Sex differences in stroke: epidemiology, clinical presentation, medical care, and outcomes

Abstract

Stroke has a greater effect on women than men because women have more events and are less likely to recover. Age-specific stroke rates are higher in men, but, because of their longer life expectancy and much higher incidence at older ages, women have more stroke events than men. With the exception of subarachnoid haemorrhage, there is little evidence of sex differences in stroke subtype or severity. Although several reports found that women are less likely to receive some in-hospital interventions, most differences disappear after age and comorbidities are accounted for. However, sex disparities persist in the use of thrombolytic treatment (with alteplase) and lipid testing. Functional outcomes and quality of life after stroke are consistently poorer in women, despite adjustment for baseline differences in age, prestroke function, and comorbidities. Here, we comprehensively review the epidemiology, clinical presentation, medical care, and outcomes of stroke in women.

Longitudinal Effect of Stroke on Cognition: A Systematic Review

“…However, not all factors were consistently observed to increase risk, including sex and APOE*E4 status. With regard to sex, global impairment was found to be more common in women in 1 study,28 which is comparable to existing literature 32. In contrast, in another study, although there was no significant sex difference, global cognitive decline was found to be more severe in men 25.…”

Field Synopsis of the Role of Sex in Stroke Prediction Models

“…In both models predicting stroke in a general population that included a coefficient for sex, being a woman was associated with reduced risk, consistent with prior studies 13, 64. Similarly, all 3 models for stroke incidence among patients with arrhythmias indicated that women were at higher risk, concordant with the literature 65, 66, 67.…”

“…CPMs have the potential to enable appropriate tailoring of prevention and treatment strategies for stroke in men and women, and to improve estimation of sex‐based treatment disparities, which have been documented among stroke patients 13, 75. Sex differences in outcome risk—estimable from CPMs—represent an appropriate determinant of clinical decision making, in addition to differences in treatment indications/contraindications and patient preferences.…”

“…For example, given the incorporation of women's higher stroke risk in the CHA 2 DS 2 ‐VASc score48 and the lack of sex‐specific harm in the HAS‐BLED score,76 we would expect to see higher rates of anticoagulation therapy in women than otherwise similar men with atrial fibrillation. However, lower rates of prophylactic anticoagulation therapy have been observed in women, suggesting inappropriate “reverse targeting.”13, 77 Whether use of CPMs can help reduce sex disparities by providing accurate sex‐specific prognostic information at the point of care is an important question deserving more research.…”

“…There are sex‐based differences in anatomy,1, 2, 3 vascular biology,4, 5 neuroprotective factors,6, 7 functional neuroanatomy,8 vascular risk factors and comorbidities,9, 10, 11, 12 and lifestyle factors and social roles13, 14 that may be important in stroke incidence and prognosis. 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.…”