Heart Association/American Stroke Association guideline dedicated to stroke prevention in women 20. In addition to drawing attention to the lack of strong, level A evidence available to support sex‐specific recommendations, the guidelines recommended development of female‐specific stroke risk scores that consider risk factors that are sex‐specific, or stronger or more prevalent in women.…”

Atypical Presentation of a Posterior Inferior Cerebellar Artery Stroke Found by Magnetic Resonance Imaging, on a Woman without Prior Known Comorbid on Implantable Contraception: A Case Report

“…In review of 55 observational studies using the newer hormonal contraception, which now has lower estradiol levels, there was a trend towards increased risk of thromboembolic events but it did not reach statistical significance. However, it was noteworthy that the hormone that seemed responsible for the higher number of events was progestin [5][6][7][8][9]. There have been no reports that Implanon® increases risk of stroke, however, it does contain progestin so manufacturer's packing insert notes that it could be associated with increased risk in high risk patients [10].…”

Differences in stroke damage in aged mice may not be due to differential cerebral blood flow dynamics

“…[1][2][3] Aging is the most important nonmodifiable risk factor for stroke, and aged patients exhibit impaired stroke recovery. [4] Consistent with clinical data, findings from animal models have demonstrated that aged mice have higher mortality and worse outcomes when subjected to same duration of occlusion compared with young mice, yet paradoxically, the infarct damage is smaller in the aged mice.…”