First AHA/ASA Guidelines to Reduce Stroke Risk in Women

February 06, 2014

The American Heart Association/American Stroke Association (AHA/ASA) has issued the first guidelines for reducing stroke risk specifically in women.

Vice-chair of the writing committee, Louise McCullough, MD, University of Connecticut Health Center, Farmington, told Medscape Medical News this is first time that guidelines have specifically addressed stroke risk in women.

"How men and women differ in stroke risks has been on the minds of many of us at the AHA/ASA for years, so this guideline has been a long time in evolution," she said.

The guidelines also call for a stroke risk score specific to women.

"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," the writing committee concludes.

Geared to primary care physicians and obstetrician-gynecologists, the guidelines are published online February 6 in Stroke.

More Strokes in Women

Dr. McCullough reported that each year in the United States, 55,000 more strokes occur in women than in men. Stroke is the fifth leading cause of death for men but the third leading cause for women, and with the aging of the population, numbers continue to rise.

"How our society adapts to the anticipated increase in stroke prevalence in women is vitally important. Now more than ever, it is critical to identify women at higher risk for stroke and initiate the appropriate prevention strategies," the guidelines document states.

Dr. McCullough explained that certain risk factors for stroke are unique to women, such as pregnancy, use of oral contraceptives, and hormone replacement therapy. Some medical conditions increase stroke risk are much more common in women. These include migraine with aura and cerebral vein thrombosis. "So we really need to take gender into account when assessing stroke risk," she said.

The guidelines contain much information on pregnancy and stroke risk, particularly if pre-eclampsia has occurred.

"Pre-eclampsia during pregnancy is associated with a doubling in the risk of stroke later in life, even if blood pressure returns to normal after delivery. Something happens to the vasculature when pre-eclampsia occurs that doesn't return to normal at the end of pregnancy," said Dr. McCullough.

"So it is important to ask older women when assessing their stroke risk whether they had pre-eclampsia during pregnancy, even if this was 30, 40, or even 50 years ago. If they did, then they are at higher stroke risk so will need to be screened for blood pressure and other risks more often, or they may need to start screening earlier," she added.

Preventing Pre-eclampsia

One of the new recommendations in the guidelines is that women with a history of high blood pressure before pregnancy should be considered for low-dose aspirin and/or calcium supplement therapy to decrease pre-eclampsia risks.

The guidelines also recommend that pregnant women with moderately high blood pressure (150 to 159 mmHg/100 to 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.

Other recommendations include screening women for high blood pressure before they begin taking birth control pills because the combination raises stroke risk. Women with migraine headaches with aura should also be encouraged to stop smoking in order to avoid increased risk.

Although many of the recommendations may already be known, the new guidelines centralize the information, said Dr. McCullough.

"We are asking doctors to be more aware of stroke risk and think about how the risk factors add up. For example, if a women smokes and has migraine with aura, then prescribing oral contraceptives is not a good idea," she said.

At the other end of the age spectrum, the guidelines recommend screening for atrial fibrillation (AF) in women older than age 75 years.

"Women over the age of 75 have a higher risk than men of having AF. But sometimes they are completely asymptomatic. We need to screen these older women more aggressively," said Dr. McCullough.

Stroke. Published online February 6, 2014. Abstract

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