Abstract
Stroke is the leading cause of acquired adult disability worldwide and the fourth leading cause of death in women in developed countries. Approximately 60% of stroke deaths occur in women. Women have a number of unique risk factors for stroke, including pregnancy and its related complications, duration of reproductive life, use of oral contraceptives and postmenopausal hormone therapy. Furthermore, the prevalence of traditional stroke risk factors and the strength of their association, varies by sex. Prior to stroke, women who develop stroke more commonly have atrial fibrillation, hypertension and migraine while men with stroke are more likely to have coronary artery and peripheral vascular disease. In this chapter we will focus specifically on risk factors for stroke in women.
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References
World Health Organization. The top 10 causes of death worldwide 2017. Available from: http://www.who.int/mediacentre/factsheets/fs310/en/.
Leading causes of death in females. In: Centers for Disease Control and Prevention Website [online]. Available at: cdc.gov/women/lcod/index.htm. Accessed 28 Jan 2018.
Leading causes of death in males: United States. In: Centers for Disease Control and Prevention Website [online]. Available at: cdc.gov/men/lcod/2013/index.htm. Accessed 20 Apr 2017.
Seshadri S, Beiser A, Kelly-Hayes M, Kase CS, Au R, Kannel WB, et al. The lifetime risk of stroke: estimates from the Framingham Study. Stroke. 2006;37(2):345–50.
Benjamin EJ, Blaha MJ, Chiuve SE, Cushman M, Das SR, Deo R, et al. Heart disease and stroke statistics-2017 update: a report from the American Heart Association. Circulation. 2017;135(10):e146–603.
Reeves MJ, Bushnell CD, Howard G, Gargano JW, Duncan PW, Lynch G, et al. Sex differences in stroke: epidemiology, clinical presentation, medical care, and outcomes. Lancet Neurol. 2008;7(10):915–26.
Leening MJ, Ferket BS, Steyerberg EW, Kavousi M, Deckers JW, Nieboer D, et al. Sex differences in lifetime risk and first manifestation of cardiovascular disease: prospective population based cohort study. BMJ. 2014;349:g5992.
Madsen TE, Khoury J, Alwell K, Moomaw CJ, Rademacher E, Flaherty ML, et al. Sex-specific stroke incidence over time in the Greater Cincinnati/Northern Kentucky Stroke Study. Neurology. 2017;89(10):990–6.
Koton S, Rexrode KM. Trends in stroke incidence in the United States. Will women overtake men? Neurology. 2017;89(10):982–3.
Koton S, Telman G, Kimiagar I, Tanne D. Gender differences in characteristics, management and outcome at discharge and three months after stroke in a national acute stroke registry. Int J Cardiol. 2013;168(4):4081–4.
Kittner SJ, Stern BJ, Feeser BR, Hebel R, Nagey DA, Buchholz DW, et al. Pregnancy and the risk of stroke. N Engl J Med. 1996;335(11):768–74.
Bushnell C, McCullough LD, Awad IA, Chireau MV, Fedder WN, Furie KL, 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;45(5):1545–88.
Scott CA, Bewley S, Rudd A, Spark P, Kurinczuk JJ, Brocklehurst P, et al. Incidence, risk factors, management, and outcomes of stroke in pregnancy. Obstet Gynecol. 2012;120(2 Pt 1):318–24.
Bushnell CD, Jamison M, James AH. Migraines during pregnancy linked to stroke and vascular diseases: US population based case-control study. BMJ. 2009;338:b664.
James AH, Bushnell CD, Jamison MG, Myers ER. Incidence and risk factors for stroke in pregnancy and the puerperium. Obstet Gynecol. 2005;106(3):509–16.
Berends AL, de Groot CJ, Sijbrands EJ, Sie MP, Benneheij SH, Pal R, et al. Shared constitutional risks for maternal vascular-related pregnancy complications and future cardiovascular disease. Hypertension. 2008;51(4):1034–41.
Steegers EA, von Dadelszen P, Duvekot JJ, Pijnenborg R. Pre-eclampsia. Lancet. 2010;376(9741):631–44.
Smith GN, Pudwell J, Walker M, Wen SW. Ten-year, thirty-year, and lifetime cardiovascular disease risk estimates following a pregnancy complicated by preeclampsia. Can: JOGC = J Obstet Gynecol Can: JOGC. 2012;34(9):830–5.
McDonald SD, Malinowski A, Zhou Q, Yusuf S, Devereaux PJ. Cardiovascular sequelae of preeclampsia/eclampsia: a systematic review and meta-analyses. Am Heart J. 2008;156(5):918–30.
