新版卒中指南关注女性风险

美国心脏协会(AHA)和美国卒中学会(ASA)新发布的指南提供了第一份有关女性卒中预防的循证建议，这部指南首次详细阐述了女性特有的(妊娠、激素治疗、避孕和偏头痛等)卒中风险增加的问题(Stroke 2014[doi:10.1161/01.str.0000442009.06663.48])。

美国北卡罗来纳州维克森林浸信会医学中心卒中部主任Cheryl Bushnell医生及其同事在《卒中》2月刊上指出：“女性在卒中危险因素方面与男性有很多相似之处，但女性的卒中风险还会受到激素、生殖健康、妊娠、生育和其他性别相关因素的影响。”

该指南就多种风险类别的预防策略提供了经过分级的证据。这些证据来源于对数十项研究、数十万女性受试者数据的分析。不过，尽管文献量颇大，Bushnell医生强调仍需开展更多相关研究。


少有研究评价伴先兆的偏头痛与卒中的关联，尽管当前数据提示有先兆的偏头痛与卒中风险翻倍有关。

“应当意识到女性的独特性和性别特异性卒中危险因素，并采用包含这些因素的风险评分来识别具有卒中风险的女性。提高卒中知晓率和向年轻女性提供更严谨的患者教育也很重要。”

妊娠

在妊娠结局和先兆子痫相关卒中方面，该指南基于17项研究的证据提出了建议。

对于患有慢性原发性或继发性高血压的孕妇，或有妊娠相关高血压病史的孕妇，A级证据支持在孕中期和孕晚期使用小剂量阿司匹林。A级证据还支持对膳食钙摄入量低的孕妇使用钙补充剂预防先兆子痫。

此外，A级证据还支持在妊娠期采用安全的降压药(甲基多巴、拉贝洛尔和硝苯地平)治疗重度高血压。B级证据支持治疗中度高血压。阿替洛尔、血管紧张素受体阻断剂(ARB)和直接肾素抑制剂因具有致畸性而禁用于妊娠期。

由于先兆子痫会增加终身卒中风险，该指南还建议对生育后1年内的女性进行评估，并且根据其个人和家族危险因素可以考虑针对心血管危险因素进行治疗。

口服避孕药

总共纳入约80万名女性的4项研究检验了使用激素类避孕药的女性的卒中风险。

A级证据不支持在开始使用口服避孕药之前常规筛查促血栓突变。但B级证据显示，口服避孕药可能对有危险因素(包括吸烟和曾发生血栓栓塞事件)的女性有害。

绝经相关激素治疗

7项研究(包括女性健康倡议)在大约3.7万名女性中检验了卒中与激素治疗的关联。指南作者基于A级证据提出了2项建议：

1.不可将激素治疗用于绝经后女性的一级或二级卒中预防。

2.不可将选择性雌激素受体调节剂(雷洛昔芬、他莫西芬和替勃龙)用于卒中的一级预防。

伴先兆的偏头痛

仅有很少的文献探讨了伴先兆的偏头痛与卒中的关联，尽管的确有数据提示总体风险可能翻倍。如果伴先兆的偏头痛并存另一种危险因素(如妊娠或先兆子痫)，卒中风险会急剧增加。不过，由于这些研究的样本量均很小，因此建议内容与男性相同。

B级证据支持伴先兆的偏头痛女性患者戒烟。C级证据提示，降低偏头痛发作频率的治疗或许也能降低卒中风险。

肥胖和代谢综合征

吃天然食物、锻炼身体和戒绝烟草的健康生活方式已被证明在男性和女性中均可降低卒中发生率。但亚组分析提示，健康生活方式对男性的益处更大。关于健康生活方式减少女性卒中的效能，针对女性的研究得出了并不一致的结果。

作者表示，有必要开展大量更多研究，以确定对女性尤其有益的干预手段。在这些研究问世之前，B级证据支持非妊娠女性保持包含锻炼、健康饮食、不吸烟和适量饮酒(每日饮酒≤1份)的生活方式。

房颤

总体而言，罹患房颤的女性与男性数量相当。但房颤患病率随年龄增加而明显上升，而女性的预期寿命长于男性。因此，作者指出，随着老年女性数量的增加，房颤会变得明显更常见。

作者建议初级保健医生对年龄≥75岁的女性积极筛查房颤。B级证据支持首选脉搏、其次是心电图作为筛查方法。

对于年龄≤65岁、无其他危险因素的女性房颤患者，尚无证据支持使用口服抗凝药物。B级证据支持给予抗血小板治疗。

Bushnell医生无相关利益冲突披露。16名合著者中有1人报告称与多家药企有关联。

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By: MICHELE G. SULLIVAN, Cardiology News Digital Network

Newly released guidelines provide the first evidence-based recommendations for preventing stroke in women.

