Risk Factors: Gender and Sex

Introduction

Reductions in stroke incidence and mortality are ongoing in the United States; however, the burden of stroke remains high for women. Stroke is the third leading cause of death for women, and roughly 60% of stroke deaths in the United States are in women. In part, this is due to the fact that women are frequently older at the time of stroke, display more nonclassical stroke symptoms that may alter early stroke recognition, and tend to have more severe stroke damage and persistent disability. Since women live longer than men, stroke-related disability and institutionalization more strongly affects women than men throughout much of the developed world. Clinical and basic science research is beginning to unveil the many unique aspects of stroke pathobiology in women vs. men, and some of these findings may lead to new, gender-specific therapy in future.

This chapter focuses on risk rather than outcome and addresses ischemic stroke, except where indicated otherwise. Although traditional cardiovascular and stroke risk factors apply to women, there are also risk factors that are more prevalent in women than men (e.g., atrial fibrillation, diabetes mellitus, migraine with aura, and depression) and female-specific risk factors that bear consideration (e.g., pregnancy, menopausal hormone status and use of replacement therapies, preeclampsia, and oral contraceptive use). Greater detail on risk and risk reduction strategies is available in the American Heart Association/American Stroke Association Guidelines for the Prevention of Stroke in Women .

Examples of Traditional, Well-Studied Risk Factors: Hypertension and Hyperlipidemia

Hypertension is the best recognized and most common modifiable risk factor for stroke in both sexes. However, some studies suggest that women are more likely to be hypertensive than men and have a higher risk of first stroke in the presence of hypertension than men. Data from the National Health and Nutrition Evaluations Survey (NHANES) also emphasize that there are time-based sex differences in the prevalence of hypertension. Although men may be more likely to experience hypertension before 45 years of age, prevalence of hypertension in women is more common after 65 years.

There are also differences on average in lipid profiles for adult women vs. men; in general women have a more favorable lipid profile on average than men. For example, women have a higher prevalence of elevated total cholesterol (greater than 200 mg/dL) than do men, whereas men have a higher prevalence of low-density lipoprotein greater than 130 mg/dL and high density lipoprotein less than 40 mg/dL .

Clinical Risk Factors More Prevalent in Women: Atrial Fibrillation, Diabetes Mellitus, Migraine With Aura, and Depression