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Recognizing and preventing Acute stroke in women

Simmons, Susan PhD, ARNP-BC

doi: 10.1097/01.NURSE.0000411431.05516.8a
Feature: CE Connection

Women not only face a higher risk of stroke than men, but they're also more likely to experience less-recognized symptoms: altered mental status, headache, and dizziness. Educate your female patients about their unique risk factors and steps they can take to prevent this devastating event.

Susan Simmons is a family NP in Olathe, Kan., and a member of the Nursing2012 editorial board.

The author and planners have disclosed that they have no financial relationships related to this article.

IN WOMEN, STROKE is the third leading cause of death, after heart disease and cancer, and the major cause of disability.1,2 One in five women will have a stroke sometime during her lifetime, compared with one in six men. The rate of midlife stroke in women has tripled in the last 20 years.3 Almost 25% of women who have a stroke will die within the first year. Sixty percent more women die from stroke than men.1,2 For more startling facts, see Statistics show women at risk.

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Despite the danger stroke poses, only 25% to 30% of women can name more than two symptoms of stroke or know that women face a higher risk for stroke than men.1,4 As nurses, we owe it to our female patients to be knowledgeable about stroke, especially its risk factors, signs, and symptoms, and to educate women about how they can protect themselves. Women are also less likely than men to receive fibrinolytic therapy within the recommended time frame of symptom onset.3,5 Besides discussing women's stroke risks and signs and symptoms, this article outlines key measures women can take to lessen their risk of having a stroke.

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Recognizing signs and symptoms

The signs and symptoms of a stroke may be subtle or dramatic. Strokes are characterized by any one of these signs and symptoms or any combination of them: sudden numbness or weakness of the face or extremities; sudden confusion, trouble speaking, or trouble understanding speech; sudden trouble seeing in one or both eyes; sudden trouble walking; loss of balance or coordination; dizziness; and sudden severe headache with no known cause.1 See Comparing ischemic and hemorrhagic strokes.

Women having a stroke are more likely than men to experience an altered mental status. In fact, this symptom is the one most commonly experienced by women. Headache is also common. Compared to men, women are more likely to experience lightheadedness or dizziness.5

Many women fail to associate these key signs and symptoms— altered mental status, headache, and dizziness—with stroke. They may be more likely to think of facial droop, extremity weakness, slurred speech, and vision changes.5 Consequently, they may delay seeking medical attention when stroke symptoms first appear.

Because “time is brain,” educating the public about the signs and symptoms of stroke is a crucial nursing responsibility. Two campaigns designed to educate the public are Give Me 5 and Act FAST. See Act FAST for Stroke and Give Me 5 for Stroke.

Act FAST is sponsored by the National Stroke Association. (See http://www.stroke.org.6) Patients can download a wallet card from the website to remind them of the symptoms of stroke and what to do.

The Give Me 5 campaign was developed by the Stroke Collaborative, composed of representatives from the American Academy of Neurology, the American College of Emergency Physicians, and the American Heart Association/American Stroke Association. They emphasize the suddenness of a stroke as well as the sudden signs and symptoms of a stroke, and they include all signs and symptoms. This group emphasizes that consumers should be aware that they may experience only one symptom and that it's the suddenness of the symptom or symptoms that should alert them to call 911.

The Stroke Collaborative group doesn't support Act FAST. This group believes that the FAST acronym, which doesn't include all stroke signs and symptoms, may fail to alert someone to a stroke or falsely reassure someone who isn't experiencing the whole constellation of symptoms. More information can be found at http://www.emergencycareforyou.org/VitalCareMagazine/BodyBasics/Default.aspx?id=1276&terms=Give+Me+Five+for+Stroke.7

Regardless of which acronym is used, educate patients about the signs and symptoms of stroke, emphasizing that strokes are sudden and that they should act fast.

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Risk factors for stroke

Some risk factors are the same for both men and women, but other risk factors are associated with only women. In general, the incidence of stroke increases with age regardless of gender.1 Other shared risk factors include hypertension, excessive sodium intake, obesity, diabetes, dyslipidemia, smoking, atrial fibrillation, and depression.1,3,8,9 Recently, researchers at the American Stroke Association International Conference presented evidence that drinking diet soda may increase the risk of myocardial infarction or stroke, or the risk of dying of either, by 50% or more.10

Risk factors that are more specific to women include hormonal differences and migraines.3,9 Longevity is also a special concern for women because women live about 5 years longer than men, on average.3 Because they live longer, women have more time to experience a stroke and to develop comorbid factors associated with aging that increase their stroke risk.

