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A R D I O V A S C U L A R
M
E D I C I N E
] (2015) ]]]–]]]
Available online at www.sciencedirect.com
www.elsevier.com/locate/tcm
Editorial Commentary
Stroke in women: Where are we in 2015? Puja K. Mehta, MDn, Margo Minissian, PhDc, and C. Noel Bairey Merz, MD Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, 27 S. San Vicente Blvd, A3212, Los Angeles, CA 90048
Stroke is the third leading cause of mortality in women, and 60% of strokes occur in women. Given that approximately 55,000 more strokes/year occur in women compared to men, and the incidence of stroke in middle-aged women is increasing, our stroke preventive strategies are of particular importance in women. Failure to recognize that there are sex-specific stroke risk factors, and lack of research regarding sex-specific mechanisms and therapy in stroke disserves women. Recognizing the need for specific guidelines to address the growing burden of stroke in women, the AHA/ASA published stroke prevention guidelines last year, a decade after the publication of prevention of heart disease guidelines in women [1]. Lundberg and Volgman [2] review this important topic of stroke burden in women, including sex-specific risk factors. They conclude the review with the following recommendations: (1) careful follow up of pregnancy-related HTN, (2) increased attention to pre-hypertensive women to reduce their blood pressure through lifestyle changes, (3) emphasize the importance of a healthy weight, and (4) more intensive
efforts to educate and increase awareness about stroke prevention, especially in the geographic regions with the highest incidence of strokes. The recent announcement by the AHA to allocate $15–19 million to study CVD in women appropriately includes strokes investigation in women. Are the Lundberg et al. recommendations sound, and what knowledge gaps should the AHA Go Red for Women Network address for stroke?
Careful follow up of pregnancy-related HTN Identifying women early who are at increased risk of future CVD could play out to be a key variable to improve primary prevention of cardiovascular diseases, specifically stroke. Pregnancy serves as a woman's first physiological stress test, with over 80% of women becoming pregnant within their lifetime [3,4]. Sex-specific risk factors such as pregnancyrelated disorders were officially added to the heart disease
This work was supported by contracts from the National Heart, Lung and Blood Institutes, USA nos. N01-HV-68161, N01-HV-68162, N01-HV-68163, and N01-HV-68164; Grants U0164829, U01 HL649141, U01 HL649241, K23HL105787, F31NR015725, R01 HL090957, and 1R03AG032631 from the National Institute on Aging, USA; GCRC Grant MO1-RR00425 from the National Center for Research Resources, USA; the National Center for Advancing Translational Sciences, USA Grant UL1TR000124; and Grants from the Gustavus and Louis Pfeiffer Research Foundation, Danville, NJ; The Women's Guild of Cedars-Sinai Medical Center, Los Angeles, CA; The Ladies Hospital Aid Society of Western Pennsylvania, Pittsburgh, PA; and QMED, Inc., Laurence Harbor, NJ; the Edythe L. Broad and the Constance Austin Women's Heart Research Fellowships, Cedars-Sinai Medical Center, Los Angeles, CA; the Barbra Streisand Women's Cardiovascular Research and Education Program, Cedars-Sinai Medical Center, Los Angeles; The Society for Women's Health Research (SWHR), Washington, DC; and The Linda Joy Pollin Women's Heart Health Program, and the Erika Glazer Women's Heart Health Project, CedarsSinai Medical Center, Los Angeles, CA. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Lectures: AACE , ACC-AZ chapter, Florida Hospital, Mayo Scottsdale, Mayo Cancun, Medscape, NAMS, Pri-Med, Scripps Clinic, VBWG, UCLA, UCSF, and Northwestern Radcliffe Institute; Vox Media (speakers bureau), and Practice Point Communications (speaker bureau); consulting from Amgen, grant review committee from Gilead, consulting from Pfizer, grant review study section from NIH-SEP; Grants: WISE CVD, RWISE, Microvascular, Normal Control, and FAMRI; consulting from Research Triangle Institute (C.N.B.M.). Gilead and General Electric research support (P.K.M.). Conflicts for Minissian: none. n Corresponding author. E-mail address: [email protected] (P.K. Mehta). http://dx.doi.org/10.1016/j.tcm.2015.06.002 1050-1738/& 2015 Elsevier Inc. All rights reserved.
