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Stroke is a major cause of death and disability in adults worldwide. Prevention focused
on modifiable risk factors, such as hypertension and hyperlipidemia, has shown them
to be of significant importance in decreasing the risk of stroke. Multiple studies have
brought to light the differences between men and women with regards to stroke
and these risk factors. Women have a higher prevalence of stroke, mortality and
disability and it has been shown that preventive and treatment options are not as
comprehensive for women. Hence, it is of great necessity to evaluate and summarize
the differences in gender and stroke risk factors in order to target disparities and
optimize prevention, especially because women have a higher lifetime risk of stroke.
The purpose of this review is to summarize sex differences in the prevalence of
hypertension and hyperlipidemia. In addition, we will review the sex differences in
stroke prevention effectiveness and adherence to blood pressure and cholesterol
medications, and suggest future directions for research to reduce the burden of
stroke in women.
Sanam Baghshomali1
&Cheryl Bushnell*,1
1
Department of Neurology, Wake Forest
School of Medicine, Winston Salem,
NC27157, USA
*Author for correspondence:
cbushnel@ wakehealth.edu
part of
ISSN 1745-5057
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Reducing stroke in women with risk factor management: blood pressure & cholesterol
Review
Women (n=5356)
Men (n=2476)
Hypertension, n (%)
2281 (42.6)
996 (40.2)
132.3 (17.0)
132.0 (16.2)
77.9 (10.2)
80.2 (10.3)
6.3 (0.3)
6.2 (0.3)
4.1 (0.4)
4.0 (0.5)
1.5 (0.4)
1.4 (0.4)
DBP: Diastolic blood pressure; HDL-C: High-density lipoprotein-cholesterol; LDL-C: Low-density lipoprotein-cholesterol; SBP: Systolic blood
pressure.
Adapted with permission from [10].
Men (n=2476)
Women (n=5356)
p-value for
heterogeneity
bysex
CHD
0.65
(0.4141.02)
0.06
0.75
(0.4541.25)
0.27
0.67
Stroke
0.66
(0.3731.20)
0.17
0.63
(0.3631.10)
0.10
0.90
CHD+stroke
0.59
(0.4040.87)
0.007
0.74
(0.5051.12)
0.15
0.42
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Table 3. Meta-analysis evaluating risk factor differences between men and women with
ischemicstroke.
Number of
studies
Women, n
(% of total)
Men, n
(% of total)
OR
(95% CI)
p-value
Hypertension
33
214,728 (69)
187,858 (65)
1.15 (1.0701.24)
<0.001
Hyperlipidemia
19
76,623 (34)
75,462 (37)
0.90 (0.8280.99)
0.033
Table 4. Prevalence of hypertension and hyperlipidemia between male and females in Korean ischemic stroke
patients, stratified by age.
Prevalence ratio, men to women (95% CI)
Age, years
<44
4554
Hypertension
1.95
(1.0201.18)
Hyperlipidemia
1.76
(1.0902.83)
5564
6574
7584
>85
1.15
0.93
0.93
(1.0001.33) (0.8681.00) (0.8880.97)
0.93
(0.8880.98)
0.90
<0.001/0.11
(0.8081.01)
0.89
(0.7271.10)
0.87
(0.7671.00)
0.82
(0.5851.16)
0.81
0.74
(0.7070.93) (0.6760.83)
p-value for
heterogeneity
unadj/adj
0.01/0.049
adj: Adjusted for diabetes, atrial fibrillation, prior stroke, prior CHD, BMI, smoking, residence and education; unadj: Unadjusted p-value for prevalence ratio of men
to women by age strata.
Data taken from [20].
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Reducing stroke in women with risk factor management: blood pressure & cholesterol
Review
AfricanAmerican Caucasian
n=462
n=719
Chinese
n=94
Hispanic
n=110
Japanese
n=105
Total
n=1490
Age (years)
46.6
46.8
46.8
46.4
47.1
46.7
197.8 (34.1)
195.0 (33.3)
197.3 (36.2)
LDL-C
(mg/dl)
119.1 (35.0)
120.1 (29.3)
113.8 (26.9)
18.1 (31.4)
HDL-C
(mg/dl)
56.3 (16.6)
55.2 (14.2)
48.3 (11.0)
60.7 (14.0)
55.7 14.9)
60.0 (11.7)
SBP
125.2 (21.0)
114.3 (14.5)
110.3 (15.9)
121.7 (9.8)
109.6 (10.8)
117.6 (17.4)
DBP
76.8. (11.8)
73.9. (9.5)
71.2 (11.0)
81.2 (6.5)
74.2 (8.8)
75.2 (10.4)
DBP: Diastolic blood pressure; HDL-C: High density lipoprotein cholesterol; LDL-C: Low-density lipoprotein cholesterol; SBP: Systolic blood
pressure.
