Use guidance to cut stroke risks in women
Executive Summary
National guidelines have just been developed for preventing stroke in women. Stroke awareness is important, as one in five women will have a stroke in her lifetime. Stroke is the number three cause of death in women; about 55,000 more women than men die of stroke each year.
• It is important to improve stroke awareness and provide more rigorous education to women at younger ages, including those of childbearing age, due to women’s increased risk of stroke with age, as well the risks of stroke associated with pregnancy, gestational hypertension, and hormonal contraception.
• The onset of stroke risk factors such as obesity, hypertension, and diabetes mellitus also occur at younger ages.
Clinicians now have in hand, for the first time, guidelines that have been developed for preventing stroke in women.1
These guidelines include the following recommendations:
• Women with a history of high blood pressure before pregnancy should be considered for low-dose aspirin and/or calcium supplement therapy to lower preeclampsia risks.
• Women who have preeclampsia have twice the risk of stroke and a four-fold risk of high blood pressure later in life. Therefore, preeclampsia should be recognized as a risk factor well after pregnancy, and other risk factors such as smoking, high cholesterol, and obesity in these women should be treated early.
• Pregnant women with moderately high blood pressure (150-159 mmHg/100-109 mmHg) may be considered for blood pressure medication, whereas expectant mothers with severe high blood pressure (160/110 mmHg or above) should be treated.
• Women should be screened for high blood pressure before taking birth control pills because the combination raises stroke risks.
• Women who have migraine headaches with aura should stop smoking to avoid higher stroke risks.1 (To review the guidelines, go to the American Heart Association web site, http://bit.ly/1gDifEg. Click on "Current Year," then under "February 2014," select "Guidelines for the Prevention of Stroke in Women.")
Stroke awareness is important, as one in five women will have a stroke in her lifetime.2 Stroke is the number three cause of death in women; about 55,000 more women than men die of stroke each year.2
"If you are a woman, you share many of the same risk factors for stroke with men, but your risk is also influenced by hormones, reproductive health, pregnancy, childbirth, and other sex-related factors," said Cheryl Bushnell, MD, MHS, director of the Wake Forest Baptist Stroke Center and education associate professor of neurology at Wake Forest School of Medicine, both in Winston-Salem, NC. Bushnell is lead author of the new guidelines published in "Stroke," the journal of the American Heart Association.
Authors of the new guidelines say it is important to improve stroke awareness and provide more rigorous education to women at younger ages, including those of childbearing age, because of women’s increased risk of stroke with age, as well the risks of stroke associated with pregnancy, gestational hypertension, and hormonal contraception. The onset of stroke risk factors such as obesity, hypertension, and diabetes mellitus also occur at younger ages.1 Future research focused on risk profile development is needed to appropriately tailor prevention strategies for women, the authors state.
"Until sex-specific risk is better understood, prevention and management of stroke and cardiovascular risk factors remains essentially the same for men and women," the authors note.
Check blood pressure
The new guidance recommends blood pressure measurement prior to initiation of hormonal contraception, which falls in line with the "U.S. Selected Practice Recommendations for Contraceptive Use, 2013."3 The relative increase in stroke risk with low-dose oral contraceptives (OCs) is small,4 and the risk of stroke with OC use is lower than the risk associated with pregnancy.5 However, certain subgroups of women, particularly those who are older, smoke cigarettes, or have hypertension, diabetes mellitus, obesity, hypercholesterolemia, or prothrombotic mutations, might be at higher risk for stroke, the guidance authors note.
Who is not a candidate for combined hormonal contraception? Severe hypertension (systolic pressure equal or greater than 160 mm Hg or diastolic pressure equal or greater than 100 mm Hg) or vascular disease is ranked as Category 4, a condition that represents an unacceptable health risk if the contraceptive method is used.3 Less severe hypertension (systolic pressure of 140-159 mm Hg or diastolic pressure of 90-99 mm Hg) or adequately controlled hypertension are ranked as Category 3 conditions, where the theoretical or proven risks usually outweigh the advantages of using the method. Use of Category 3 methods is not generally recommended unless other methods are unavailable or unacceptable to the patient.3
Women with a history of high blood pressure before pregnancy should be considered for low-dose aspirin and/or calcium supplement therapy to lower preeclampsia risks, the new guidance states. Women who have preeclampsia have twice the risk of stroke and a four-fold risk of high blood pressure later in life; therefore, the condition should be recognized as a risk factor well after pregnancy, and other risk factors such as smoking, high cholesterol, and obesity in these women should be treated early.1
Stroke hits women hard
Women need to protect themselves against stroke; findings from a new study indicate that women who survive stroke have a worse quality of life than men.6 The study findings showed that at three months, women were more likely than men to report problems with mobility, pain/discomfort, and anxiety and depression.
What can women do to cut their risk of disease? Tell patients they don’t need to run marathons or do intense aerobics to reduce their risks; moderate intensity exercise, such as brisk walking or playing tennis, might do the trick, according to research presented at the 2014 International Stroke Conference in San Diego.7
Researchers analyzed information from 133,479 women in the California Teachers Study to see how many suffered a stroke between 1996 and 2010. The California Teacher Study encompasses a wide range of ages, from those in their 20s to those in their 90s. Those who reported doing moderate physical activity in the three years before enrolling in the study were 20% less likely than women who reported no activity to suffer a stroke.
"You don’t have to do an extreme boot camp," said Sophia Wang, PhD, the study’s lead author and professor in the Department of Population Sciences within the Beckman Research Institute at the City of Hope in Duarte, CA. "The types of activities we’re talking about are accessible to most of the population."
- Bushnell C, McCullough LD, Awad IA, et al; on behalf of the American Heart Association Stroke Council, Council on Cardiovascular and Stroke Nursing, Council on Clinical Cardiology, Council on Epidemiology and Prevention, and Council for High Blood Pressure Research. Guidelines for the prevention of stroke in women: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2014; doi: 10.1161/ 01.str.0000442009.06663.48.
- American Heart Association and American Stroke Association. Stroke prevention in women. Accessed at http://bit.ly/1hcVUvd.
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention (CDC). U.S. Selected Practice Recommendations for Contraceptive Use, 2013: adapted from the World Health Organization selected practice recommendations for contraceptive use, second edition. MMWR Recomm Rep 2013; 62(RR-05):1-60.
- Lidegaard Ø, Løkkegaard E, Jensen A, et al. Thrombotic stroke and myocardial infarction with hormonal contraception. N Engl J Med 2012; 366(24):2,257-2,266.
- James AH, Bushnell CD, Jamison MG, et al. Incidence and risk factors for stroke in pregnancy and the puerperium. Obstet Gynecol 2005; 106:509-516.
- Bushnell CD, Reeves MJ, Zhao X, et al. Sex differences in quality of life after ischemic stroke. Neurology 2014; doi: 10.1212/WNL.0000000000000208.
- Wang SS, Lakshminarayan K, Elkind M, et al. Physical activity reduces stroke risk among women in the California Teachers Study Cohort. Presented at the International Stroke Conference. San Diego; February 2014.