2
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prevention guidelines in 2011 [5]. Unfortunately, there continues to be a failure in reporting reproductive history in most women's medical records. Preeclampsia, eclampsia, hypertension during pregnancy, preterm delivery, and gestational diabetes have been well documented to result in increased future maternal cardiovascular risk [6] and could potentially improve CVD risk assessment for women in a sex-specific fashion [7]. In addition to addressing pregnancy-related disorders, young women in general are overlooked when it comes to cardiovascular risk. Schmittdiel et al. [8] report that only 33% of women under the age of 55 years have proper identification in medicine and OB–GYN clinics of new onset hypertension, an important identifier of stroke risk. Sex-specific Women's Heart Screening Programs and Postpartum Heart Health Programs that partner with obstetricians and gynecologists should be targeted for prevention of established hypertension and stroke in women. Research should be directed to understand best practice referral and treatment feasibility strategies.
Increased attention to pre-hypertensive women to reduce their blood pressure through lifestyle changes Lundberg et al. recommend therapeutic lifestyle change (TLC) in pre-hypertensive women. While data do not support that this is specific only to women, because there are no randomized intervention trials reporting on sex differences for prehypertension treatment via lifestyle changes with resultant improved stroke outcomes in women, this may be an appropriate recommendation due to the relationship between increasing blood pressure and increased stroke risk in both men and women, and 30–40% stroke risk lowering with treatment of hypertension [9]. Further, the lack of sexspecific guidelines in hypertension (such as the JNC8 Hypertension guidelines [10]) that raise the threshold for treating BP in the elderly, may disproportionately harm women, since the prevalence of hypertension over the age of 65 years is higher in women than men [11]. Women may need to know to be relatively more vigilant to TLC, given the current guideline and practice disparities that place them at higher stroke risk. There are data that pre-hypertension treatment via lifestyle modifications (i.e., reduction in sodium intake) prevents progression to hypertension in both men and women [12]. While pharmacologic treatment of pre-hypertension may reduce stroke risk by 22% according to a meta-analysis of 16 randomized trials in 70,664 men and women [13], in Action to Control Cardiovascular Risk in Diabetes (ACCORD) randomized study of diabetic men and women, there was no difference in major cardiovascular events (including stroke) with intensive blood pressure lowering [14]. Whether TLC changes can be sustained over several years to be an effective primary preventive stroke strategy is also unknown. The Coronary Artery Risk Development in Young Adults (CARDIA) study suggested that maintaining a healthy lifestyle throughout young adulthood was strongly associated with a low CVD risk profile in middle age; however, observational data are
M
E D I C I N E
] (2015) ]]]–]]]
confounded and pragmatic clinical trials should test whether adoption (rather than maintenance) of healthy lifestyle should be a treatment target in young adult women [15]. In Prevencion con Dieta Mediterranea (PREDIMED) [16] trial (age range: 55–80 years, 57% women) who were followed for a median of 4.8 years, there was a significant reduction in risk of stroke in those randomized to the two Mediterranean diet groups, and the relationship between Mediterranean diet and stroke reduction has been shown in other studies. Specific nutrition supplement strategies, such as the PREDIMED tree nuts and olive oil daily supplements, are a potentially good stroke prevention opportunity. Research should aim to identify optimal cost-efficient dissemination and acceptance strategies in large, simple outcome trials.