Now let's take a closer look at factors that put women at higher risk of stroke, including hormones, migraines, and depression.

Hormones. Endogenous estrogen may play a protective role before menopause.11 The risk of stroke from use of exogenous estrogens, such as those in oral contraceptives, is controversial. The absolute risk of stroke in female nonsmokers of any age with normal BP appears to be only 4.1 in 100,000. However, data on women who take estrogen supplementation after menopause tell a different story. Results of the Women's Health Initiative (WHI) research program showed that stroke risk increased 40% to 50% in postmenopausal women on estrogen therapy, whether or not estrogen was combined with a progestin. In the WHI research program, risk was found to be greatest during the first year of therapy. However, women in the WHI research program were hormone-naive, without endogenous or exogenous hormones, for an average of 10 years and were in their 60s.1,3,9 For women who started estrogen early in menopause, on the lowest dose needed to reduce symptoms such as hot flashes, it isn't known if stroke risk will be similar to what's seen with those using oral contraceptives or similar to what was noted in the WHI.

Migraines with aura. Migraines are classified as migraine with aura or migraine without aura.12 An aura is a transient visual, sensory, or speech disturbance associated with headache.

Migraines without aura are more common than migraines with aura and aren't associated with an increased risk of stroke. On the other hand, those who have migraine with aura do have an increased risk of stroke. Although the reason for this isn't known, the vascular aspect of migraines may be what leads to stroke. About 75% of those who experience migraine are women, and almost 25% of women suffer from migraines. Luckily, less than 20% of migraines are associated with an aura.3

Depression was noted in up to 15% of the women studied in the WHI. Of those in the study, Black and Hispanic women were most likely to experience depression, followed by White women; Asian women were the least likely to be depressed. In general, twice as many women are depressed as men.1,9 The WHI research program found that women who were depressed experience more strokes. Depression may be associated with increased inflammation due to changes in levels of dopamine, norepinephrine, and serotonin. Or, it may be that people with depression are generally in poorer health. New onset of depression in older adults could be a manifestation of vascular disease.1,9

In the WHI research program, almost half of the women who'd been diagnosed with depression were on selective serotonin reuptake inhibitors (SSRIs) for depression. A known adverse effect of SSRIs is platelet inhibition, which may increase the risk of hemorrhagic stroke, but decrease the risk of acute ischemic stroke. However, no evidence has shown that treating depression reduces stroke risk.1,9 Does depression pose a risk for women taking SSRIs because platelets are inhibited or because late-onset depression is a vascular disease or due to some combination of factors? Whether depression is a cause or an early marker for stroke isn't known. More research is needed in this area.

Now consider the risks that affect women as well as men.

Atrial fibrillation. In women, the greatest single risk factor for stroke is atrial fibrillation. Ischemic strokes are caused by thrombi, and atrial fibrillation is the risk factor discussed here that's most likely to cause thromboembolism. The incidence of atrial fibrillation rises with age, with 9% of women over age 80 having this dysrhythmia.1 Among patients with atrial fibrillation, the stroke risk is three to four times greater in women than in men. This may be because women's blood vessels have smaller diameters, atrial fibrillation is more difficult to manage in women, and healthcare providers are less likely to achieve goals of care for women.1

Hypertension. For women who don't have atrial fibrillation, the most important risk factor for stroke is hypertension. Isolated systolic hypertension, common in older women, is the most significant BP risk factor for stroke. A BP greater than 140/90 mm Hg increases stroke risk; if it's combined with atrial fibrillation, stroke risk escalates substantially. BP control has improved remarkably since practice guidelines became available.1 BP control has increased from 10% in the 1980s to 70% in 2006, except in women! Only 30% of women ages 70 to 79 have achieved BP control.1 BP control can be achieved inexpensively by taking advantage of programs offered by many large chains of pharmacies that provide certain generic medications costing only $4 for a month's supply.

