Recommendations on the Risk of Ischaemic Stroke Associated With Use of Combined Oral Contraceptives and Hormone Replacement Therapy in Women With Migraine

1,300

577

Background and Purpose-This guideline provides an overview of the evidence on established and emerging risk factors for stroke to provide evidence-based recommendations for the reduction of risk of a first stroke. Methods-Writing group members were nominated by the committee chair on the basis of their previous work in relevant topic areas and were approved by the American Heart Association (AHA) Stroke Council Scientific Statement Oversight Committee and the AHA Manuscript Oversight Committee. The writing group used systematic literature reviews (covering the time since the last review was published in 2006 up to April 2009), reference to previously published guidelines, personal files, and expert opinion to summarize existing evidence, indicate gaps in current knowledge, and when appropriate, formulate recommendations using standard AHA criteria (Tables 1 and 2). All members of the writing group had the opportunity to comment on the recommendations and approved the final version of this document. The guideline underwent extensive peer review by the Stroke Council leadership and the AHA scientific statements oversight committees before consideration and approval by the AHA Science Advisory and Coordinating Committee. Results-Schemes for assessing a person's risk of a first stroke were evaluated. Risk factors or risk markers for a first stroke were classified according to potential for modification (nonmodifiable, modifiable, or potentially modifiable) and strength of evidence (well documented or less well documented). Nonmodifiable risk factors include age, sex, low birth weight, race/ethnicity, and genetic predisposition. Well-documented and modifiable risk factors include hypertension, exposure to cigarette smoke, diabetes, atrial fibrillation and certain other cardiac conditions, dyslipidemia, carotid artery stenosis, sickle cell disease, postmenopausal hormone therapy, poor diet, physical inactivity, and obesity and body fat

Section: Oral Contraceptivesmentioning

confidence: 99%

Guidelines for the Primary Prevention of Stroke

Goldstein¹,

Bushnell²,

Adams³

et al. 2011

1,300

577

“…Our data support previous studies that reported an increase in stroke risk associated with smoking and the use of OCs among young women 11,16,18,21 and clinical recommendations to modify these risk factors in the presence of migraine with aura. 32,33 There were 145 ischemic stroke patients among women with PMVA. When we stratified our analyses by ischemic stroke subtype, we found that PMVA was associated with strokes of undetermined origin and showed a strong trend toward an association with lacunar stroke, which is more a descriptive than an etiologic category.…”

Section: Discussionmentioning

confidence: 99%

Probable Migraine With Visual Aura and Risk of Ischemic Stroke

MacClellan

Giles

Cole

et al. 2007

296

291

Background and Purpose-Migraine with aura is associated with ischemic stroke, but few studies have investigated the clinical and anatomic features of this association. We assessed the association of probable migraine with and without visual aura with ischemic stroke within subgroups defined by stroke subtype, vascular territory, probable migraine characteristics, and other clinical features. Methods-Using data from a population-based, case-control study, we studied 386 women ages 15 to 49 years with first ischemic stroke and 614 age-and ethnicity-matched controls. Based on their responses to a questionnaire on headache symptoms, subjects were classified as having no migraine, probable migraine without visual aura, or probable migraine with visual aura (PMVA). Results-Women with PMVA had 1.5 greater odds of ischemic stroke (95% CI, 1.1 to 2.0); the risk was highest in those with no history of hypertension, diabetes, or myocardial infarction compared to women with no migraine. Women with PMVA who were current cigarette smokers and current users of oral contraceptives had 7.0-fold higher odds of stroke (95% CI, 1.3 to 22.8) than did women with PMVA who were nonsmokers and non-oral contraceptive users. Women with onset of PMVA within the previous year had 6.9-fold higher adjusted odds of stroke (95% CI, 2.3 to 21.2) compared to women with no history of migraine. Conclusions-PMVA was associated with an increased risk of stroke, particularly among women without other medical conditions associated with stroke. Behavioral risk factors, specifically smoking and oral contraceptive use, markedly increased the risk of PMVA, as did recent onset of PMVA.

“…5 The combination of oral contraceptives and migraine with aura increases the risk of ischemic stroke 5-to17-fold. 6 Our patient also had recent infection and increased stress, which may have contributed to a prothrombotic state. Importantly, none of these factors by themselves are sufficient to explain the patient's stroke.…”

Section: Martinez Majander Et Al Cryptic Loss Of Consciousness E165mentioning

confidence: 73%

Cryptic Loss of Consciousness in a 36-Year-Old Woman

Majander

Sinisalo

Sundararajan

et al. 2015

4 These factors can either be present in isolation or in combination. Presumably multiple factors will further increase the total risk.Our patient had both migraine without aura and oral contraceptive use. Migraine with aura roughly doubles the risk of ischemic stroke when compared with the general population, but such an increase has not been consistently documented for migraine without aura. 5 The combination of oral contraceptives and migraine with aura increases the risk of ischemic stroke 5-to17-fold. 6 Our patient also had recent infection and increased stress, which may have contributed to a prothrombotic state. Importantly, none of these factors by themselves are sufficient to explain the patient's stroke.The prevalence of PFO is about 25% in the general population. Its role as a causal factor for stroke remains hard to prove in individual patients, although case-control studies consistently show a statistical association between PFO and otherwise cryptogenic stroke. This association is higher in young patients, in patients with large right-to-left shunts, and in patients with structural heart abnormalities, such as atrial septal aneurysms, and in patients with large right-to-left shunts.7 However, also contradictory evidence exists, especially when it comes to the size of PFO.8 Our patient had a PFO and her stroke may have been caused by paradoxical embolism. However, there was no evidence of a prothrombotic state. In this case, there was no evaluation for deep vein thrombosis or pulmonary embolus, which if found would have increased suspicion for paradoxical embolization. Young patients with cryptogenic transient ischemic attack or stroke and PFO should be evaluated for lower extremity or pelvic venous thrombosis, which would also be an indication for anticoagulation. 8 According to recent randomized trials, 9 prolonged ECG monitoring detects paroxysmal atrial fibrillation in patients with cryptogenic stroke or transient ischemic attack at a rate of about 10% per year. However, this rate includes patients with traditional risk factors and likely overestimates the incidence of atrial fibrillation in young patients without risk factors for atherosclerotic disease. It should be noted that intracardiac thrombus may be missed on echocardiography either because it is small or it has already embolized. Arterial dissections can heal and may not be present when imaging is completed weeks or months after the stroke.According to ASCO classification, 10 our case had eventual phenotype of A0-S0-C3-O0. This classification takes into account all the possible causes of an ischemic stroke, not just the most likely one. The categories of ASCO classification are as following: A for atherosclerosis, S for small vessel disease, C for cardiac source, and O for other cause. Each of the subtype is further graded into 4 groups according to its likelihood of being the cause of the ischemic stroke or into group 9 if certain category cannot be graded. The prevalence of cryptogenic stroke is mainly influenced by the completeness ...