Emphasize the importance of a healthy weight While weight reduction contributes to lowering blood pressure, improved insulin sensitivity, and cholesterol levels, to date, weight loss trials have failed to demonstrate either reduction in stroke or CVD with the exception of bariatric surgery in the morbidly obese [17]. Similarly, the metabolic syndrome is not established as an independent risk factor for stroke or CVD. Given that in the recent LOOK AHEAD trial, weight reduction failed to reduce CVD including stroke in diabetic women and men followed for a median of 9.6 years despite improvements in blood pressure, blood sugar, and blood lipids [18], emphasis on weight reduction does not appear to be a good stroke prevention opportunity for women. Indeed, women are often told to lose weight rather than having risk factors addressed by healthcare providers [19]. Knowledge gap research should address understanding socio-cultural gender differences among healthcare providers with regard to body image and weight. Further public health campaigns should be directed at alerting women to the dominant paradigm of poor CVD risk advisement and low utilization of effective risk factor management.
More intensive efforts to educate and increase awareness about stroke prevention, especially in the geographic regions with the highest incidence of strokes A survey by AHA in 2012 found that knowledge of stroke warning signs is low among American women [20]. Further, prior work confirms that younger women's CVD risk is underestimated compared to their actual risk by healthcare providers [21]. Education regarding warning signs of stroke, for both patients and the providers, though ethnically sensitive materials and use of social media may be helpful, especially in geographic areas with high stroke burden as Lundberg et al. discuss. While education is important, education alone does not appear to alter behavior; for example, even though cardiac rehabilitation reduces disability and mortality in heart disease, it is utilized by less than 15% of Medicare beneficiaries post myocardial infarction [22]. It is only when education/awareness is paired with specific action campaigns that behavior effectively changes. For example, disparities in
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C
A R D I O V A S C U L A R
blood pressure, cholesterol, and glucose control for blacks in all regions of the US failed to improve, EXCEPT the west, where Kaiser Permanente used systematic approaches in their integrated health system to detect and control hypertension, deploying pharmacy, nursing, and physician action via the electronic health record [23]. Research should be directed at understanding how to deploy prevention opportunities, as has been accomplished by Kaiser, using systems of care in the rapidly integrating health systems of the US. Treatment and prevention of stroke are important for both men and women, however women are currently both a majority (52%) of the population and a majority of stroke victims. We need substantially increased research and funding focused on the abovementioned knowledge gaps and assessment and treatment disparities. New sex-specific advocacy, support from our leaders in the government, and female-specific actionoriented strategies (Postpartum Heart Health clinics, systematic systems-based approach with the use of electronic health record for risk assessment, risk factor treatment, nutrition supplementation education, and behavioral strategies) are needed to address the large and present burden of stroke that has heretofore been relatively ignored in women.
re fe r en ces
[1]
[2] [3]
[4]
[5]
[6]
[7]
[8]
[9]
Bushnell C, McCullough LD, Awad IA, Chireau MV, Fedder WN, Furie KL, et al. Guidelines for the prevention of stroke in women: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2014;45:1545–88. Lundberg GP, Volgman AS. Burden of stroke in women. Trends Cardiovasc Med 2015 [this issue]. Rich-Edwards JW, McElrath TF, Karumanchi SA, Seely EW. Breathing life into the lifecourse approach: pregnancy history and cardiovascular disease in women. Hypertension 2010;56:331–4. Sattar N, Greer IA. Pregnancy complications and maternal cardiovascular risk: opportunities for intervention and screening? Br Med J 2002;325:157–60. Mosca L, Benjamin EJ, Berra K, Bezanson JL, Dolor RJ, LloydJones DM, et al. Effectiveness-based guidelines for the prevention of cardiovascular disease in women—2011 update: a guideline from the American Heart Association. J Am Coll Cardiol 2011;57:1404–23 [United States]. Irgens HU, Reisaeter L, Irgens LM, Lie RT. Long term mortality of mothers and fathers after pre-eclampsia: population based cohort study. Br Med J 2001;323:1213–7. Stuart JJ, Bairey Merz CN, Berga SL, Miller VM, Ouyang P, Shufelt CL, et al. Maternal recall of hypertensive disorders in pregnancy: a systematic review. J Womens Health 2013;22:37–47. Schmittdiel J, Selby JV, Swain B, Daugherty SL, Leong TK, Ho M, et al. Missed opportunities in cardiovascular disease prevention?: low rates of hypertension recognition for women at medicine and obstetrics–gynecology clinics. Hypertension 2011;57:717–22. Lawes CM, Bennett DA, Feigin VL, Rodgers A. Blood pressure and stroke: an overview of published reviews. Stroke 2004;35:1024.