Sodium intake. This factor affects both BP and stroke risk. Sodium intake greater than 4,000 mg a day doubles stroke risk. The U.S. Dietary Guidelines recommend a daily sodium intake of 2,300 mg or less. In certain higher risk groups, daily intake shouldn't exceed 1,500 mg. These higher risk groups include Black Americans; people older than 51; and those with diabetes, hypertension, or chronic kidney disease.13

Potassium intake. Potassium seems to help maintain normal BP due to a mild vasodilatory effect. Patients who consume more than 1.64 g of potassium in food have less hypertension and cardiovascular disease and a 21% decrease in stroke. The reasons for these effects aren't clear.14,15

Dyslipidemia is a risk factor for stroke in both genders, especially in adults with high low-density lipoprotein (LDL) and triglyceride levels. LDL increases as a woman ages. For each 10% reduction in LDL, stroke risk can be reduced 15% to 20%.1,3,8

Obesity. A body mass index greater than 30 doubles a woman's risk for stroke. Central adiposity or an increased waist circumference may encourage production of hepatocyte growth factor (HCF), leading to inflammation and insulin resistance. In turn, inflammation and insulin resistance raise the risk of diabetes, stroke, and other cardiovascular diseases. Levels of HCF have been found to be higher in women who've suffered a stroke. In fact, increased HCF levels seem to be an independent risk factor for stroke in women ages 50 to 79.1,3

Smoking. Many people realize that smoking increases the risk of lung cancer. They may not know that smoking also doubles the risk of stroke.1

Diabetes. The risk of stroke associated with diabetes affects women more than men. Women with diabetes face two to six times the risk of stroke compared to women who don't have diabetes. Diabetes increases women's risk for obesity, hypertension, dyslipidemia, metabolic syndrome, and other comorbid conditions. A woman's risk for stroke increases with the acquisition of each comorbid condition.1

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Preventing stroke

To decrease their risk of stroke, the most important steps women can take are to maintain a normal body weight, BP, and lipid profile. Patients with diabetes should also optimize glycemic control. To accomplish these goals, women can consume fewer calories from a diet lower in sodium and cholesterol, and increase physical activity. Trading simple carbohydrates (such as white bread and other baked goods) with more complex ones (such as fruits and vegetables) will increase potassium intake, which reduces stroke risk.14 Drinking less diet soda helps decrease sodium consumption. Smokers should quit the habit.3,9

To help women manage their BP and lipid profile, encourage them to participate in preventive healthcare visits and, when problems are found, to collaborate with their healthcare providers on treatment programs that suit their lifestyle. Advise them to follow up with their healthcare provider as recommended.

For women, taking an aspirin daily appears to be better at primary prevention (preventing a stroke) than secondary prevention (preventing another one). Encourage your older female patients to ask their healthcare provider about a regimen of low-dose aspirin.3

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What can nurses do?

Educate all of your patients about their stroke risk, signs and symptoms of stroke, and prevention measures. And be sure to teach your female patients about risk factors and signs and symptoms that are specific to women but may not be as well-known. Remember to reinforce that stroke symptoms are sudden and that anyone experiencing one or more symptoms should act fast.

Prevention should start with living a healthy lifestyle. Teach your patients what a healthy diet means in terms of cholesterol, sodium, and calorie intake. A potential starting place can be http://www.choosemyplate.gov.16 For nurses, a more detailed nutritional guideline can be found at http://www.cnpp.usda.gov/Publications/DietaryGuidelines/2010/PolicyDoc/PolicyDoc.pdf.17 Help your patients realize that lifestyle changes can reduce stroke risk by 50% or more and that changing modifiable risk factors such as smoking and abdominal obesity can cut risk by as much as 80%. Just a few simple changes in our patients can make a world of difference.

The good news is that many strokes can be prevented, and when strokes do occur, rapid recognition and treatment can improve outcomes and minimize long-term effects. Be sure your patient doesn't become one more victim of stroke.

