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Healthy Aging

Stroke Risk: Women (and Men) Beware

Stroke can be a catastrophic life-changing event in our lives. Nearly one million Americans a year will have a new or repeat stroke. It is the fourth leading overall cause of death, and for women it is the third leading cause of death. If a stroke occurs and does not kill, it can leave you with life-long disability that ranges from some minor motor impairment to major movement and mental disabilities. In other words, stroke is something that we should strive to prevent, if possible.

The American Heart Association (AHA) has compiled the risk factors for stroke that are shown in the table. Last month the AHA released new risk factors that pertain only to women. It is important to single out women from men since they are more likely to die from stroke: 40 percent of stroke deaths occur in men and 60 percent in women.

Risk Factors and Prevention

Many of the risk factors for stroke cannot be changed, but they can and should be carefully noted and being aware of them can help us get help quickly if we understand we are at increased risk (in other words we are aware of the danger). Increasing age (a risk factor we wish to continue!) is clearly related to stroke. In fact, in people over the age of 65 the risk of stroke increases about one percent per year. Another way of looking at this statistic is that every decade after 55 we have a 10 percent greater chance of having a stroke. Diabetes Mellitus is another stroke risk factor, and is more important in women. A very strong predictor of stroke is a prior history of stroke or symptoms such as transient ischemic attacks (TIAs). The presence of significant (greater and 60 percent) carotid artery obstruction (major arterial blood vessels leading from the aorta to the brain) with or without a bruit (sound audible with a stethoscope) is predictive of a stroke. Certain heart diseases, especially heart arrhythmias like atrial fibrillation carry increased risk of stroke as does a family history of stroke.

Risk Factors That We Can Influence

There are a good number of things you can do to reduce the risk of stroke, and it is our responsibility to do so. If you know you have hypertension (the silent killer) you need to be sure it is well controlled by diet, exercise and medication under the supervision of your doctor. If you have diabetes, like hypertension, it needs to be under control. Other disorders that you and your physician need to be aware of and manage well are carotid and other peripheral arterial diseases that are caused by cholesterol deposition. One way to control those is to be strict with diet--keeping cholesterol within normal limits--and exercise regularly. It is essential to avoid the saturated fat, trans fat and processed sugars that are so prevalent among our dietary choices.

Several cardiac diseases predispose to stroke. Most important is atrial fibrillation. The atria, when in fibrillation allow blood clots to form within them, and the clots can embolism to the brain causing stroke. This is why many patients with atrial fibrillation will be given anticoagulants (blood thinners) to prevent the clots from forming. Other heart diseases predispose to embolism and if you have any listed in the table, you and your doctor need to make sure preventive steps are being taken against a possible stroke.

There are important choices we make that influence stroke risk. The single most important is smoking. Smoking is detrimental to health in general and a major risk factor for causing strokes: if you smoke, quit. Another is how much we eat: obesity is a risk factor for stroke and being overweight is in part related to conscious decisions we make about how many calories we eat and expend with exercise. Drinking alcohol in excess and certain drugs such as cocaine, amphetamines and heroin are associated with increased stroke and should be avoided.

What's New for Women

The table now includes risk factors specifically for women to use in assessing your incremental risk for stroke. Pregnancy is not a problem for those of us in the elderly group, but it is for younger women and pregnancy per se can be associated with stroke as well as birth control pills used to keep women from getting pregnant. Older women who have taken or do take hormonal replacement after menopause are at increased risk of stroke, and this needs to be discussed with your physician. Two important historical facts also predispose women to stroke: one is migraine headaches with aura and the other is if you had preeclampsia (high blood pressure) with your pregnancies. If either of these are part of your past medical history it is important to discuss this with your physician as it relates to your stroke risk. A history of preeclampsia produces twice the risk of stroke than not having it.

The Bottom Line

As we age we are all at increased risk of having a stroke which is a  major cause of death and disability in the United States. Therefore, we must pay close attention to those factors that put each of us at risk for stroke. If you have these risk factors consult with your physician about preventive strategies. Even if we are doing everything possible to prevent strokes they can occur and it is crucial that you go immediately to the emergency room if you suspect you are having a stroke. Time to treatment is very important in minimizing the brain damage from a stroke.

Stroke Risk Factors

What risk factors for stroke can't be changed?

  • Age
  • Heredity (family history)
  • Race
  • Sex
  • Prior stroke, TIA or heart attack

What stroke risk factors CAN be changed, treated or controlled?

  • High blood pressure
  • Cigarette smoking
  • Diabetes mellitus
  • Carotid or other artery disease
  • Peripheral artery disease
  • Atrial fibrillation
  • Other heart disease
    • coronary heart disease
    • heart failure
    • dilated cardiomyopathy
    • heart valve disease
    • some types of congenital heart defects
  • Sickle cell disease (also called sickle cell anemia)
  • High blood cholesterol
  • Poor diet
  • Physical inactivity and obesity

What are other, less well-documented risk factors?

  • Geographic location - strokes are more common in the southeastern United States, the so-called "stroke belt" states
  • Socioeconomic factors - strokes are more common among low-income people than among more affluent people
  • Alcohol abuse - alcohol abuse can lead to multiple medical complications, including stroke
  • Drug abuse - drugs that are abused, including cocaine, amphetamines and heroin, have been associated with an increased risk of stroke

Specific female risk factors

  • Pregnancy
  • Preeclampsia with pregnancy
  • Birth control pills
  • Hormone replacement after menopause
  • Migraine headaches with aura

Table modified from accessed February 10, 2014.