M
E D I C I N E
[10]
[11]
[12]
[13]
[14]
[15]
[16]
[17]
[18]
[19]
[20]
[21]
[22]
[23]
] (2015) ]]]–]]]
3
James PA, Oparil S, Carter BL, Cushman WC, DennisonHimmelfarb C, Handler J, et al. 2014 Evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). J Am Med Assoc 2014;311: 507–20. Krakoff LR, Gillespie RL, Ferdinand KC, Fergus IV, Akinboboye O, Williams KA, et al. 2014 Hypertension recommendations from the eighth joint national committee panel members raise concerns for elderly black and female populations. J Am Coll Cardiol 2014;64:394–402. Eckel RH, Jakicic JM, Ard JD, de Jesus JM, Houston MN, Hubbard VS, et al. 2013 AHA/ACC guideline on lifestyle management to reduce cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014;63:2960–84. Sipahi I, Swaminathan A, Natesan V, Debanne SM, Simon DI, Fang JC. Effect of antihypertensive therapy on incident stroke in cohorts with prehypertensive blood pressure levels: a meta-analysis of randomized controlled trials. Stroke 2012;43:432–40. Group AS, Cushman WC, Evans GW, Byington RP, Goff DC Jr, Grimm RH Jr, et al. Effects of intensive blood-pressure control in type 2 diabetes mellitus. N Engl J Med 2010;362: 1575–85. Liu K, Daviglus ML, Loria CM, Colangelo LA, Spring B, Moller AC, et al. Healthy lifestyle through young adulthood and the presence of low cardiovascular disease risk profile in middle age: the Coronary Artery Risk Development in (Young) Adults (CARDIA) study. Circulation 2012;125:996–1004. Estruch R, Ros E, Salas-Salvado J, Covas MI, Corella D, Aros F, et al. Primary prevention of cardiovascular disease with a Mediterranean diet. N Engl J Med 2013;368:1279–90. Sjostrom L, Peltonen M, Jacobson P, Ahlin S, AnderssonAssarsson J, Anveden A, et al. Association of bariatric surgery with long-term remission of type 2 diabetes and with microvascular and macrovascular complications. J Am Med Assoc 2014;311:2297–304. Look AHEAD Research Group, Wing RR, Bolin P, Brancati FL, Bray GA, Clark JM, et al. Cardiovascular effects of intensive lifestyle intervention in type 2 diabetes. N Engl J Med 2013;369:145–54. Andersen SS, Andersson C, Berger SM, Jensen TB, TorpPedersen CT, Gislason GH, et al. Impact of metabolic disorders on the relation between overweight/obesity and incident myocardial infarction and ischaemic stroke in fertile women: a nationwide cohort study. Clin Obes 2015;5: 127–35. Mochari-Greenberger H, Towfighi A, Mosca L. National women's knowledge of stroke warning signs, overall and by race/ethnic group. Stroke 2014;45:1180–2. Mosca L, Hammond G, Mochari-Greenberger H, Towfighi A, Albert MA. Fifteen-year trends in awareness of heart disease in women: results of a 2012 American Heart Association national survey. Circulation 2013;127:1254–63 [e1-29]. Suaya JA, Shepard DS, Normand SL, Ades PA, Prottas J, Stason WB. Use of cardiac rehabilitation by Medicare beneficiaries after myocardial infarction or coronary bypass surgery. Circulation 2007;116:1653–62. Ayanian JZ, Landon BE, Newhouse JP, Zaslavsky AM. Racial and ethnic disparities among enrollees in Medicare advantage plans. N Engl J Med 2014;371:2288–97.
