Abstract
Stroke is a major cause of morbidity and mortality in both men and women. Gender disparities in evaluation and treatment of stroke in women have been previously described. 1 Women tend to experience higher rates of stroke due to increased life expectancy. They bear greater disability after stroke and are more likely to be discharged to a facility. 2,3
In this issue of Journal of Women's Health, Phan et al. present the results of their study 4 on gender differences in causes of death after stroke: evidence from a national prospective registry. A total of 9441 patients with first ever strokes between 2010 and 2013 were selected from the Australian stroke clinical registry and linked to national death registry to identify rates of mortality. Demographic, clinical, hospital care, and discharge data including stroke severity were abstracted. The association of stroke severity with gender and individual cause of death was examined. Stroke severity measured by the ability to walk on admission has been previously established to be a predictor of all-cause mortality. 5
Women comprised 46% of this population and were older than men by an average of 7 years, which is an expected observation given higher life expectancy in women. Women were also noted to have higher mortality poststroke due to cerebrovascular and cardiovascular causes, which was explained by age at stroke and incident stroke severity.
Several points are worth noting that influence the results of this study. First, not only were the women older than men, they also differed significantly in terms of their baseline risk factors. Women were more likely to have dementia, hypertension, and a higher incidence of atrial fibrillation (AF), heart failure, and myocardial infarction. Higher incidence of stroke and cardiovascular risk factors could have contributed to higher mortality in women.
Second, prior research has established that women are less likely to be anticoagulated for underlying AF, less likely to receive lipid testing and treatment and care for diabetes. 6,7 In addition, the decreased use of aspirin in women in this study likely led to increased stroke-related and cardiovascular mortality.
It is also important to note the limitations of this study. Critical data points that are relevant to modern day stroke care such as stroke severity measurement with the NIH Stroke Scale, utilization of statins, anticoagulation, medical management of heart failure, and AF, and premorbid functioning were not reported. The processes of care for stroke have changed significantly since 2013 with endovascular thrombectomy becoming the standard of care for large vessel strokes since 2015. As this study included patients from 2010 to 2013, it may not be fully representative of our current stroke population.
How does this study change our clinical practice? It reinforces that there are significant gender disparities in stroke evaluation, treatment, and outcomes. Women are likely to have more risk factors, less likely to receive preventative care, and have worse outcomes poststroke. Stroke severity is higher in women than men, and directly impacts mortality.
Moving forward, our efforts should be directed toward increasing stroke education for women and addressing inequities in access to preventative medications such as statins, anticoagulants, antihypertensives, and medications for diabetes. Innovative programs such as screening high-risk women for AF should also be considered. The greatest gains in stroke care will arise from diligent screening and evaluation of women for selected risk factors. Hopefully, these efforts will lead to decreased gender differences in stroke mortality.