Bellamy L, Casas JP, Hingorani AD, Williams DJ. Pre-eclampsia and risk of cardiovascular disease and cancer in later life: systematic review and meta-analysis. BMJ. 2007;335(7627):974.
Brown MC, Best KE, Pearce MS, Waugh J, Robson SC, Bell R. Cardiovascular disease risk in women with pre-eclampsia: systematic review and meta-analysis. Eur J Epidemiol. 2013;28(1):1–19.
Timpka S, Stuart JJ, Tanz LJ, Rimm EB, Franks PW, Rich-Edwards JW. Lifestyle in progression from hypertensive disorders of pregnancy to chronic hypertension in Nurses’ Health Study II: observational cohort study. BMJ. 2017;358:j3024.
Romundstad PR, Magnussen EB, Smith GD, Vatten LJ. Hypertension in pregnancy and later cardiovascular risk: common antecedents? Circulation. 2010;122(6):579–84.
Tobias DK, Stuart JJ, Li S, Chavarro J, Rimm EB, Rich-Edwards J, et al. Association of history of gestational diabetes with long-term cardiovascular disease risk in a large prospective cohort of US women. JAMA Intern Med. 2017;177(12):1735–42.
Fadl H, Magnuson A, Ostlund I, Montgomery S, Hanson U, Schwarcz E. Gestational diabetes mellitus and later cardiovascular disease: a Swedish population based case-control study. BJOG: Int J Obstet Gynaecol. 2014;121(12):1530–6.
Peters SA, Woodward M. Women’s reproductive factors and incident cardiovascular disease in the UK Biobank. Heart. 2018;104:1069–75.
Tanz LJ, Stuart JJ, Williams PL, Rimm EB, Missmer SA, Rexrode KM, et al. Preterm delivery and maternal cardiovascular disease in young and middle-aged adult women. Circulation. 2017;135(6):578–89.
Ley SH, Li Y, Tobias DK, Manson JE, Rosner B, Hu FB, et al. Duration of reproductive life span, age at menarche, and age at menopause are associated with risk of cardiovascular disease in women. J Am Heart Assoc. 2017;6(11):e006713.
Lidegaard O, Lokkegaard E, Jensen A, Skovlund CW, Keiding N. Thrombotic stroke and myocardial infarction with hormonal contraception. N Engl J Med. 2012;366(24):2257–66.
Gillum LA, Mamidipudi SK, Johnston SC. Ischemic stroke risk with oral contraceptives: a meta-analysis. JAMA. 2000;284(1):72–8.
Chan WS, Ray J, Wai EK, Ginsburg S, Hannah ME, Corey PN, et al. Risk of stroke in women exposed to low-dose oral contraceptives: a critical evaluation of the evidence. Arch Intern Med. 2004;164(7):741–7.
Peragallo Urrutia R, Coeytaux RR, McBroom AJ, Gierisch JM, Havrilesky LJ, Moorman PG, et al. Risk of acute thromboembolic events with oral contraceptive use: a systematic review and meta-analysis. Obstet Gynecol. 2013;122(2 Pt 1):380–9.
Baillargeon JP, McClish DK, Essah PA, Nestler JE. Association between the current use of low-dose oral contraceptives and cardiovascular arterial disease: a meta-analysis. J Clin Endocrinol Metab. 2005;90(7):3863–70.
Chakhtoura Z, Canonico M, Gompel A, Thalabard JC, Scarabin PY, Plu-Bureau G. Progestogen-only contraceptives and the risk of stroke: a meta-analysis. Stroke. 2009;40(4):1059–62.
Kemmeren JM, Tanis BC, van den Bosch MA, Bollen EL, Helmerhorst FM, van der Graaf Y, et al. Risk of arterial thrombosis in relation to oral contraceptives (RATIO) study: oral contraceptives and the risk of ischemic stroke. Stroke. 2002;33(5):1202–8.
Slooter AJ, Rosendaal FR, Tanis BC, Kemmeren JM, van der Graaf Y, Algra A. Prothrombotic conditions, oral contraceptives, and the risk of ischemic stroke. J Thromb Haemost. 2005;3(6):1213–7.
Grodstein F, Manson JE, Stampfer MJ, Rexrode K. Postmenopausal hormone therapy and stroke: role of time since menopause and age at initiation of hormone therapy. Arch Intern Med. 2008;168(8):861–6.