E N D S I N
C
A R D I O V A S C U L A R
M
E D I C I N E
] (2015) ]]]–]]]
Available online at www.sciencedirect.com
www.elsevier.com/locate/tcm
Editorial Commentary
Stroke in women: Where are we in 2015? Puja K. Mehta, MDn, Margo Minissian, PhDc, and C. Noel Bairey Merz, MD Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, 27 S. San Vicente Blvd, A3212, Los Angeles, CA 90048
Stroke is the third leading cause of mortality in women, and 60% of strokes occur in women. Given that approximately 55,000 more strokes/year occur in women compared to men, and the incidence of stroke in middle-aged women is increasing, our stroke preventive strategies are of particular importance in women. Failure to recognize that there are sex-specific stroke risk factors, and lack of research regarding sex-specific mechanisms and therapy in stroke disserves women. Recognizing the need for specific guidelines to address the growing burden of stroke in women, the AHA/ASA published stroke prevention guidelines last year, a decade after the publication of prevention of heart disease guidelines in women [1]. Lundberg and Volgman [2] review this important topic of stroke burden in women, including sex-specific risk factors. They conclude the review with the following recommendations: (1) careful follow up of pregnancy-related HTN, (2) increased attention to pre-hypertensive women to reduce their blood pressure through lifestyle changes, (3) emphasize the importance of a healthy weight, and (4) more intensive
efforts to educate and increase awareness about stroke prevention, especially in the geographic regions with the highest incidence of strokes. The recent announcement by the AHA to allocate $15–19 million to study CVD in women appropriately includes strokes investigation in women. Are the Lundberg et al. recommendations sound, and what knowledge gaps should the AHA Go Red for Women Network address for stroke?
Careful follow up of pregnancy-related HTN Identifying women early who are at increased risk of future CVD could play out to be a key variable to improve primary prevention of cardiovascular diseases, specifically stroke. Pregnancy serves as a woman's first physiological stress test, with over 80% of women becoming pregnant within their lifetime [3,4]. Sex-specific risk factors such as pregnancyrelated disorders were officially added to the heart disease
This work was supported by contracts from the National Heart, Lung and Blood Institutes, USA nos. N01-HV-68161, N01-HV-68162, N01-HV-68163, and N01-HV-68164; Grants U0164829, U01 HL649141, U01 HL649241, K23HL105787, F31NR015725, R01 HL090957, and 1R03AG032631 from the National Institute on Aging, USA; GCRC Grant MO1-RR00425 from the National Center for Research Resources, USA; the National Center for Advancing Translational Sciences, USA Grant UL1TR000124; and Grants from the Gustavus and Louis Pfeiffer Research Foundation, Danville, NJ; The Women's Guild of Cedars-Sinai Medical Center, Los Angeles, CA; The Ladies Hospital Aid Society of Western Pennsylvania, Pittsburgh, PA; and QMED, Inc., Laurence Harbor, NJ; the Edythe L. Broad and the Constance Austin Women's Heart Research Fellowships, Cedars-Sinai Medical Center, Los Angeles, CA; the Barbra Streisand Women's Cardiovascular Research and Education Program, Cedars-Sinai Medical Center, Los Angeles; The Society for Women's Health Research (SWHR), Washington, DC; and The Linda Joy Pollin Women's Heart Health Program, and the Erika Glazer Women's Heart Health Project, CedarsSinai Medical Center, Los Angeles, CA. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Lectures: AACE , ACC-AZ chapter, Florida Hospital, Mayo Scottsdale, Mayo Cancun, Medscape, NAMS, Pri-Med, Scripps Clinic, VBWG, UCLA, UCSF, and Northwestern Radcliffe Institute; Vox Media (speakers bureau), and Practice Point Communications (speaker bureau); consulting from Amgen, grant review committee from Gilead, consulting from Pfizer, grant review study section from NIH-SEP; Grants: WISE CVD, RWISE, Microvascular, Normal Control, and FAMRI; consulting from Research Triangle Institute (C.N.B.M.). Gilead and General Electric research support (P.K.M.). Conflicts for Minissian: none. n Corresponding author. E-mail address: [email protected] (P.K. Mehta). http://dx.doi.org/10.1016/j.tcm.2015.06.002 1050-1738/& 2015 Elsevier Inc. All rights reserved.
