Stroke Prevention in Women Stroke is the 3rd leading cause of death in women.

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1 Stroke Prevention in Women Stroke is the 3rd leading cause of death in women. Stroke is the leading cause of disability and the third leading cause of death in women. In the United States, more than half (53.5%) of the estimated 795,000 new or recurrent strokes occur in women each year, resulting in ~55,000 more strokes in women than men. Moreover, ~60% of deaths related to stroke occur in women. With an aging population, the prevalence of stroke survivors is expected to increase especially in women, who have longer life spans than men. Many of the risk factors for stroke are the same for both men and women. These include high blood pressure, high cholesterol, diabetes, smoking, obesity, alcohol use, and lack of exercise. However, women differ from men in important physiologic ways, including hormonal factors, pregnancy and childbirth, and psychosocial factors that can all influence risk for stroke. To highlight these differences recently the American Heart Association/American Stroke Association for the first time created guidelines for the prevention of stroke in women.

2 The majority of strokes in women are ischemic (87%) while the remainder is hemorrhagic (10% intracerebral and 3% subarachnoid). There is a higher lifetime risk of stroke in women than men and a greater number of deaths related to stroke in women. Hypertension, or high blood pressure, is the most common modifiable risk factor for stroke in both women and men. Among stroke patients, women are more likely to have hypertension, and post-menopausal. Women have a higher prevalence of hypertension with ~75% of women older than 60 years of age having hypertension. It is important to control hypertension with medications but there are no differences in the responses of sexes to different blood pressure medications. However, hypertension is poorly controlled in high-risk elderly women with only ~23% of women over 80 years of age with well-controlled blood pressures. Although stroke is uncommon in pregnancy, there is an increased risk of stroke in pregnant women. The highest stroke risk occurs in the third trimester and the post-partum time period up to 3 months after the pregnancy. Hypertension in women of childbearing age increases the risk of pregnancyrelated complications and stroke during pregnancy.

3 Pregnancy-related hypertension is the leading cause of both ischemic and hemorrhagic stroke in pregnant and post-partum women. Preeclampsia/eclampsia and pregnancy-related hypertension are the two most important disorders of high blood pressure during pregnancy that increase the risk of stroke later in life. Preeclampsia is the term for high blood pressure that develops in the setting of increased protein in the urine during pregnancy. Eclampsia is preeclampsia that progresses to seizures. Preeclampsia and eclampsia cause major pregnancy-related complications, including stroke during or after delivery, premature birth, and increase the risk of stroke many years after childbearing. Pregnancy-related or gestational hypertension is defined as an increase in blood pressure typically near term. It is associated with risk factors such as obesity, age more than 40 years, chronic hypertension, family or personal history of pregnancy-related hypertension, multiple pregnancies, diabetes, and kidney disease. The most important predisposing factor is chronic elevated blood pressure. Pregnant women with very high blood pressure should be treated with safe blood pressure medications. Women with history of chronic hypertension before pregnancy or previous pregnancy-related hypertension should be considered for low-dose aspirin from the 12th week of gestation to lower preeclampsia risk. Women who have preeclampsia have twice the risk of stroke and four-fold risk of elevated blood pressure later in life. Thus, preeclampsia should be recognized as a risk factor well

4 after pregnancy and other risk factors, including obesity, high cholesterol, and smoking should be treated earlier in these women. Women should be screened for high blood pressure before taking birth control pills since the combination of hypertension and birth control pills increases the risk for stroke. Moreover, the use of hormone replacement therapy in post-menopausal women has been associated with increased risk of stroke and heart attacks. Hormone replacement therapy should not be used for primary or secondary stroke prevention in post-menopausal women. Women are 4 times more likely to have migraine headaches than men, and rarely migraines have been associated with stroke. Migraine with aura is defined as a migraine headache that is usually associated with a visual disturbance, but can also be a sensory, motor, or speech disturbance. The association between migraine with aura and stroke risk is higher for women than men. This risk is increased for both ischemic and hemorrhagic strokes. In women with migraine with aura, the risk of stroke increases even more in those using oral contraceptives and in cigarette smokers. Also, smoking increases the risk of stroke even more in women with migraine with aura. Thus, smoking cessation is strongly recommended in women with migraine headaches and reducing the frequency of migraines may be helpful.

5 Atrial fibrillation is the most common arrhythmia and increases the risk for stroke by 4- to 5- fold. Atrial fibrillation increases with age and since women have a greater life expectancy than men, there will be increasing numbers of elderly women with atrial fibrillation. Female sex has also been shown to be an independent predictor of stroke in patients with atrial fibrillation. It is important to screen all women over the age of 75 years for atrial fibrillation. Anti-coagulation is the most effective treatment to decrease the risk of stroke due to atrial fibrillation. There are several risk stratification tools that can be used to stratify the risk of stroke and aid physicians in the decision to start anti-coagulation therapies. Newer oral anticoagulants can be used as alternatives to warfarin, which is the traditional anticoagulant that has been used, for the prevention of stroke. The advantage of these newer anticoagulant medications is there are no blood tests necessary to check if the medications are therapeutic. However, the decision to be placed on anticoagulation is one to be discussed with the healthcare provider. Women have more strokes than men and stroke kills more women than men. It is important to improve stroke awareness and provide more education to younger women since the risk of stroke in women increases with age. Elevated blood pressure is the single most important modifiable risk factor. It is essential to assess for pregnancy-related causes of elevated blood pressure and to assess for the traditional stroke risk factors, including obesity, smoking, hypertension, high cholesterol, and diabetes.

6 Younger women should be aware that smoking and the use of oral contraceptives increases the risk of stroke. In post-menopausal women, hormone replacement therapy should not be used to prevent stroke. Women with migraines with aura that smoke should quit to avoid higher risk of stroke. Also, all women over the age of 75 years should be screened for atrial fibrillation. Finally, all women should be screened for depression as one more risk factor for stroke. ~ Dr. Ali Razmara, MD, PhD University of Southern California - Assistant Professor of Clinical Neurology - Division of Critical Care and Stroke - Department of Neurology