Journal issue focuses on growing epidemic of stroke in women
Dallas, TX, February 10, 2009 - Stroke among women is the third leading cause of death and an ongoing epidemic with women accounting for more than 60 percent of all stroke deaths in the United States. Reasons for this, including unique risk factors and gender disparities in care, are addressed in research published in a special issue of Stroke: Journal of the American Heart Association.
Publishing such research is timely, according to an editorial introducing the special issue. Tobias Kurth, M.D., Sc.D., associate epidemiologist at Brigham and Women's Hospital in Boston, Mass. and Marie-Germaine Bousser, M.D., head of the Neurology Department of the Hospital Lariboisière in Paris, editorial co-authors, wrote, "Projections indicate that the prevalence and incidence of stroke will increase by 2020 in both sexes, but that these figures are magnified in women. By 2050, mortality from stroke will be 30 percent higher in women than men."
They said while the understanding of stroke in women has been substantially improved over the last decades, "Many open questions in the epidemiology, clinical etiology, and outcome of stroke among women remain, however. Substantive efforts by the American Heart Association/American Stroke Association with their Go Red For Women campaign have been started and will continue and improve the awareness of cardiovascular disease and stroke in women and will induce new research efforts."
"Science and research have been critical components of our Go Red For Women initiative since its inception," said Lori Mosca, M.D., Go Red For Women spokesperson and director of preventive cardiology at New York-Presbyterian Hospital. "What we learn through this research, whether it's about the unique risk factors of women or about the treatment gaps between genders, translates into the knowledge base we need to empower women and their healthcare providers to make simple choices that can become life-saving actions."
The following is a sampling of the studies presented in this special issue:
- A study of Get with the Guidelines-Stroke (GWTG-S), a program of the American Heart Association/American Stroke Association, found the overall quality of care for women with ischemic stroke was lower than that for men.
Researchers compared the use of seven different treatments that are indicative of excellent evidence-based stroke care in more than 380,000 men and women hospitalized with acute stroke. The treatments included timely use of tPA (clot-busting drug), aspirin, blood thinners (Warfarin, in the hospital and at discharge, which accounts for two treatments), cholesterol treatment, smoking cessation and prevention of blood clots in the legs. The data are from more than 1,100 U.S. hospitals that participated in the GWTG-S quality improvement program between 2003 and 2008.
"After accounting for differences in age and other health conditions, we found that the chance of receiving defect-free care was 14 percent lower in women compared to men," said Mathew Reeves, Ph.D., the study's lead author and associate professor of epidemiology at Michigan State University in East Lansing. "The lower quality of care in women was seen in all measures, but the largest differences were seen in the proportion of women arriving within two hours of stroke treated with intravenous tPA and in cholesterol treatment."
Additionally, the researchers they found that women have a 6 percent in-hospital rate of death following stroke compared to 5.2 percent for men and that women are 16 percent less likely to be discharged home following stroke compared to men.
"We found that these sex differences in care cannot be 'explained away' based on the obvious established factors, such as age," Reeves said. "Future studies should look at differences in care that were not collected in this study; for example, patient or family preference for limitations in care, or physician choices in care delivery."
Contact: Mathew J. Reeves, Ph.D., Michigan State University, East Lansing, Mich.; (517) 353-8623; reevesm@msu.edu.
- In an analysis of the Get With The Guidelines-Stroke database in Colorado, researchers looked at stroke demographics, risk factors, lifestyles, treatments, and responses to treatment. They noted 47 gender differences among the 126 elements that they studied. As compared to men, women in Colorado were older and more significantly impacted by acute stroke. Risk factor profiles differed between the two genders, with men having higher incidences of coronary artery disease, high cholesterol, diabetes, carotid stenosis and tobacco smoking, while women had higher incidences of atrial fibrillation and hypertension. Common prevention strategies, such as use of cholesterol-lowering drugs were less likely to be used in women at risk for stroke than in men. Authors noted overall acute stroke treatment of women appeared "less aggressive" than for men.
