Stroke Impact: Women's Health Crisis

In 2019, there were 12.2 million incident strokes globally, with 101 million prevalent strokes, 143 million DALYs due to stroke, and 6.55 million deaths from stroke.

Stroke is the second-leading cause of death and the third-leading cause of death and disability combined in the world.

In the US, there are 795,000 people who have a stroke each year, with about 610,000 of these being first or new strokes.

In the UK, there are 100,000 people who have a stroke each year.

Women account for over half of all people who experience a stroke

Women are disproportionately affected by strokes, accounting for over half of all people who experience a stroke. In 2019, 56% of all stroke cases were women. This is a significant statistic, and it highlights the importance of understanding the unique risk factors and outcomes associated with strokes in women.

Firstly, it is important to note that the lifetime risk of stroke is higher in women than in men. This is largely due to women's longer life expectancy. However, recent studies have also indicated that younger women may be at a higher or similar risk of stroke compared to men in the same age group. This trend is particularly notable in older women, with Black and Hispanic women aged 70 and above having a 76%-77% higher risk of stroke than White women, while no such differences were observed in men.

Furthermore, women have worse stroke outcomes than men and are more likely to experience poorer functional recovery, lower quality of life, and post-stroke depression and anxiety. These disparities in outcomes cannot be fully explained by adjusting for factors such as age, stroke severity, and social support, indicating the need for further research.

In addition to the traditional risk factors for stroke, such as hypertension, diabetes, and atrial fibrillation, women also face unique risk factors. These include pregnancy-related complications, such as gestational diabetes or preeclampsia, the use of hormonal birth control, particularly while smoking, and menopausal hormone therapy. Understanding and addressing these women-specific risk factors are crucial for optimal risk assessment and tailored preventive strategies.

While stroke affects both men and women, the impact on women is more significant due to their higher lifetime risk and poorer outcomes. Therefore, it is essential to recognize and address the gender-specific aspects of stroke to improve prevention, treatment, and long-term care for women.

Women have a higher lifetime risk of stroke than men

Women are disproportionately affected by strokes, with a higher lifetime risk of experiencing a stroke than men. This is due to a combination of biological, physiological, and societal factors, which are often unique to women.

Biological factors

Physiological factors

Physiological changes during pregnancy can also increase the risk of stroke in women. These changes include increased blood volume and cardiac output, which can worsen pre-existing heart conditions and lead to cardioembolic events, including stroke. Pregnancy can also induce a hypercoagulable state, increasing the risk of thrombotic events such as stroke. Furthermore, the increase in intravascular volume and cardiac output during pregnancy can lead to hemodynamic stress on the arterial wall, potentially affecting the enlargement and rupture risk of arteriovenous malformations and cerebral aneurysms.

Societal factors

Finally, societal factors, such as the underrepresentation of women in clinical trials, can also contribute to the higher lifetime risk of stroke in women. This underrepresentation makes it challenging to fully understand the impact of risk factors and develop tailored preventive strategies for women.

Women have worse stroke outcomes than men

Stroke is the third leading cause of death in women, and women account for over half of all people who experience a stroke. Women have a higher lifetime risk of stroke than men, and several risk factors are more strongly associated with stroke in women than in men. Women also have unique risk factors that men do not have, such as pregnancy, menopause, and being a woman of colour.

Women have poorer functional recovery and lower quality of life than men after a stroke. They are more likely to experience post-stroke depression and anxiety, and have a higher likelihood of being widowed. These factors contribute to less favourable outcomes for women.

Women are also more likely to be discharged into assisted-living facilities or hospices after a stroke. They have a higher risk of stroke-related disability and death, and are more likely to require assistance after a stroke.

Despite comparable care in the hospital and equal access to rehabilitation, women have poorer functional outcomes than men.

Women have unique risk factors for stroke, e.g. pregnancy

Women are disproportionately affected by strokes, with a higher lifetime risk than men. Pregnancy is a unique risk factor for women, with a three times higher risk of stroke during pregnancy and the postpartum period than for non-pregnant women of similar reproductive age. The risk of maternal stroke is higher in the peripartum and postpartum periods, with both ischemic and hemorrhagic strokes more likely during these times.

Physiological changes during pregnancy can affect stroke occurrence. There are three major changes associated with stroke: alterations to the hemodynamic/vascular system, the coagulation system, and the immune system. Blood volume and cardiac output increase by around 45% during pregnancy, meeting the increased metabolic demands of the mother and fetus. This can worsen pre-existing heart conditions and contribute to a higher risk of cardioembolic events, including stroke. Additionally, the increase in intravascular volume and cardiac output can lead to hemodynamic stress on the arterial wall, potentially affecting the enlargement and rupture risk of arteriovenous malformations and cerebral aneurysms.

Pregnancy also induces a hypercoagulable state, with a 4-10 times increased thrombotic risk. This is due to increased procoagulant activity and decreased physiological anticoagulants. The concentrations of coagulation factors and fibrinogen levels rise significantly, while protein S activity and physiological anticoagulation are reduced. These changes further elevate the risk of thrombotic events, including stroke.

Furthermore, pregnancy is considered a period of immunomodulation, with greater inflammation in early and late pregnancy and reduced inflammation in mid-pregnancy. While immune cells and their byproducts play a crucial role in implantation and placenta development, an exaggerated inflammatory response can lead to endothelial dysfunction, increasing the risk of preterm birth, preeclampsia, and stroke.

Hypertensive disorders of pregnancy (HDPs) are common medical complications and are associated with a higher risk of maternal stroke. Preeclampsia, gestational hypertension, chronic hypertension, and superimposed preeclampsia on chronic hypertension are all subtypes of HDPs that can impact stroke risk. The pathogenesis of HDPs is not fully understood, but one proposed mechanism involves reduced placental perfusion leading to oxidative stress and a systemic inflammatory response, resulting in endothelial dysfunction and vasoconstriction.

Peripartum cardiomyopathy (PPCM) is another condition related to pregnancy that can increase the risk of maternal stroke. PPCM is characterized by left ventricular systolic dysfunction and heart failure symptoms during late pregnancy or the early postpartum period. While the pathogenesis of PPCM is not well understood, it may be linked to genetic predispositions and hormonal fluctuations during the third trimester and childbirth.

In summary, pregnancy is a unique risk factor for stroke in women, with various physiological and pathological changes occurring during this time that can elevate the likelihood of stroke. These changes include alterations to the hemodynamic, coagulation, and immune systems, as well as hypertensive disorders and peripartum cardiomyopathy. Understanding these risk factors is essential for optimal risk assessment and tailored preventive strategies for women.

Stroke is the third leading cause of death for women

There are several risk factors for stroke that are unique to women, including pregnancy, hormonal birth control, and menopause. Women are also more likely to have a history of problems during pregnancy, such as gestational diabetes or preeclampsia, which can increase their risk of stroke. Additionally, the use of hormonal birth control while smoking and menopausal hormone therapy can further elevate the risk of stroke in women.

Some risk factors for stroke are also more common in women than in men. These include migraine with aura, atrial fibrillation (irregular heartbeat), and diabetes. Furthermore, women are more likely to experience another stroke within five years of their first stroke.

The impact of conventional risk factors on stroke also differs between men and women. For example, high blood pressure, a major risk factor for stroke, has a greater impact on women than men. As a result, optimal management of stroke risk factors may vary between the two sexes.

While stroke disproportionately affects women, it is important to note that many strokes are preventable and treatable. By understanding their risk factors and making healthy changes, women can take proactive steps to lower their risk of stroke.

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