The document addresses the issues that uniquely increase stroke risk in women – pregnancy, hormonal therapy, contraception, and migraine – along with factors like atrial fibrillation and obesity, Dr. Cheryl Bushnell and her colleagues wrote in the February issue of Stroke.

"If you are a woman, you share many of the same risk factors for stroke with men, but your risk is also influenced by hormones, reproductive health, pregnancy, childbirth, and other sex-related factors," Dr. Bushnell noted in a press statement.

The document – created by the American Heart Association and American Stroke Association – is the first to look at these gender-specific issues, wrote Dr. Bushnell, director of the Stroke Center at Wake Forest Baptist Medical Center in Winston-Salem, N.C. (Stroke 2014 [doi:10.1161/01.str.0000442009.06663.48]).

It provides graded evidence for preventive strategies in a number of risk categories. Evidence was obtained by examining dozens of studies numbering hundreds of thousands of women. But despite the extant literature, Dr. Bushnell and her colleagues said more research needs to be conducted.

"There is a need for recognition of women’s unique, sex-specific stroke risk factors, and a risk score that includes these factors would thereby identify women at risk," they wrote. "Similarly, it is important to improve stroke awareness and provide more rigorous education to women at younger ages, including childbearing ages."

The guidelines are aimed at primary care providers, who have the biggest interface with women at a prevention level – and intended to help them forge an active partnership with patients.

"More importantly," the authors wrote, "this guideline may empower women and their families to understand their own risk and how they can minimize the chances of having a stroke."

Pregnancy

For recommendations on pregnancy outcomes and stroke related to preeclampsia, the guidelines drew on evidence from 17 studies.

For women with chronic primary or secondary hypertension, or with a history of pregnancy-related hypertension, Level A evidence supports using low-dose aspirin during the second and third trimester. Level A evidence also supports calcium supplementation to prevent preeclampsia in women with low dietary intake.

There was also a Level A recommendation to treat severe hypertension during pregnancy with safe antihypertensives (methyldopa, labetalol, and nifedipine). Level B evidence supported treating moderate hypertension. The use of atenolol, angiotensin receptor blockers, and direct renin inhibitors is contraindicated because of teratogenicity.

Because preeclampsia increases lifelong stroke risk, the guidelines also recommended evaluating these women within 1 year of giving birth, and, based on their individual and family risk factors, possibly treating them for cardiovascular risk factors.

Oral contraceptives

Four studies comprising about 800,000 women examined the risk of stroke in women using hormonal birth control.

Level A evidence did not support routine screening for prothrombotic mutations before starting oral contraception. But there was Level B evidence that oral contraceptives may be harmful in women who had risk factors, including cigarette use and prior thromboembolic events.

Menopause-related hormone therapy

Seven studies – including the Women’s Health Initiative – examined the links between stroke and hormone therapy in about 37,000 women. Two recommendations supported by Level A evidence were made.

Hormone therapy should not be used for either primary or secondary stroke prevention in postmenopausal women.

Selective estrogen receptor modulators (raloxifene, tamoxifen, and tibolone) should not be used for primary prevention of stroke.

Migraine with aura

There is scant literature examining the link between migraine with aura and stroke, although what does exist suggests that the risk may be doubled overall. The addition of another factor, like pregnancy or preeclampsia, dramatically increases the risk. But because these data are low in number, the recommendations are the same as they are for men.

Level B evidence supports smoking cessation in women with migraine and aura. Level C evidence suggests that treatments that reduce the frequency of migraine may also reduce the risk of stroke.

Obesity and metabolic syndrome

A healthy lifestyle of eating whole foods, exercise, and abstaining from tobacco has been shown to lower stroke incidence in both women and men. But subgroup analyses hint that men derive the most benefit. Women-only studies of these interventions have posted mixed results about their ability to reduce stroke in women.

The authors said much more research is necessary to target interventions that are especially beneficial for women. Until then, Level B evidence supports maintaining a lifestyle of exercise, healthy eating, no tobacco use, and moderate alcohol intake (a drink a day or less) for women who aren’t pregnant.

Atrial fibrillation

Overall, similar numbers of women and men have atrial fibrillation. But the condition becomes more common with age, and women have a longer life expectancy than do men. Therefore, the authors noted, atrial fibrillation will become more common as the population of elderly women increases.

They recommend that primary care physicians actively screen women for atrial fibrillation once they reach age 75 years. The screening method, supported by Level B evidence, should be pulse followed by an electrocardiogram.

For women aged 65 years and younger who have atrial fibrillation but no other risk factors, there is no evidence supporting oral anticoagulation. Level B evidence does support antiplatelet therapy.

Dr. Bushnell had no financial disclosures. One of the 16 coauthors reported relationships with several pharmaceutical companies