Adapted with permission from [21].
Differentiating the impact of age versus the menopause (i.e., the physiologic hormonal changes) on
hypertension and hyperlipidemia is important as
women experience this midlife transition. As part of the
SWAN, the investigators evaluated changes in CHD
risk factors in 1,054 women during their transition to
their final menstrual period (FMP) [25] . They divided
the longitudinal transition into three segments: more
than 12 months before the FMP; within 12 months
before and after the FMP (corresponding to the decrease
in follicle stimulating hormone or FSH); and, more
than 12 months after the FMP. Using the slope of the
changes in each risk factor during each of these timeframes allowed the investigators to determine whether
the risk factor change slope was steepest during one of
the phases or was linear across all three timeframes.
Analyzing the slopes of change in risk factors during
the year immediately before and after the FMP would
suggest this occurred because of menopause rather than
age alone. Results of this study showed that there was
a significant increase in LDL-C and total cholesterol
within a year of the FMP [25] . HDL-C showed a steady
increase with peak at FMP and then declined after and
plateaued during the transition to menopause. Interestingly, there was no difference between changes in lipid
profile and ethnicity among participants in this study.
Another important finding was that changes in systolic and diastolic BP and other risk factors (glucose,
insulin, lipoprotein(a), C reactive protein, Factor VII-c)
were linear across all three timeframes, and therefore
likely to be a function of age rather than the menopausal
transition.
The recognition of modifiable risk factors in women,
such as hypertension and hyperlipidemia, is increasingly
important, especially in midlife. As described in this
review, the prevalence of hyperlipidemia increases in
women after menopause and hypertension increases
after midlife due to aging. Recognition of these risk factors early, and the initiation of healthy lifestyle practices
before or during the perimenopausal timeframe, could
improve cardiovascular risk profiles [26] , potentially
reduce the need for cholesterol- and BP-lowering drugs,
and provide the long-term benefit of reducing the risk of
stroke and cardiovascular disease [3] .
Sex differences in intermediate outcomes of
stroke: carotid artery atherosclerosis
Subclinical detection of stroke risk can be performed
with ultrasound through measurement of carotid
intimal media thickness (CIMT) or with clinical
ultrasound to detect stenosis or plaque size. Since BP
and cholesterol are major factors in the progression of
carotid disease, this review includes the sex differences
in this intermediate outcome because of its importance
in stroke risk identification [27,28] .
Carotid atherosclerosis manifested in stenosis
greater than 6070% stenosis is associated with a risk
of ischemic stroke [27] . Based on multiple clinical trials
of carotid endarterectomy (CEA) for symptomatic or
asymptomatic stenosis, the procedure is recommended
if the surgical risk is appropriately low [28] .
However, there are significant differences in benefit from CEA in men and women, especially in
asymptomatic carotid stenosis. A Cochrane Systematic Review from 2005 reported the stroke relative
risk (RR) reduction after CEA for asymptomatic
carotid stenosis was 51% for men (RR: 0.49, 95% CI:
0.3630.66) versus 4% for women (RR: 0.96, 95%
CI: 0.6461.44; p=0.008), suggesting it was more
beneficial for men[29] . There are many theories as to
why women do not benefit as much or do worse after
CEA for asymptomatic stenosis. Women have smaller
arteries, have higher surgical risk, and may have more
embolic phenomenon during the surgery [30] .
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Reducing stroke in women with risk factor management: blood pressure & cholesterol
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Executive summary
Sex differences in stroke outcomes
Demographic studies have shown, that when matched by age, women have a lower risk of stroke but their
rates of stroke are higher after the age of 85years, since they are more likely to reach and exceed that age.
Women compose 60% of stroke mortality, have higher rates of disability and it has been shown that
preventive and treatment options are not as comprehensive for women as for men.
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Reducing stroke in women with risk factor management: blood pressure & cholesterol
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