2
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prevention guidelines in 2011 [5]. Unfortunately, there continues to be a failure in reporting reproductive history in most women's medical records. Preeclampsia, eclampsia, hypertension during pregnancy, preterm delivery, and gestational diabetes have been well documented to result in increased future maternal cardiovascular risk [6] and could potentially improve CVD risk assessment for women in a sex-specific fashion [7]. In addition to addressing pregnancy-related disorders, young women in general are overlooked when it comes to cardiovascular risk. Schmittdiel et al. [8] report that only 33% of women under the age of 55 years have proper identification in medicine and OB–GYN clinics of new onset hypertension, an important identifier of stroke risk. Sex-specific Women's Heart Screening Programs and Postpartum Heart Health Programs that partner with obstetricians and gynecologists should be targeted for prevention of established hypertension and stroke in women. Research should be directed to understand best practice referral and treatment feasibility strategies.
Increased attention to pre-hypertensive women to reduce their blood pressure through lifestyle changes Lundberg et al. recommend therapeutic lifestyle change (TLC) in pre-hypertensive women. While data do not support that this is specific only to women, because there are no randomized intervention trials reporting on sex differences for prehypertension treatment via lifestyle changes with resultant improved stroke outcomes in women, this may be an appropriate recommendation due to the relationship between increasing blood pressure and increased stroke risk in both men and women, and 30–40% stroke risk lowering with treatment of hypertension [9]. Further, the lack of sexspecific guidelines in hypertension (such as the JNC8 Hypertension guidelines [10]) that raise the threshold for treating BP in the elderly, may disproportionately harm women, since the prevalence of hypertension over the age of 65 years is higher in women than men [11]. Women may need to know to be relatively more vigilant to TLC, given the current guideline and practice disparities that place them at higher stroke risk. There are data that pre-hypertension treatment via lifestyle modifications (i.e., reduction in sodium intake) prevents progression to hypertension in both men and women [12]. While pharmacologic treatment of pre-hypertension may reduce stroke risk by 22% according to a meta-analysis of 16 randomized trials in 70,664 men and women [13], in Action to Control Cardiovascular Risk in Diabetes (ACCORD) randomized study of diabetic men and women, there was no difference in major cardiovascular events (including stroke) with intensive blood pressure lowering [14]. Whether TLC changes can be sustained over several years to be an effective primary preventive stroke strategy is also unknown. The Coronary Artery Risk Development in Young Adults (CARDIA) study suggested that maintaining a healthy lifestyle throughout young adulthood was strongly associated with a low CVD risk profile in middle age; however, observational data are
M
E D I C I N E
] (2015) ]]]–]]]
confounded and pragmatic clinical trials should test whether adoption (rather than maintenance) of healthy lifestyle should be a treatment target in young adult women [15]. In Prevencion con Dieta Mediterranea (PREDIMED) [16] trial (age range: 55–80 years, 57% women) who were followed for a median of 4.8 years, there was a significant reduction in risk of stroke in those randomized to the two Mediterranean diet groups, and the relationship between Mediterranean diet and stroke reduction has been shown in other studies. Specific nutrition supplement strategies, such as the PREDIMED tree nuts and olive oil daily supplements, are a potentially good stroke prevention opportunity. Research should aim to identify optimal cost-efficient dissemination and acceptance strategies in large, simple outcome trials.