Contact: Don B. Smith, M.D., Colorado Stroke Alliance and Colorado Neurological Institute, Englewood, Colo.; (303) 788-4010; dbsmd@qwest.net.
- Researchers analyzing data from the Framingham Heart Study observed 1136 incident strokes (638 in women) during 56 years of follow-up and found that women were significantly older than men at the time of their first-ever stroke. They also found that women had a higher stroke incidence above 85 years of age; lower incidence than men at all other ages; but a higher lifetime risk of stroke at all ages. While there were no significant differences between the genders in stroke subtype, severity and case fatality (or death) rates between genders, women were significantly more disabled prior to stroke and in the acute phase of stroke in dressing, grooming and in their abilities to transfer from a bed to chair. At three-to-six months post-stroke, women were more likely than men to be disabled, single and institutionalized.
Contact: Philip A. Wolf, M.D., Boston University School of Medicine, Boston, Mass.; (617)-638-5450; pawolf@bu.edu.
- Previous research suggests that women with stroke experience longer delays in stroke diagnosis than men after arriving at the emergency department (ED). Researchers found presenting symptoms do not explain gender differences in ED waiting times. They collected data on 1,922 acute stroke cases at 15 hospitals across Michigan, evaluating the time it took for patients in the ED to be examined by a physician (door-to-doctor time) and the time it took to undergo brain imaging (door-to-image time). They found:
- Women were significantly less likely than men to present with typical stroke warning signs or to report trouble with walking, balance or dizziness.
- Women had 12 percent longer door-to-doctor and 16 percent longer door-to-image intervals than men.
The authors adjusted the results after taking into consideration presenting symptoms and found no change, including the women who have acute stroke experience greater ED delays than men, but that these delays are not attributable to differences in presenting symptoms, age or other confounders.
Contact: Julia Warner Gargano, Michigan State University, East Lansing, Mich.; (517) 353-8623; jgargano@epi.msu.edu.
- Researchers at the University of Connecticut looked at how women at high risk for stroke perceive their risk by studying a group of predominately white, well-educated and high income women, ages 50 to 70, who had at least one stroke risk factor. They asked the women to answer a five-part questionnaire about stroke knowledge, risk perception, risk factors, access to health care and demographics.
Only seven of the 37 (18.9 percent) women with atrial fibrillation and 11 out of the 71 women with heart disease (15.5 percent) identified their health condition as a risk factor for stroke.
Only 63.9 percent of the women with atrial fibrillation reported taking warfarin or a blood thinner to reduce their stroke risk.
The researchers conclude that educational strategies must advocate for and target high-risk women.
Contact: Louise D. McCullough, The University of Connecticut Health Center, Farmington, Conn.; 860-679-3186; lmccullough@uchc.edu.
- Current recommendations for stroke prevention during early pregnancy in women with a prior stroke history are based on limited evidence, with uncertainty involved in balancing the fetal risk of medication against the maternal risk of recurrent stroke. Researchers in this study sent a survey to 384 actively practicing U.S. members of the American Academy of Neurology Stroke and Vascular Neurology section asking what antithrombotic (or anti-clotting medication), if any, they would use during first trimester pregnancy in women with a prior history of stroke, either unrelated or related to a previous pregnancy.
Of the 230 responses, 75 percent used some form of antithrombotic therapy for women with a history of prior stroke not related to pregnancy and 88 percent used an antithrombotic for women with a history of prior stroke related to pregnancy.
About half chose aspirin and 7 percent chose low molecular weight heparin for stroke unrelated to pregnancy; while 41 percent chose aspirin and 25 percent chose low molecular weight heparin for stroke related to pregnancy.
The authors conclude that while most practitioners agree that women with a history of stroke should receive a medication to prevent stroke during the first trimester, they tend to disagree which drug or drugs to use. They recommend a national registry of maternal and fetal outcome data is needed to guide practitioners in this setting.
Contact: Ann K. Helms, M.D., Medical College of Wisconsin, Milwaukee, Wis.; (414)805-5223; ahelms@mcw.edu.
Funding sources and individual author disclosures can be found on the respective manuscripts.
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