Grodstein F, Manson JE, Colditz GA, Willett WC, Speizer FE, Stampfer MJ. A prospective, observational study of postmenopausal hormone therapy and primary prevention of cardiovascular disease. Ann Intern Med. 2000;133(12):933–41.
Anderson GL, Limacher M, Assaf AR, Bassford T, Beresford SA, Black H, et al. Effects of conjugated equine estrogen in postmenopausal women with hysterectomy: the women’s health initiative randomized controlled trial. JAMA. 2004;291(14):1701–12.
Hendrix SL, Wassertheil-Smoller S, Johnson KC, Howard BV, Kooperberg C, Rossouw JE, et al. Effects of conjugated equine estrogen on stroke in the Women’s Health Initiative. Circulation. 2006;113(20):2425–34.
Rossouw JE, Anderson GL, Prentice RL, LaCroix AZ, Kooperberg C, Stefanick ML, et al. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results from the Women’s Health Initiative randomized controlled trial. JAMA. 2002;288(3):321–33.
Renoux C, Dell’aniello S, Garbe E, Suissa S. Transdermal and oral hormone replacement therapy and the risk of stroke: a nested case-control study. BMJ. 2010;340:c2519.
Rossouw JE, Prentice RL, Manson JE, Wu L, Barad D, Barnabei VM, et al. Postmenopausal hormone therapy and risk of cardiovascular disease by age and years since menopause. JAMA. 2007;297(13):1465–77.
Viscoli CM, Brass LM, Kernan WN, Sarrel PM, Suissa S, Horwitz RI. A clinical trial of estrogen-replacement therapy after ischemic stroke. N Engl J Med. 2001;345(17):1243–9.
Clarke SC, Kelleher J, Lloyd-Jones H, Slack M, Schofiel PM. A study of hormone replacement therapy in postmenopausal women with ischaemic heart disease: the Papworth HRT atherosclerosis study. BJOG: Int J Obstet Gynaecol. 2002;109(9):1056–62.
Merikangas KR. Contributions of epidemiology to our understanding of migraine. Headache. 2013;53(2):230–46.
Vetvik KG, MacGregor EA. Sex differences in the epidemiology, clinical features, and pathophysiology of migraine. Lancet Neurol. 2017;16(1):76–87.
Champaloux SW, Tepper NK, Monsour M, Curtis KM, Whiteman MK, Marchbanks PA, et al. Use of combined hormonal contraceptives among women with migraines and risk of ischemic stroke. Am J Obstet Gynecol. 2017;216(5):489.e1–7.
Li H, Yu Y. Association between ischemic stroke and migraine in elderly Chinese: a case-control study. BMC Geriatr. 2013;13:126.
Li L, Schulz UG, Kuker W, Rothwell PM, Oxford Vascular S. Age-specific association of migraine with cryptogenic TIA and stroke: population-based study. Neurology. 2015;85(17):1444–51.
Rambarat CA, Elgendy IY, Johnson BD, Reis SE, Thompson DV, Sharaf BL, et al. Migraine headache and long-term cardiovascular outcomes: an extended follow-up of the women’s ischemia syndrome evaluation. Am J Med. 2017;130(6):738–43.
Kurth T, Winter AC, Eliassen AH, Dushkes R, Mukamal KJ, Rimm EB, et al. Migraine and risk of cardiovascular disease in women: prospective cohort study. BMJ. 2016;353:i2610.
Schurks M, Rist PM, Bigal ME, Buring JE, Lipton RB, Kurth T. Migraine and cardiovascular disease: systematic review and meta-analysis. BMJ. 2009;339:b3914.
Abanoz Y, Gulen Abanoz Y, Gunduz A, Uluduz D, Ince B, Yavuz B, et al. Migraine as a risk factor for young patients with ischemic stroke: a case-control study. Neurol Sci. 2017;38(4):611–7.
Peng KP, Chen YT, Fuh JL, Tang CH, Wang SJ. Migraine and incidence of ischemic stroke: a nationwide population-based study. Cephalalgia. 2017;37(4):327–35.
O’Donnell MJ, Xavier D, Liu L, Zhang H, Chin SL, Rao-Melacini P, et al. Risk factors for ischaemic and intracerebral haemorrhagic stroke in 22 countries (the INTERSTROKE study): a case-control study. Lancet. 2010;376(9735):112–23.
Johansson BB. Hypertension mechanisms causing stroke. Clin Exp Pharmacol Physiol. 1999;26(7):563–5.
Yoon SS, Carroll MD, Fryar CD. Hypertension prevalence and control among adults: United States, 2011-2014. NCHS Data Brief. 2015(220):1–8.
