This is the Time for Gender-Specific Guidelines: Preventing Strokes in Women

Gregory W. Rutecki, MD

Last month the American Heart Association and the American Stroke Association released the first set of guidelines focused solely on stroke risk factors for women.1 If I was offered a pre-test assessment on strokes in women, it would become immediately apparent that I needed a refresher course. 

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Did you know?

• Stroke is the 5th leading cause of death in men, but 3rd leading cause in women.

• Women require institutionalization after a stroke more often than men because of poorer recoveries.

• Women also have a greater frequency of subarachnoid hemorrhage than men. 

• Finally, 60% of deaths after strokes occur in women.

Medical school teaches us early on that children are not little adults. It is high time we also acknowledge that women are different than men—and that reality is very apparent in the context of strokes. Note: This month’s Top Paper1 is hefty (the guidelines approaches 50 pages including references!), but it is worth saving to your hard drive. 

Below is a summary of some key recommendations, and I should note that the data really opened my eyes. My efforts merely scratch the surface. 

• Women with chronic primary or secondary hypertension or previous pregnancy-related hypertension should take low-dose aspirin from the 12th week of gestation through delivery.

• Women who experience preeclampsia are at a higher risk for future stroke. A 2012 study reported that 18.2% of women with a history of preeclampsia versus 1.7% of women with uncomplicated pregnancies incurred a cardiovascular event over a 10-year follow up.

• Measurement of blood pressure before starting oral contraceptives (OCPs) is recommended. In a complicated mix of vascular risk factors (eg,  cigarettes and a history of thromboembolism), OCPs can add to baseline risk.

• Hormone replacement should not be used for primary or secondary prevention of stroke in postmenopausal women

• Reducing migraine frequency in women with prophylactic medications is a good idea. More frequent migraines are associated with a greater risk of stroke.

• Atrial fibrillation in elderly women is associated with a higher incidence of stroke than other cohorts. Pulse palpation followed by EKG is a good way to uncover atrial fibrillation in a particularly stroke-prone demographic.

I think that this “innovation”—that is, gender-specific guidelines for stroke—will be the first of many. The material is far-reaching. For example, knowing that a young mother is at higher risk of stroke after she has preeclampsia is important information for primary care practice. 

To quote the authors, “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.”1 Hear, hear! ■

Gregory W. Rutecki, MD, is a physician at the National Consult Service at the Cleveland Clinic. He is also a member of the editorial board of Consultant. Dr Rutecki reports that he has no relevant financial relationships to disclose.


1. Bushnell C, McCullough LD, Awad IA, et al. Guidelines for the Prevention of Stroke in Women: A Statement for Healthcare Professionals from the American Heart Association/American Stroke Association. Stroke. 2014 Feb 6. [epub ahead of print]