Expert Review: Thrombosis

Guidelines for the Prevention of Stroke in Women. A Statement for Healthcare Professionals From the American Heart Association/American Stroke Association

Stroke is the third leading cause of death in several industrial countries and occurs in the general context of atherosclerosis. Conventional (sex, age, heredity, dyslipidemia, diabetes mellitus, hypertension, sedentary lifestyle, smoking, and endothelial dysfunction) and non conventional (elevated levels of inflammatory markers, e.g., serum C-reactive protein, homocysteine, or lipoprotein) atherosclerosis risk factors, concur in the development of aortic atheroma1,2. The risk for embolic complications is increased with age, and women live longer than men. Women are also more likely to be living by themselves when they have a stroke, to have a more complicated and prolonged recovery, and to require assisted living or institutionalized care after suffering a stroke.
Therefore, it is important to focus on stroke in women due to genetic and gender differences which can increase the risk for stroke. Differences in blood clotting (coagulation), hormonal factors, genetic differences in immunity, and reproductive factors including childbearing and pregnancy can elevate the risk for stroke as well as influence the outcomes after a woman has suffered a stroke.
Based on these facts, the American Heart Association (AHA) and the American Stroke Association (ASA) have issued stroke prevention guidelines which focus on women’s unique risks. This is the first time guidelines have been issued which focus on stroke prevention in women.

Methods
Writing group members were nominated by the committee chair on the basis of their previous work in relevant topic areas and were approved by the AHA Stroke Council’s Scientific Statement Oversight Committee and the AHA’s Manuscript Oversight Committee. The panel reviewed relevant articles on adults using computerized searches of the medical literature through May 15, 2013. The evidence is organized within the context of the AHA framework and is classified according to the joint AHA/American College of Cardiology and supplementary AHA Stroke Council methods of classifying the level of certainty and the class and level of evidence. The document underwent extensive AHA internal peer review, Stroke Council Leadership review, and Scientific Statements Oversight Committee review before consideration and approval by the AHA Science Advisory and Coordinating Committee.

Results
The new guidelines add gender-specific advice in some key areas that can be summarized as follows:
 Before beginning oral contraceptives, women should be checked for high blood pressure because the combination elevates risk for stroke.
 Migraines alone don’t raise the risk of stroke, but ones with aura do. Using oral contraceptives and smoking raise this risk even more, so the guidelines urge stopping smoking.
 Women who have high blood pressure before pregnancy should be considered for low-dose aspirin (81 milligrams) after the first three months of pregnancy, along with calcium supplements to lower the risk of preeclampsia.
 Preeclampsia should be seen as a risk factor for stroke long after pregnancy, since women who have the condition have twice the risk of stroke and four times the risk of high blood pressure later in life. Women who have preeclampsia should be treated early for obesity, smoking and high cholesterol.
 Women over the age of 75 should be screened for atrial fibrillation because of its association with increased stroke risk. A cardiac examination including an EKG, checking the pulse or listening to the heart with stethoscope can be used to evaluate for this ailment.
 Pregnant women with significantly elevated blood pressure (160/110 and above) should be placed on certain medications, and treatment may be considered for those with moderately high blood pressure (150 to 159 over 100 to 109) as well.
 Cerebral venous thrombosis (CVT) is caused by a blood clot in the cerebral venous circulation and has been shown to be more common in women especially during pregnancy as well as post-partum. Therefore, routine blood tests including a complete blood count (CBC), serum chemistries, prothrombin time (PT) and activated partial thromboplastin time (PTT) are recommended. The PT and PTT are indicators of coagulation or ability to form blood clots. Clinicians rely on cerebral imaging (MRI of the Brain along with an MRV) to diagnose this dangerous condition.

Clinical Impact:
These guidelines provide current evidence, research gaps, and recommendations on risk of stroke related to preeclampsia, oral
contraceptives, menopause, and hormone replacement, as well as those risk factors more common in women, such as obesity/metabolic syndrome, atrial fibrillation, and migraine with aura.
Noteworhty, to more accurately reflect the risk of stroke in women across the lifespan, as well as the clear gaps in current risk scores, a female-specific stroke risk score is warranted.

Corresponding author from original paper

Cheryl Bushnell
Department of Neurology, Medical Center Boulevard, Wake Forest University Health Sciences, Winston Salem, NC 27157, USA
Email: cbushnel@wfubmc.edu

References
1. Agmon Y, Khandheria BK, Meissner I, Schwartz GL, Petterson TM, O’Fallon WM, Gentile F, Whisnant JP, Wiebers DO, Seward JB. Independent association of high blood pressure and aortic atherosclerosis: A population-based study. Circulation. 2000;102:2087-2093
2. Tsimikas S, Brilakis ES, Miller ER, McConnell JP, Lennon RJ, Kornman KS, Witztum JL, Berger PB. Oxidized phospholipids, lp(a) lipoprotein, and coronary artery disease. The New England journal of medicine. 2005;353:46-57

Citation: Bushnell C, McCullough LD, Awad IA, Chireau MV, Fedder WN, Furie KL, Howard VJ, Lichtman JH, Lisabeth LD, Piña IL, Reeves MJ, Rexrode KM, Saposnik G, Singh V, Towfighi A, Vaccarino V, Walters MR; 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;45:•••–•••.

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