New stroke guidelines offer more warnings for women

Next time you see the doctor, you may be asked more questions than ever.

The conversation is part of a nationwide push to help make sure you aren't one of the almost 800,000 Americans who suffers a stroke in the coming year.

A leading source of disability and third-leading cause of death in North Carolina, strokes can happen at any age — and most are preventable.

That's why the American Heart Association and the American Stroke Association recently rewrote their treatment guidelines for doctors. The new playbook includes stroke screening by primary-care doctors and OB/GYNs with a focus on risks for women, people of color and the poor, as well as on trans women who take estrogen for gender affirmation.

"The risk of stroke is going up, and a lot of it's related to food, high-blood pressure and us as a nation being sicker as time goes on — it's a deadly combination of things that are all trending in the wrong direction," said Dr. Cara Doyle, who sees the fallout as she cares for patients Novant Health Presbyterian Medical Center in Charlotte.

"Patients should expect to be asked a lot of screening questions and hopefully, have a lot more preventive support coming their way," she said about the new guidelines.

As a neurohospitalist who only treats patients within the hospitals, Doyle is often the first specialist to care for patients who arrive at the ER with stroke symptoms. Strokes occur when a clot blocks an artery supplying blood to the brain (ischemic) or a blood vessel breaks and bleeds into the brain (hemorrhagic). Either way, brain cells begin to die. Delays in treatment can lead to permanent disability or even death.

And risk rises with age. More than half of seniors who have a stroke are less able to get around afterward. While many of us assume strokes are for older adults here’s the reality: More than one-third of patients hospitalized for stroke in North Carolina are under 65.

Doyle recently discussed how the new guidelines stand to affect patient care.

Q: There’s a strong focus on women. Why?

There is a unique risk with pregnancy — 1 in 5 pregnancies has an adverse outcome of some kind. Women who develop preeclampsia, a pregnancy-related high blood pressure disorder, have a sharply higher stroke risk that persists even after the baby is born.

Q: How does estrogen factor in?

The female hormone, estrogen, in general, is a risk factor for stroke because it may cause blood clots. For birth control, there are many alternatives to methods containing estrogen. It's also important for menopausal women to talk to their OB/GYN if they need hormone replacement therapy.

Fortunately, new research shows that lower doses of estrogen pose little risk. Creams may be safer than pills for relieving symptoms. Trans women using estrogen should take the lowest possible dose to achieve gender-affirmation goals.

Q: What should women know about the new guidelines?

They call for women to be screened for stroke risk factors before, during and after pregnancy — and for aggressive treatment of high blood pressure. Doctors are encouraged to ask patients about family history, as well.

The guidelines say women should be screened for three conditions that put them at increased risk: ovarian failure before age 40, menopause before age 45 and endometriosis, a condition in which uterine-like tissue grows outside the uterus.

Q: What else can patients expect doctors to ask about?

Because issues such as racism, homelessness, food insecurity and education strongly affect stroke risk, the guidelines focus on these so-called social determinants of health. The intent is to make sure patients with access to care are screened for things that would increase their risk of stroke, such as food insecurity, homelessness and poor lifestyle habits.

Q: What else is changing?

The guidelines emphasize the importance of discussing other risk factors linked to stroke, such as a family history of blood clots, personal use of tobacco and substances like cannabis — and, of course, blood pressure (120/80 is normal). For patients whose blood pressure is high, aggressive treatment — sometimes with more than one medication — is recommended.

Q: What's the patient's role in prevention?

It sounds silly but live a healthy lifestyle: Don't smoke tobacco or vape. Don't do drugs. Limit your alcohol use, exercise, eat a healthy diet. And have regular checkups — and not only with your primary care doctor. See your dentist regularly, because infections caused by tooth disease can lead to strokes from heart disease. Get regular screenings such as colonoscopies and mammograms, as recommended, because cancers cause the blood to clot. I see these things a lot in my practice.

Q: Besides the risks posed by estrogen, do other gender-based issues affect stroke risk?

I can't tell you how many men come into the hospital with a stroke for the first time, and I ask, 'What are your medical problems?' And they'll say, 'None that I know of, Doc.' Then they tell me they've never seen a doctor: They have high cholesterol, high blood pressure, they're smoking — and their stroke could have been prevented if they just saw their doctor for screening once a year.

Q: What else should patients keep in mind?

If you have sickle cell disease or some autoimmune diseases, such as lupus or rheumatoid arthritis, you are at higher risk for stroke. Conditions like high blood pressure in pregnancy or blood clots may run in families. Talk to parents and siblings to understand your family history, and then share it with your doctor.