Emphasize the importance of a healthy weight While weight reduction contributes to lowering blood pressure, improved insulin sensitivity, and cholesterol levels, to date, weight loss trials have failed to demonstrate either reduction in stroke or CVD with the exception of bariatric surgery in the morbidly obese [17]. Similarly, the metabolic syndrome is not established as an independent risk factor for stroke or CVD. Given that in the recent LOOK AHEAD trial, weight reduction failed to reduce CVD including stroke in diabetic women and men followed for a median of 9.6 years despite improvements in blood pressure, blood sugar, and blood lipids [18], emphasis on weight reduction does not appear to be a good stroke prevention opportunity for women. Indeed, women are often told to lose weight rather than having risk factors addressed by healthcare providers [19]. Knowledge gap research should address understanding socio-cultural gender differences among healthcare providers with regard to body image and weight. Further public health campaigns should be directed at alerting women to the dominant paradigm of poor CVD risk advisement and low utilization of effective risk factor management.
More intensive efforts to educate and increase awareness about stroke prevention, especially in the geographic regions with the highest incidence of strokes A survey by AHA in 2012 found that knowledge of stroke warning signs is low among American women [20]. Further, prior work confirms that younger women's CVD risk is underestimated compared to their actual risk by healthcare providers [21]. Education regarding warning signs of stroke, for both patients and the providers, though ethnically sensitive materials and use of social media may be helpful, especially in geographic areas with high stroke burden as Lundberg et al. discuss. While education is important, education alone does not appear to alter behavior; for example, even though cardiac rehabilitation reduces disability and mortality in heart disease, it is utilized by less than 15% of Medicare beneficiaries post myocardial infarction [22]. It is only when education/awareness is paired with specific action campaigns that behavior effectively changes. For example, disparities in
TR
E N D S I N
C
A R D I O V A S C U L A R
blood pressure, cholesterol, and glucose control for blacks in all regions of the US failed to improve, EXCEPT the west, where Kaiser Permanente used systematic approaches in their integrated health system to detect and control hypertension, deploying pharmacy, nursing, and physician action via the electronic health record [23]. Research should be directed at understanding how to deploy prevention opportunities, as has been accomplished by Kaiser, using systems of care in the rapidly integrating health systems of the US. Treatment and prevention of stroke are important for both men and women, however women are currently both a majority (52%) of the population and a majority of stroke victims. We need substantially increased research and funding focused on the abovementioned knowledge gaps and assessment and treatment disparities. New sex-specific advocacy, support from our leaders in the government, and female-specific actionoriented strategies (Postpartum Heart Health clinics, systematic systems-based approach with the use of electronic health record for risk assessment, risk factor treatment, nutrition supplementation education, and behavioral strategies) are needed to address the large and present burden of stroke that has heretofore been relatively ignored in women.
re fe r en ces
[1]
[2] [3]
[4]
[5]
[6]
[7]
[8]
[9]
Bushnell C, McCullough LD, Awad IA, Chireau MV, Fedder WN, Furie KL, et al. Guidelines for the prevention of stroke in women: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2014;45:1545–88. Lundberg GP, Volgman AS. Burden of stroke in women. Trends Cardiovasc Med 2015 [this issue]. Rich-Edwards JW, McElrath TF, Karumanchi SA, Seely EW. Breathing life into the lifecourse approach: pregnancy history and cardiovascular disease in women. Hypertension 2010;56:331–4. Sattar N, Greer IA. Pregnancy complications and maternal cardiovascular risk: opportunities for intervention and screening? Br Med J 2002;325:157–60. Mosca L, Benjamin EJ, Berra K, Bezanson JL, Dolor RJ, LloydJones DM, et al. Effectiveness-based guidelines for the prevention of cardiovascular disease in women—2011 update: a guideline from the American Heart Association. J Am Coll Cardiol 2011;57:1404–23 [United States]. Irgens HU, Reisaeter L, Irgens LM, Lie RT. Long term mortality of mothers and fathers after pre-eclampsia: population based cohort study. Br Med J 2001;323:1213–7. Stuart JJ, Bairey Merz CN, Berga SL, Miller VM, Ouyang P, Shufelt CL, et al. Maternal recall of hypertensive disorders in pregnancy: a systematic review. J Womens Health 2013;22:37–47. Schmittdiel J, Selby JV, Swain B, Daugherty SL, Leong TK, Ho M, et al. Missed opportunities in cardiovascular disease prevention?: low rates of hypertension recognition for women at medicine and obstetrics–gynecology clinics. Hypertension 2011;57:717–22. Lawes CM, Bennett DA, Feigin VL, Rodgers A. Blood pressure and stroke: an overview of published reviews. Stroke 2004;35:1024.