Ong KL, Cheung BM, Man YB, Lau CP, Lam KS. Prevalence, awareness, treatment, and control of hypertension among United States adults 1999-2004. Hypertension. 2007;49(1):69–75.
2016. Available from: https://www.cdc.gov/nchs/data/hus/2016/.
Muntner P, Davis BR, Cushman WC, Bangalore S, Calhoun DA, Pressel SL, et al. Treatment-resistant hypertension and the incidence of cardiovascular disease and end-stage renal disease: results from the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). Hypertension. 2014;64(5):1012–21.
Wenger NK, Ferdinand KC, Bairey Merz CN, Walsh MN, Gulati M, Pepine CJ. Women, hypertension, and the systolic blood pressure intervention trial. Am J Med. 2016;129(10):1030–6.
Appelman Y, van Rijn BB, Ten Haaf ME, Boersma E, Peters SA. Sex differences in cardiovascular risk factors and disease prevention. Atherosclerosis. 2015;241(1):211–8.
Peters SA, Huxley RR, Woodward M. Comparison of the sex-specific associations between systolic blood pressure and the risk of cardiovascular disease: a systematic review and meta-analysis of 124 cohort studies, including 1.2 million individuals. Stroke. 2013;44(9):2394–401.
Wolf P, Abbott R, Kannel W. Atrial fibrillation as an independent risk factor for stroke: the Framingham Study. Stroke. 1991;22(8):983–8.
Wolf PA, Abbott RD, Kannel WB. Atrial fibrillation: a major contributor to stroke in the elderly. The Framingham Study. Arch Intern Med. 1987;147(9):1561–4.
McGrath ER, Kapral MK, Fang J, Eikelboom JW, O’Conghaile A, Canavan M, et al. Association of atrial fibrillation with mortality and disability after ischemic stroke. Neurology. 2013;81(9):825–32.
Ko D, Rahman F, Schnabel RB, Yin X, Benjamin EJ, Christophersen IE. Atrial fibrillation in women: epidemiology, pathophysiology, presentation, and prognosis. Nat Rev Cardiol. 2016;13(6):321–32.
Feinberg WM, Blackshear JL, Laupacis A, Kronmal R, Hart RG. Prevalence, age distribution, and gender of patients with atrial fibrillation. Analysis and implications. Arch Intern Med. 1995;155(5):469–73.
Shroff GR, Solid CA, Herzog CA. Atrial fibrillation, stroke, and anticoagulation in Medicare beneficiaries: trends by age, sex, and race, 1992-2010. J Am Heart Assoc. 2014;3(3):e000756.
Emdin CA, Wong CX, Hsiao AJ, Altman DG, Peters SA, Woodward M, et al. Atrial fibrillation as risk factor for cardiovascular disease and death in women compared with men: systematic review and meta-analysis of cohort studies. BMJ. 2016;532:h7013.
Lip GY, Nieuwlaat R, Pisters R, Lane DA, Crijns HJ. Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: the euro heart survey on atrial fibrillation. Chest. 2010;137(2):263–72.
Gage BF, Waterman AD, Shannon W, Boechler M, Rich MW, Radford MJ. Validation of clinical classification schemes for predicting stroke: results from the National Registry of Atrial Fibrillation. JAMA. 2001;285(22):2864–70.
Wagstaff AJ, Overvad TF, Lip GY, Lane DA. Is female sex a risk factor for stroke and thromboembolism in patients with atrial fibrillation? A systematic review and meta-analysis. QJM. 2014;107(12):955–67.
Hong Y, Yang X, Zhao W, Zhang X, Zhao J, Yang Y, et al. Sex differences in outcomes among stroke survivors with non-valvular atrial fibrillation in China. Front Neurol. 2017;8:166.
Phan HT, Blizzard CL, Reeves MJ, Thrift AG, Cadilhac D, Sturm J, et al. Sex differences in long-term mortality after stroke in the INSTRUCT (INternational STRoke oUtComes sTudy): a meta-analysis of individual participant data. Circ Cardiovasc Qual Outcomes. 2017;10(2):e003436. https://doi.org/10.1161/CIRCOUTCOMES.116.003436.
Thompson LE, Maddox TM, Lei L, Grunwald GK, Bradley SM, Peterson PN, et al. Sex differences in the use of oral anticoagulants for atrial fibrillation: a report from the National Cardiovascular Data Registry (NCDR(R)) PINNACLE Registry. J Am Heart Assoc. 2017;6(7):e005801. https://doi.org/10.1161/JAHA.117.005801.
