Perspective:

The following are 10 points to remember about stroke prevention in women:

1. An estimated 6.8 million persons in the United States have had a stroke, most of whom are women (3.8 million). At the time of stroke, women are older and more likely to be living alone and have worse premorbid status than men. After stroke, they also are more likely to be institutionalized and have a poorer recovery and worse quality of life than men. In February 2014, the American Heart Association/ American Stroke Association released their first guideline focused on stroke prevention in women.

2. Hypertension, the most modifiable risk factor for stroke, is more prevalent in women than men. Hypertension is more often poorly controlled in older women; only 23% of women versus 38% of men ages >80 years have a blood pressure <140/90 mm Hg. Improved diagnosis and control of hypertension for the prevention of stroke are recommended among women. A new recommendation is to consider treating women with a systolic blood pressure between 150 and 159 mm Hg or a diastolic blood pressure between 100 and 109 mm Hg of new onset during pregnancy. This recommendation differs from that of the guideline of the American Congress of Obstetricians and Gynecologists, which recommends only treating patients with a blood pressure >160/110 mm Hg. This new recommendation is based on evidence that treatment of mild to moderately elevated blood pressure in pregnancy is associated with a 50% reduction in risk for severe hypertension.

3. Sex differences in atrial fibrillation include a higher prevalence and a higher associated risk for thromboembolic events in women. Risk stratification tools which include age and sex are preferred for clinical use. Women, particularly those ages >75 years, should be actively screened for atrial fibrillation with pulse rate measurement and electrocardiography as appropriate. It is also suggested that antiplatelet therapy be used for women with lone atrial fibrillation who are ages ≤65 years.

4. Women are four times more likely than men to have a migraine headache. Although the absolute risk for stroke associated with migraine headache is low, the association between migraine headache with aura and stroke seems strongest in women ages <55 years. Given a synergistic relationship between smoking and migraine headache with aura, it is recommended that smoking cessation treatments and counseling be provided for persons who smoke and have migraine headache. Clinicians are also recommended to caution women with migraine headache about the use of oral contraceptives.

5. The use of oral contraceptives is a risk factor for stroke in young women, increasing the risk from 1.4- to 2.0-fold compared with that of women who do not use these agents; although the absolute risk is low. It is recommended to identify women with modifiable risk factors (hypertension, smoking, hyperlipidemia, diabetes, and obesity) and increase efforts to manage such risk factors in women who use oral contraceptives. Among postmenopausal women, the use of hormone therapy in postmenopausal women is a unique risk factor for stroke in women.

6. Several cohort studies and a meta-analysis have identified depression and psychosocial stress as factors that increase the risk for incident stroke by 25-45% in women. More research is needed to understand the subgroups of women at risk, such as those who are treated versus not, and the method of determining depression and psychosocial stress.

7. A healthy weight, eating a healthy diet, abstinence from smoking, regular physical activity, moderate alcohol intake, and activities and interventions aimed at achieving or maintaining normal blood pressure and cholesterol and blood glucose levels are recommended for reducing stroke risk.

8. Women with symptomatic carotid stenosis may be less likely to receive carotid endarterectomy than men. Whether benefits and risks of carotid angioplasty and stenting differ between women and men is not known. There are clear sex differences in carotid artery plaque (women have less inflammatory features) and a higher risk for periprocedural complications with endarterectomy for asymptomatic stenosis. There are many gaps in our understanding of the sex-specific treatment of carotid disease, so future trials are needed to determine whether surgery is superior to aggressive medical management in women with symptomatic carotid stenosis.

9. The present guideline suggests considering aspirin in women ≥65 years if blood pressure is controlled and the benefit of preventing ischemic stroke or myocardial infarction outweighs the risk for gastrointestinal bleeding and hemorrhagic stroke. Whether a woman <65 years old may benefit from aspirin could be addressed if a sex-specific risk score were available.

10. The risk for stroke during pregnancy is fairly low (about 34 per 100,000 deliveries), but risk is highest in the postpartum period. Suspicion for a postpartum stroke or vasculopathy (the posterior reversible encephalopathy syndrome or the reversible cerebral vasoconstriction syndrome) or cerebral venous thrombosis should be heightened for women who develop new-onset headache, blurred vision, or seizures or any new neurologic signs or symptoms during the postpartum period. Because of evidence that a history of preeclampsia is associated with a twofold risk for stroke and a fourfold risk for hypertension later in life, it is recommended that clinicians document preeclampsia as a risk factor for stroke later in life.