M
E D I C I N E
[10]
[11]
[12]
[13]
[14]
[15]
[16]
[17]
[18]
[19]
[20]
[21]
[22]
[23]
] (2015) ]]]–]]]
3
James PA, Oparil S, Carter BL, Cushman WC, DennisonHimmelfarb C, Handler J, et al. 2014 Evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). J Am Med Assoc 2014;311: 507–20. Krakoff LR, Gillespie RL, Ferdinand KC, Fergus IV, Akinboboye O, Williams KA, et al. 2014 Hypertension recommendations from the eighth joint national committee panel members raise concerns for elderly black and female populations. J Am Coll Cardiol 2014;64:394–402. Eckel RH, Jakicic JM, Ard JD, de Jesus JM, Houston MN, Hubbard VS, et al. 2013 AHA/ACC guideline on lifestyle management to reduce cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014;63:2960–84. Sipahi I, Swaminathan A, Natesan V, Debanne SM, Simon DI, Fang JC. Effect of antihypertensive therapy on incident stroke in cohorts with prehypertensive blood pressure levels: a meta-analysis of randomized controlled trials. Stroke 2012;43:432–40. Group AS, Cushman WC, Evans GW, Byington RP, Goff DC Jr, Grimm RH Jr, et al. Effects of intensive blood-pressure control in type 2 diabetes mellitus. N Engl J Med 2010;362: 1575–85. Liu K, Daviglus ML, Loria CM, Colangelo LA, Spring B, Moller AC, et al. Healthy lifestyle through young adulthood and the presence of low cardiovascular disease risk profile in middle age: the Coronary Artery Risk Development in (Young) Adults (CARDIA) study. Circulation 2012;125:996–1004. Estruch R, Ros E, Salas-Salvado J, Covas MI, Corella D, Aros F, et al. Primary prevention of cardiovascular disease with a Mediterranean diet. N Engl J Med 2013;368:1279–90. Sjostrom L, Peltonen M, Jacobson P, Ahlin S, AnderssonAssarsson J, Anveden A, et al. Association of bariatric surgery with long-term remission of type 2 diabetes and with microvascular and macrovascular complications. J Am Med Assoc 2014;311:2297–304. Look AHEAD Research Group, Wing RR, Bolin P, Brancati FL, Bray GA, Clark JM, et al. Cardiovascular effects of intensive lifestyle intervention in type 2 diabetes. N Engl J Med 2013;369:145–54. Andersen SS, Andersson C, Berger SM, Jensen TB, TorpPedersen CT, Gislason GH, et al. Impact of metabolic disorders on the relation between overweight/obesity and incident myocardial infarction and ischaemic stroke in fertile women: a nationwide cohort study. Clin Obes 2015;5: 127–35. Mochari-Greenberger H, Towfighi A, Mosca L. National women's knowledge of stroke warning signs, overall and by race/ethnic group. Stroke 2014;45:1180–2. Mosca L, Hammond G, Mochari-Greenberger H, Towfighi A, Albert MA. Fifteen-year trends in awareness of heart disease in women: results of a 2012 American Heart Association national survey. Circulation 2013;127:1254–63 [e1-29]. Suaya JA, Shepard DS, Normand SL, Ades PA, Prottas J, Stason WB. Use of cardiac rehabilitation by Medicare beneficiaries after myocardial infarction or coronary bypass surgery. Circulation 2007;116:1653–62. Ayanian JZ, Landon BE, Newhouse JP, Zaslavsky AM. Racial and ethnic disparities among enrollees in Medicare advantage plans. N Engl J Med 2014;371:2288–97.
