Stroke Outcomes in Women: A Population-Based Cohort Study

Abstract

BACKGROUND: Limited data are available on sex-related disparities in long-term outcomes after stroke. We estimated sex differences in various stroke long-term outcomes among survivors after stroke in a prospective 25-year follow-up study. METHODS: Individuals recruited to the South London Stroke Register, an ongoing multi-ethnic urban-based population stroke register, from 1995 onward were included in the analyses (n=6687). The outcomes were death, subsequent stroke, activity of daily living, instrumental activity of daily living, cognitive impairment, depression, anxiety, and health-related quality of life. Kaplan-Meier curves were generated for mortality, stroke recurrence, and recurrence-free survival by sex and Cox proportional hazards model used to model sex differences up to 25 years. Generalized estimating equation were used to model sex differences in risk of self-reported stroke outcomes over 10 years poststroke outcomes, adjusting for age, preexisting activity of daily living, case-mix, stroke subtypes, and other potential confounding risk factors. RESULTS: There were 49% women (mean age, 72 years; SD, 15.6) and 51% men (mean age, 67 years; SD, 14.3) in 6687 participants. Compared with men, women had 9% (95% CI, 3%–15%) lower covariate-adjusted risk of death and 6% (0%–13%) lower risk of stroke recurrence or death. Generally, women had significantly poorer outcomes in activity of daily living and anxiety than men, and the sex differences persisted to up to 5 years after stroke. Women also had poorer health-related quality of life in physical (β=−2.06 [95% CI, −3.01 to −1.10]) and mental domains (β=−1.48 [95% CI, −2.44 to −0.52]). Although not significant, there was a suggestive trend for poorer outcomes in cognitive impairment and depression in women. No significant difference in stroke recurrence were found between men and women. CONCLUSIONS: Female patients with stroke tended to have better covariate-adjusted survival but poorer outcomes among survivors than male patients, with deficits persisting to up to 5 years poststroke.

Quality of life and mood disorders of mild to moderate stroke survivors in the early post-hospital discharge phase: a cross-sectional survey study

“…For instance, our findings suggest that female stroke survivors may represent an important sub-group who may be in greater need of support in the early discharge phase, given their poorer quality of life and greater severity depression and anxiety. This is consistent with previous studies which have found that female survivors have poorer outcomes than males even up to 5 years post-stroke [ 61 ]. Further research examining the effectiveness of strategies to improve psychosocial outcomes of stroke survivors is urgently needed, given few studies have demonstrated efficacy of such interventions.…”

Stroke in Women: A Review Focused on Epidemiology, Risk Factors, and Outcomes

“…124 Similarly, in a recent prospective 25-year follow-up study from the UK, women had a 9% lower risk of death than men after full adjustment, while they had a 30% higher risk of death than men in an unadjusted analysis. 4 In a pooled analysis of individual participant data from five acute stroke randomized controls trials, after multivariable adjustments, women with ischemic stroke had higher survival rates at 3-6 months than men; however, this higher survival rate in women was not significant for ICH. 125 Women have poorer functional recovery and lower quality of life (QOL) than men after stroke.…”

“…123 Stroke outcomes (Figure 3) Regarding stroke mortality, contradictory results have been shown depending on adjustments for confounders. 4,124 In the INSTRUCT (International Stroke Outcomes Study), a meta-analysis of individual participant data from 13 population-based incidence studies, the crude mortality rate ratio (MRR) was higher for women than men at 1 year (MRR [95% CI], 1.35 [1.24-1.47]) and 5 years (MRR [95% CI], 1.24 [1.12-1.38]). 124 However, these results were reversed after adjusting for confounders including age, pre-stroke functional limitations, stroke severity, and history of AF (1-year MRR [95% CI], 0.81 [0.72-0.92] and 5-year MRR [95% CI], 0.76 [0.65-0.89]); this indicates that women's higher mortality after stroke is attributable to these confounders (advanced age, greater stroke severity, worse pre-stroke status, and higher prevalence of AF).…”

“…4,10,[125][126][127][128] Advanced age, more severe strokes, poorer pre-stroke function, more comorbidities, less social support, and a higher likelihood of being a widow are factors considered to contribute to a less favorable outcome in women; however, the causes have yet to be fully elucidated because adjustment for these factors does not adequately explain the sex differences in functional recovery and QOL after stroke. 4,10,[125][126][127][128] Post-stroke depression (PSD) is more common in women than in men. 126,129 A previous systematic review suggested that the prevalence of PSD is 78% higher among women than among 10 https://j-stroke.org men.…”

“…1 Stroke is a particularly important issue for women, who account for over half (56% in 2019) of all persons who have experienced a stroke. 2 Women have higher lifetime risk (LTR) of stroke 3 and poorer stroke outcome 4 than men. In women, the distribution of some risk factors and the risk of stroke with those risk factors are different from men.…”