Humphries KH, Kerr CR, Connolly SJ, Klein G, Boone JA, Green M, et al. New-onset atrial fibrillation: sex differences in presentation, treatment, and outcome. Circulation. 2001;103(19):2365–70.
Singer DE, Chang Y, Fang MC, Borowsky LH, Pomernacki NK, Udaltsova N, et al. The net clinical benefit of warfarin anticoagulation in atrial fibrillation. Ann Intern Med. 2009;151(5):297–305.
McGrath ER, Kapral MK, Fang J, Eikelboom JW, Conghaile AO, Canavan M, et al. Antithrombotic therapy after acute ischemic stroke in patients with atrial fibrillation. Stroke. 2014;45(12):3637–42.
Avgil Tsadok M, Jackevicius CA, Rahme E, Humphries KH, Pilote L. Sex differences in dabigatran use, safety, and effectiveness in a population-based cohort of patients with atrial fibrillation. Circ Cardiovasc Qual Outcomes. 2015;8(6):593–9.
Emerging Risk Factors C, Sarwar N, Gao P, Seshasai SR, Gobin R, Kaptoge S, et al. Diabetes mellitus, fasting blood glucose concentration, and risk of vascular disease: a collaborative meta-analysis of 102 prospective studies. Lancet. 2010;375(9733):2215–22.
Iso H, Rexrode K, Hennekens CH, Manson JE. Application of computer tomography-oriented criteria for stroke subtype classification in a prospective study. Ann Epidemiol. 2000;10(2):81–7.
Ohira T, Shahar E, Chambless LE, Rosamond WD, Mosley TH Jr, Folsom AR. Risk factors for ischemic stroke subtypes: the Atherosclerosis Risk in Communities study. Stroke. 2006;37(10):2493–8.
Madsen TE, Khoury JC, Alwell KA, Moomaw CJ, Demel SL, Flaherty ML, et al. Sex differences in cardiovascular risk profiles of ischemic stroke patients with diabetes in the Greater Cincinnati/Northern Kentucky Stroke Study. J Diabetes. 2017;10:496–501.
Peters SA, Huxley RR, Woodward M. Diabetes as a risk factor for stroke in women compared with men: a systematic review and meta-analysis of 64 cohorts, including 775 385 individuals and 12 539 strokes. Lancet. 2014;383:1973–80.
Stevens RJ, Coleman RL, Adler AI, Stratton IM, Matthews DR, Holman RR. Risk factors for myocardial infarction case fatality and stroke case fatality in type 2 diabetes: UKPDS 66. Diabetes Care. 2004;27(1):201–7.
Ho JE, Paultre F, Mosca L. Is diabetes mellitus a cardiovascular disease risk equivalent for fatal stroke in women? Data from the women’s pooling project. Stroke. 2003;34(12):2812–6.
Pan A, Sun Q, Okereke OI, Rexrode KM, Hu FB. Depression and risk of stroke morbidity and mortality: a meta-analysis and systematic review. JAMA. 2011;306(11):1241–9.
Pan A, Okereke OI, Sun Q, Logroscino G, Manson JE, Willett WC, et al. Depression and incident stroke in women. Stroke. 2011;42(10):2770–5.
Wassertheil-Smoller S, Shumaker S, Ockene J, Talavera GA, Greenland P, Cochrane B, et al. Depression and cardiovascular sequelae in postmenopausal women. The Women’s Health Initiative (WHI). Arch Intern Med. 2004;164(3):289–98.
Smoller JW, Allison M, Cochrane BB, Curb JD, Perlis RH, Robinson JG, et al. Antidepressant use and risk of incident cardiovascular morbidity and mortality among postmenopausal women in the Women’s Health Initiative study. Arch Intern Med. 2009;169(22):2128–39.
Mackay J, Mensah G. The atlas of heart disease and stroke. Geneva: World Health Organization; 2004.
House A, Dennis M, Mogridge L, Hawton K, Warlow C. Life events and difficulties preceding stroke. J Neurol Neurosurg Psychiatry. 1990;53(12):1024–8.
Rich-Edwards JW, Mason S, Rexrode K, Spiegelman D, Hibert E, Kawachi I, et al. Physical and sexual abuse in childhood as predictors of early-onset cardiovascular events in women. Circulation. 2012;126(8):920–7.
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McGrath, E.R., Rexrode, K.M. (2019). Stroke Risk Factors in Women. In: O’Neal, M. (eds) Neurology and Psychiatry of Women. Springer, Cham. https://doi.org/10.1007/978-3-030-04245-5_23
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