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Dr. Kenneth Gaines, Ochsner Health System Chairman of Neurology

Research Shows Gender Disparities are Real

Nothing less than an epidemic. That's what the American Stroke Association calls the prevalence of stroke among women, who account for more than 60 percent of stroke deaths in the United States. In a special issue of the organization's journal Stroke, published in February, researchers report results of several studies that reveal gender disparities for stroke risk, treatment and education initiatives.

"Projections indicate that the prevalence and incidence of stroke will increase by 2020 in both sexes, but that these figures are magnified for women. By 2050, mortality from stroke will be 30 percent higher in women than men," according to the Stroke issue's editorial.

Kenneth Gaines, MD, chairman of neurology at Louisiana-based Ochsner Health System, said, "We've known some things about stroke and gender in the past, and we've known that women tend to have stroke at later ages than men do, but the lifetime risk for women is certainly higher than it is for men. Of course, as the population ages, this is becoming more and more of an issue."

In one of the more startling recent research findings, investigators at Michigan State University found that the overall quality of care for women with ischemic stroke was lower than for men. The study compared the use of seven treatments indicative of high-quality, evidence-based stroke care, including the timely use of tPA, the clot-busting drug. Data indicated that women were 14 percent less likely overall to receive optimum care and less likely to be treated with intravenous tPA.

"I guess what we don't know is, what are the reasons underlying that? Is it something about the age of the patients, being 10 years older and being less able to tolerate some of these medications?" asked Gaines, noting that research in Scandinavia shows similar trends. He added that acute therapies like tPA "are actually a little bit more efficacious in women than in men, so it's distressing that they don't seem to get that treatment as often."

Gaines noted that the Michigan State findings don't take into account the extent of the strokes suffered by the patients considered in the study. "Absent knowing the severity of the stroke, it's sometimes hard to understand why these differences are there. It's certainly going to merit some additional work to try to understand that," he said. He added that research shows that women are more likely to have a cardioembolic stroke, and men are more likely to have a less-severe stroke with a better prognosis. "Probably the worst stroke you can have is an acute embolic stroke from the heart," he said.

Patricia Vanhook, a faculty member at the East Tennessee State University College of Nursing, agreed that recent gender-related research findings beg for further study. Certified as a family nurse practitioner and as a neuroscience registered nurse, Vanhook surmised that some treatment disparities may be because women's stroke symptoms sometimes don't mimic the classic list of symptoms, which includes arm weakness or numbness, speech changes, facial drooping or paralysis. "In practice, I thought there were some differences, and the research is now validating that, that women more often have a change in mental status as a stroke symptom, more so than men," she said.

Vanhook concurred with Gaines that the advanced age at which most women suffer stroke ultimately may be cited as a reason why treatment for women is different. She predicted that, as more stroke registries come on board, particularly in the "stroke belt" states, rich data will help confirm when in their lives and to what degree women suffer stroke. Treatment changes could follow.

Research cited in the Stroke journal in February also reveals that gender-specific educational efforts regarding stroke are lacking. One study at the University of Connecticut asked predominately white, well-educated and high-income women ages 50 to 70 years – and who had a least one stroke risk factor – to respond to a stroke-knowledge questionnaire. Only 5.7 percent of the women with atrial fibrillation and 15 .5 percent of women with heart disease identified their health condition as a stroke risk. What's more, just 63.9 percent of the women with atrial fibrillation reported taking warfarin, which is an anticoagulant, or a blood thinner to reduce stroke risk.

"In the past, we thought stroke was a disease of males. I, in fact, will give talks occasionally, and women in the audience are quite surprised when I start talking about the risk of stroke in women. That's an opportunity for education. If anything, the lifetime risk is greater for a woman than it is for a man, and some of our educational literature that's out there may not be what we need... I think better patient and community education efforts clearly are needed," Gaines said.

This is particularly important since women are suffering stroke at younger ages – and not always related to pregnancy. Gaines said migraine headaches are a risk factor for younger women, as are birth-control pills and smoking. "Add those three things together, and you increase the risk a fair amount," he said.

Vanhook said one of her research interests is younger women. Another is "come back" after stroke. While some victims may recover, many others are plagued with disabilities related to movement, speech and memory. Vanhook has been studying "come back" women ages 40-78 a year after the stroke and living at home. She's now ready to extend the study – and here's another gender difference: She'd like to study "come back" men and is having trouble recruiting male study participants.

Tags:

American Stroke Association, ETSU College of Nursing, Kenneth Gaines, Ochsner Health System, Patricia Vanhook, Stroke, stroke gender disparities

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