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Statistics show women at risk

More than a third of women who have a stroke will be severely disabled, and less than 25% will fully recover.1,3 Women who experience stroke also have a longer hospital stay and a longer recovery. When finally discharged, these women are likely to be admitted to long-term care facilities. Female stroke victims are more likely to be depressed before having the stroke.18 Women are also less likely to achieve BP and lipid targets, two factors that influence stroke risk.8

In women, the highest incidence of stroke occurs in Black Americans, followed by White Americans, and then Hispanic Americans. Four in 1,000 Black women will die from stroke, which is twice the mortality of White women.1,3

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REFERENCES

1. Wassertheil-Smoller S. Stroke in women. Nutr Metab Cardiovasc Dis. 2010;20(6):419–425. Epub 2010 Jul 6.
2. Sattelmair JR, Kurth T, Buring JE, Lee IM. Physical activity and risk of stroke in women. Stroke. 2010; 41(6):1243–1250. Epub 2010 Apr 6.
3. Jamieson DG, Skliut M. Stroke in women: what is different? Curr Atheroscler Rep. 2010;12(4):236–243.
4. National Stroke Foundation. Women and Stroke. 2010. http://www.stroke.org/site/PageServer?pagename=women.
5. Lisabet LD, Brown DL, Hughes R, Majersik JJ, Morganstern LB. Acute stroke symptoms: comparing women and men. Stroke. 2009;40(6):2031–2036. Epub 2009 Feb 19.
6. National Stroke Association: Act FAST. http://www.stroke.org.
7. The American College of Emergency Physicians. Body basics. Strokes: early warning signs. http://www.emergencycareforyou.org/VitalCareMagazine/BodyBasics/Default.aspx?id=1276&terms=Give+Me+Five+for+Stroke.
8. Saposnik G, Kapral MK. Understanding stroke in women: similar care, worse outcomes? Stroke. 2009;40(3):674–675.
9. Rexrode KM. Emerging risk factors in women. Stroke. 2010;41(suppl 10):S9-S11.
10. Laino C. Is diet soda linked to heart, stroke risk? 2011. http://www.webmd.com/stroke/news/20110209/is-diet-soda-linked-to-heart-stroke-risk.
11. National Institute of Neurological Disorders and Stroke. Stroke: hope through research. What special risks do women face? http://www.ninds.nih.gov/disorders/stroke/detail_stroke.htm# 177091105.
12. International Headache Society. HIS Classification ICHD-II. http://ihs-classification.org/en/02_klassifikation/02_teil1/01.02.00_migraine.html.
13. Schwamm L, Fayad P, Acker JE, 3rd, Duncan P, Fonarow GC, Girgus M, et al. Translating evidence into practice: a decade of efforts by the American Heart Association/American Stroke Association to reduce death and disability due to stroke: a Presidential Advisory from the American Heart Association/American Stroke Association. Stroke. 2010;41(5): 1051–1065. Epub 2010 Feb 24.
14. D'Elia L, Barba G, Cappuccio FP, Strazzullo P. Potassium intake, stroke, and cardiovascular disease: a meta-analysis of prospective studies. J Am Coll Cardiol. 2011;57(10):1210–1219.
15. Braschi A, Naismith DJ. The effect of a dietary supplement of potassium chloride or potassium citrate on blood pressure in predominately normotensive volunteers. Br J Nutr. 2008;99(6):1284–1292.
16. U.S. Department of Agriculture. ChooseMyPlate.gov. http://www.ChooseMyPlate.gov.
17. U.S. Department of Agriculture, U.S. Department of Health and Human Services. Dietary Guidelines for Americans, 2010. 7th ed. Washington, DC: U.S. Government Printing Office; 2010. http://www.cnpp.usda.gov/Publications/DietaryGuidelines/2010/PolicyDoc/PolicyDoc.pdf.
18. Pan A, Okereke OI, Sun Q, et al. Depression and incident stroke in women. Stroke. 2011;42:2770–2775. http://stroke.ahajournals.org/content/42/10/2770.abstract.
19. Marsh JD, Keyrouz SG. Stroke prevention and treatment. J Am Coll Cardiol. 2010;56(9):683–691.
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RESOURCE

Experts recommend low-dose aspirin to prevent stroke in women. Lower doses are as effective as higher doses and are likely to be safer. Harv Womens Health Watch. 2009;16(9):1.
© 2012 Lippincott Williams & Wilkins, Inc.