Published online before print December 31, 2008, doi: 10.1161/STROKEAHA.108.531830
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(Stroke. 2009;40:674.)
© 2009 American Heart Association, Inc.
Editorials |
Understanding Stroke in Women
Similar Care, Worse Outcomes?
From the Stroke Research Unit (G.S.), Division of Neurology, Department of Medicine, St. Michael’s Hospital and Li Ka Shing Knowledge Translation Institute, University of Toronto, Toronto, Ontario, Canada; the Department of Health Policy (G.S., M.K.K.), Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; the Institute of Clinical Evaluative Sciences (M.K.K.), Ontario, Canada; the Division of General Internal Medicine and Clinical Epidemiology (M.K.K.), Department of Medicine, University Health Network, Toronto, Ontario, Canada; and the University Health Network Women’s Health Program Toronto, Ontario, Canada.
Correspondence to Dr Gustavo Saposnik, 55 Queen St East, Suite 931, St. Michael’s Hospital, University of Toronto, Toronto, M5C 1R6 Canada. E-mail saposnikg{at}smh.toronto.on.ca
Key Words: stroke • outcome • sex differences • gender • prevention
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Introduction |
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 Top Introduction What Is Different in...References |
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See related article, pages 909–914.
"The pure and simple truth is rarely pure and never simple".
—Oscar Wilde
Sex differences in clinical care and outcomes have been documented in multiple studies of patients with coronary artery disease, with research showing differences in presentation, disparities in diagnosis and management, and worse clinical outcomes in women compared to men.1,2 There has been concern that similar sex differences exist in the care and outcomes of patients with stroke, given the parallels in patient populations and risk factors in individuals with cardiac and cerebrovascular disease. To date, however, the research on the interaction between gender and stroke has been limited and results have been inconsistent. Thus, any new information on this topic is welcome.
In this issue of Stroke, Eriksson et al3 report on an analysis of 24 633 stroke events in 2006 from the large, well-designed, population-based Swedish National Quality Register (RIKS-Stroke). They found that compared to men, women were older (mean age difference 4.8 years) and were more often unconscious on presentation. No differences were found in processes of care such as administration of thrombolysis or discharge on anticoagulants. Women were more likely to develop deep venous thromboses and fractures, whereas men were more likely to develop pneumonia during their hospital stay. Three months poststroke, women were more likely to report depression, and to express dissatisfaction with their hospital care. Women were more likely than men to be dead or institutionalized at 3 months poststroke, even after adjustment for age; this difference was no longer significant after adjustment for level of consciousness on presentation.
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What Is Different in Men and Women With Stroke? |
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TopIntroductionWhat Is Different in...References |
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On the whole, the nature and prevalence of vascular risk factors, including hypertension, diabetes, obesity, smoking and hyperlipidemia are similar in men and women.4–6 In the WHO MONICA project, the prevalence of hypertension appeared to be higher among women than among men in those aged 60 years and older.7 According to the National Diabetes Clearinghouse, there is a slightly higher prevalence of diabetes among men (12.0 million or 11.2%) compared to women (11.5 million, or 10.2%) for those aged 20 years or older (National Diabetes Statistics, 2007). Although the overall prevalence of hypercholesterolemia is higher in men than women, LDL cholesterol levels plateau in men and increase in women with advancing age and in the postmenopausal period.8,9 Smoking is more prevalent in men than in women in North America and other developing countries.10 Lower socioeconomic status has also been associated with a higher prevalence of chronic conditions and mortality.11 Although measuring socioeconomic status is difficult, differences in cardiovascular mortality between low and high socioeconomic strata appear to be more pronounced in women than in men.12
The finding of similar processes of care in women and men with stroke adds to a growing body of literature suggesting that in contrast to coronary artery disease, there appear to be few systematic sex differences in stroke care delivery.13 This may be due in part to the organized systems of stroke care delivery that have been developed around the world in order to facilitate delivery of thrombolysis for acute ischemic stroke. Despite this, however, sex differences in stroke outcomes persist. Consistent with previous studies, the RIKS-Stroke group found a longer length of stay and greater incidence of disability, institutionalization and depression poststroke in women compared to men. The mechanisms behind these findings are largely unexplained, but likely relate at least in part to sex differences in social supports as well as disability before stroke. There may also be sex differences in the quality or intensity of secondary stroke prevention.14 For example, in a study including 4933 high risk ambulatory patients with cardiovascular disease, women with stroke were less likely to achieve the recommended blood pressure and lipid targets.15 Underappreciation of cardiovascular risk may lead to reduced use or lower doses of vasoprotective medications in women.
The authors also speculate that women may have more severe strokes (perhaps due to higher prevalence of cardioembolic stroke),16,17 an assertion supported by the lower level of consciousness and higher complication rates (thromboembolic disease, fractures) seen in women poststroke. Unfortunately, stroke severity—the major determinant of stroke outcome—was not documented in the present study. In addition, this study could not provide information on possible sex/gender differences in stroke presentation or subtype, interventions such as carotid endarterectomy, and outcomes such as quality of life. Finally, subanalyses of differential outcomes in women and men treated with thrombolysis were not reported; prior work has suggested that treatment with thrombolysis may nullify the worse outcomes seen in untreated women compared to men.18,19
Interestingly, the current study found that women were less satisfied than men with the care, rehabilitation and information received after stroke. Although the absolute differences were small (90.7% of women versus 92.7% of men were satisfied with their hospital care), and thus of uncertain clinical significance, these results are consistent with a previous study which found that women faced with a decision about stroke care prefer more detailed information than men.20 Together, these findings support the concept that it may be important for providers to consider gender differences in preferences for the delivery of stroke education and other communication materials.
In summary, a broad range of factors (patient, physician and health system-related) likely interact to explain sex and gender differences in clinical outcomes of patients with stroke. The acceptance of sex disparities is the initial step before making changes in health policy aimed at ameliorating the observed asymmetry in stroke outcomes.
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Acknowledgments |
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Sources of Funding
This research was supported in part by the Clinician Scientist Award from Heart Stroke Foundation of Ontario (HSFO), Department of Research at St Michael’s Hospital and Connaught Foundation (University of Toronto) given to Dr Gustavo Saposnik. Dr Moira Kapral is supported by a New Investigator Award from the CIHR and also received support from the Canadian Stroke Network and the University Health Network Women’s Health Program. These grants were obtained based on competitive applications following publication of grant advertisements.
Disclosures
None.
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Footnotes |
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The opinions in this editorial are not necessarily those of the editors or of the American Heart Association.
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References |
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19. Saposnik G, Di Legge S, Webster F, Hachinski V. Predictors of major neurologic improvement after thrombolysis in acute stroke. Neurology. 2005; 65: 1169–1174.
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Related Article:
Stroke 2009 40: 909-914.
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