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Certain stroke risk factors occur only or more commonly in women. To address these risk factors, the AHA/ASA have released guidelines for stroke prevention in women.
During pregnancy, women with hypertension should take low-dose aspirin from 12 weeks of gestation until delivery (Class I, Level A). Prescribe appropriate antihypertensive drugs (e.g., methyldopa, labetalol, nifedipine) for severe hypertension (I, A) and consider them for moderate hypertension (IIa, B).
Consider screening for pre-eclampsia/eclampsia history and documenting it as a stroke risk factor (IIa, C).
Screen patients with cerebral venous thrombosis (CVT) for underlying prothrombotic conditions (e.g., infection, inflammatory disease, oral contraceptive use) (I, C). Test for primary hypercoagulable states, but not acutely or during warfarin use (IIa, B).
Warfarin therapy duration should be 3 to 6 months if CVT is provoked, 6 to 12 months if unprovoked, and lifelong if recurrent or if a primary hypercoagulable state is present (IIb, C).
Acute CVT during pregnancy can be treated with low-molecular-weight heparin (LMWH) rather than unfractionated heparin (IIa, C). LMWH should be continued throughout pregnancy and either LMWH or warfarin for ≥6 weeks postpartum, ≥6 months total (I, C).
Prior CVT does not contraindicate future pregnancy (IIa, B), although gestational and postpartum LMWH should be considered (IIa, C).
Measure blood pressure before initiating oral contraceptives (I, B).
Perform pulse palpation for atrial fibrillation (AF) in the primary care setting for women older than 75 (I, B).
Bushnell C 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 Feb 6; [e-pub ahead of print]. (http://dx.doi.org/10.1161/01.str.0000442009.06663.48)
Comment
To be effective, many of these recommendations — such as pulse screening for atrial fibrillation — will require diffusion into routine primary care practice. Other recommendations — such as guidelines on the management of cerebral venous thrombosis, which occurs much more commonly in women — are directly useful to neurologists. Ultimately, more-tailored treatment of these gender-specific factors may reduce the overall burden of stroke.