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WOMEN WITH STROKE UNDERSERVED WITH STANDARD DIAGNOSTIC TESTS

MIAMI BEACH—Women with stroke are less likely to undergo standard diagnostic tests than are men, according to investigators who reported the data comparing use of carotid ultrasound, MRI, and echocardiography at the AAN Annual Meeting here in April.

The findings show that women need improved access to quality stroke care and that neurologists need to dispel the myth that stroke is a “male disease,” said Lewis B. Morgenstern, MD, Associate Professor of Neurology at the University of Michigan in Ann Arbor. Dr. Morgenstern, who led the study, is also the Director of the stroke program at the university.

“Women who have ischemic stroke get less care than men,” he said. “This is a wake-up call for physicians to improve their awareness of stroke symptoms in women and treat them more aggressively.”

Dr. Morgenstern said investigators did not expect to find any differences. “We thought physicians would practice appropriately for both genders. These tests – [carotid ultrasound, MRI, and echocardiagraphy] – are common and inexpensive and should be done. Carotid ultrasound and echocardiography help us know a patient's risk for recurrent stroke,” he said, noting that a history of stroke is the biggest stroke risk factor. “Women who have a stroke are 50 percent less likely than men to get a carotid ultrasound and 30 percent less likely to get echocardiography,” Dr. Morgenstern said. “We think that this is an important finding…Physicians need to make the effort to evaluate women as aggressively as men and to address the morbidity and mortality of stroke in women.”

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Dr Lewis B. Morgenstern: This is a wake-up cal for physicians to improve their awareness of stroke symptoms in women and treat them more aggressively.”

HIGH MORTALITY RATES

The investigators conducted the study because stroke outcomes for women are worse compared with men; 62 percent of all deaths from stroke in the US occur among women. They were concerned that this disparity may reflect reduced access to quality health care. They used data from a population-based study conducted in a non-academic setting, the Brain Attack Surveillance in Corpus Christi Project.

In the NIH-funded study, the investigators obtained a random sample of 381 ischemic stroke cases that occurred between 2000 and 2002. The sample consisted of 161 men and 220 women, who were a median of 74.3 years old. When the investigators compared the patients' NIH Stroke Scale (NIHSS) data, they found no difference by gender in median NIHSS scores.

They then assessed whether men and women received echocardiography, consisting of combined transesophogeal and transthoracic studies; MRI; and carotid ultrasound. In their analysis, they adjusted for demographic and medical factors that could affect their treatment. They also assessed the relationship between gender and having an EKG, and adjusted for age, hypertension, atrial fibrillation, and ethnicity.

Within this sample, 71 percent of men and 60 percent of women received a carotid ultrasound. Physicians ordered brain MRIs for 43 percent of men and 41 percent of women; echocardiography was ordered for 57 percent of men and 48 percent of women; and 90 percent of men and 86 percent of women had an EKG. The investigators found that women had an odds ratio (OR) of 0.64 for receiving echocardiography and an OR of 0.50 for receiving a carotid ultrasound. Men and women had similar ORs for getting MRIs and EKGs.

DIFFERENT SYMPTOMS FOR WOMEN

“We don't know why there's a difference, but we're finding a consistent pattern,” Dr. Morgenstern said. “Women who have stroke are more likely to die of stroke; they get to the hospital slower; and they have different symptoms that may make their strokes more difficult to recognize.” For example, they are more likely to have pain and altered consciousness, while men will typically have the conventional symptoms of weakness or numbness on one side, difficulty speaking or understanding, or inability to walk (Ann Emerg Med 2002; 40(5):453–460).

In addition to leveling the field of diagnostic testing, the public could benefit from a larger effort to educate people about the different symptoms that women have and that those symptoms require urgent medical attention.

“In some women, generalized symptoms are their predominant complaint,” Dr. Morgenstern said. Their doctors and nurses should ask about the full range of traditional and non-traditional symptoms when they call and know when to direct the patient to the emergency room.” A trip to the primary care physician first will delay the diagnosis and the ability to give antithrombotic medication, he said.

Women stroke patients are already slower to arrive at the hospital, because they are older and more likely to live alone than men, he added. They are also more likely to be caregivers than care recipients, so that husbands are less likely to call for medical care for their wives. “What bothers me is that, even after they arrive at the hospital, the physician will see a man with stroke symptoms quicker than a woman,” Dr. Morgenstern said, referring to earlier research (Neurology 1998; 51(2):427–432).

In order to find out why women with stroke receive less prompt attention than men, Dr. Morgenstern and his co-investigators are planning a prospective study that will assess physician behavior, he said.

DIFFERENT TREATMENT, DIFFERENT OUTCOMES?

The next challenge may be to find out whether the disparity in diagnostic tests leads to different stroke outcomes for men and women, according to Cheryl Bushnell, MD, who was not involved in the study.

“This is a well-designed, important study,” said Dr. Bushnell, Assistant Professor of Medicine at the Duke Center for Cerebrovascular Disease of Duke University Medical Center in Durham, NC, in a telephone interview. “Does this difference in the diagnostic tests offered to men and women affect their stroke outcomes? We don't know yet.”

Women may have worse stroke outcomes than men because they are older than men when they have their first stroke and have a worse premorbid status than men, she said. “It's hard to know if the findings in the current research are generalizable, but it's important for neurologists to be aware of them,” she said.

“When we find differences in diagnostic test ordering patterns, we often find in physician surveys that physicians are unaware of treating the two groups differently.” Similarly, a survey of neurologists would probably show that the difference in treatment is not intentional, and that multiple factors lead to such disparities, Dr. Bushnell added.

ARTICLE IN BRIEF

  • ✓ Investigators reported that women get less diagnostic testing for stroke than men: for example, women who have a stroke are 50 percent less likely than men to get a carotid ultrasound and 30 percent less likely to get echocardiography.

REFERENCES

• Labiche LA, Chan W, Saldin KR, Morgenstern LB. Sex and acute stroke presentation. Ann Emerg Med 2002;40(5):453–460.
• Menon SC, Pandey DK, Morgenstern LB. Critical factors determining access to acute stroke care. Neurology 1998;51(2):427–432.