Guidelines focus on stroke prevention in women

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Women have unique risk factors for stroke, and a joint panel of experts from the American Heart Association and the American Stroke Association made recommendations that take these risk factors into account. Their guidelines were published online Feb. 6 in Stroke

The writing panel, led by chair Cheryl Bushnell, MD, MHS, of Wake Forest Baptist Medical Center in Winston-Salem, N.C., reviewed studies on adults published through May 2013 and examined the risk factors relevant only to women, such as pregnancy, as well as those more common in women, including migraine with aura, obesity, metabolic syndrome and atrial fibrillation (AF). They did not examine risk factors not unique to women, such as diabetes mellitus and cholesterol. 

Pregnancy is associated with an increased risk of stroke. Pregnant women have a higher risk of stroke than non-pregnant women and risk is highest in the final trimester and in the post-partum period. Complications of pregnancy, including preeclampsia, gestational diabetes and pregnancy-induced hypertension, raise the risk of future cardiovascular disease. Therefore, some of their recommendations included low-dose aspirin after the 12th week of pregnancy for women with chronic primary or secondary hypertension or a history of pregnancy-related hypertension and treating severe hypertension during pregnancy with safe and effective antihypertensives.

Atenolol, ARBs and direct renin inhibitors should not be used. 

For cerebral venous and sinus thrombosis (CVT), which is associated with hormonal factors, the panel’s recommendations included routine blood work for suspected CVT, testing for prothrombotic conditions and low molecular weight heparin throughout pregnancy.  Women who use oral contraceptives are also at risk for stroke, and the panel suggested aggressively managing stroke risk factors if necessary and measuring blood pressure before starting oral contraceptives.

They did not recommend routine screening for a predisposition to prothrombotic conditions.

Postmenopausal women should not use hormonal therapy (conjugated equine estrogen [CEE] with or without medroxyprogesterone) to prevent stroke. Selective estrogen receptor modulators should also not be used for primary prevention of stroke.

As for migraines with aura, there is not enough evidence that migraine treatment lowers the risk of a first stroke, so the panel stated only that treatment “may be reasonable.” However, given the increased risk of stroke associated with smoking in these women, they strongly recommended smoking cessation.

For women who are obese or have metabolic syndrome, the authors recommended lifestyle modification that includes regular exercise, a healthy diet and alcohol intake of less than one drink a day (for women who are not pregnant).

For women with AF, the panel recommended risk stratification tools, such as the CHA 2DS2-VASc  score, that take sex and age into consideration. They also recommended screening with pulse measurement and electrocardiograms, especially for women older than 75 years of age. As far as medication therapy is concerned, they suggested antiplatelet therapy for low-risk women, but did not recommend oral anticoagulants for women 65 and younger with only AF. They also recommended new oral anticoagulants as alternatives to warfarin in certain women.

Data also support the development of a stroke risk score specific to women that may be a more accurate reflection of their unique risk profile, the panel explained.

However, they also noted that research is needed to learn more about sex-based differences in stroke risk. “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 wrote.