A-Fib and Stroke: A Woman’s Perspective

By Lynn Haye, October 2013

Stroke prevention is the primary focus for all people with A-Fib; men and women, young and old – regardless of the type of A-Fib. Patients with A-Fib have a 5-fold increased risk of stroke. This risk factor increases steeply with age (1.5% at ages 50-59 to 23.5% at ages 80-89)¹  In addition, since A-Fib is often asymptomatic and may go clinically undetected, the stroke risk attributed to A-Fib may be substantially underestimated.

The National Stroke Association estimates that at least 1 in 6 strokes are actually caused by A-Fib and that A-Fib strokes are more debilitating with higher rates of mortality. However, three out of four A-Fib strokes can be prevented in patients who have been diagnosed with A-Fib and are receiving appropriate treatment.²

Women with A-Fib and Stroke Risk

Recent publications have highlighted the gender differences in stroke risk.³,⁴ Women have a higher lifetime risk of stroke from all causes, and this is probably related to both life expectancy and treatment variables. The question of female sex as a separate risk factor for stroke in A-Fib is a bit more complicated.

There are two stroke risk tools currently used by physicians to predict risk in A-Fib patients; CHADS2 in the US and the newer CHA2DS2-VASc in Europe.⁵   The newer tool adds an independent risk factor for female sex and lowers the age range to 65 for risk. This development puts younger women with A-Fib into consideration for anticoagulation medication. Because of the increased risk for bleeding on these medications, there is concern about putting more and younger patients on them.  Anticoagulants are not like taking vitamins. No one should be on anticoagulants unless there is a real risk of stroke.

A recent Danish study ⁶ found that while female sex increased stroke risk by 20% in A-Fib patients older than 75, it did not do so in female A-Fib patients age 65-74.  This suggests no increased risk for younger women, while older women remain at risk due to age. The current UK protocol in the GARFIELD study ⁷may answer this difference as they are evaluating the significance of female sex as an independent risk factor for A-Fib stroke in younger patients, age 65-74.

Women with A-Fib Under-Diagnosed and Under-Treated

As with other cardiovascular disorders, women with arrhythmias in the US have been under-treated and under-referred.  This less aggressive and/or less effective treatment for A-Fib may put women at higher risk for stroke overall.  Studies have shown that women with A-Fib have been less likely to receive anticoagulation and ablation procedures compared to men, although their treatment benefits are comparable.⁴

How Do Strokes Happen to Women?

Let’s take the example of Elaine, a College-educated professional who marries at age 25 to Bob, a 32-year-old accountant. They both lead busy but fulfilling lives and have two wonderful children. Elaine is naturally protected from a stroke during her child-bearing years by her menstrual cycle. The blood she loses every month thins her blood and makes her less susceptible to forming clots and having a stroke. But once Elaine enters menopause and no longer has her menstrual cycle, all too soon her risk of stroke becomes the same as her husband, Bob.

Bob unfortunately passes away at age 76 leaving Elaine a widow at age 69. (Women in the US live an average of five years longer than men.) As Elaine ages she becomes more limited in her physical activities. Her blood becomes thicker and more viscous. Clots can more easily form in her heart, especially in the Left Atrial Appendage (where 90%-95% of A-Fib clots form). She may develop A-Fib which is more likely to happen as people get older. At age 81 Elaine has an A-Fib stroke.

This unfortunately is an all too common scenario for women.

What can We Women Do to Prevent an A-Fib Stroke?

Is there anything women can do to reduce their risk of stroke? Some things come to mind:

Recognize Important Signs

If you haven’t been formally diagnosed with A-Fib, be sure to take seriously signs such as palpitations, shortness of breath, fatigue, dizziness, chest pain and fainting.  These signs may be significant, not just moods or the result of an ‘off’ day.  Check your pulse for any irregularity – it’s the rhythm not the rate that should concern you here.  Remember, A-Fib stroke may be avoided with early diagnosis and treatment.

See an Electrophysiologist (EP)

If you are newly diagnosed, have you followed up with a cardiologist or, better still, an electrophysiologist (EP)?  EPs see arrhythmias all the time and are usually more current on treatment options.  Sometimes it feels just ‘too’ serious or inappropriate to contact a ‘heart’ specialist, but it’s really more comforting when you are in the care of someone who regularly treats A-Fib.

If you need help locating an electrophysiologist in your area, check the provider list on this web site.

Be Aware—We Women Communicate Differently

Most women agree that we tend to communicate differently!  Contrary to some popular opinion, we often hesitate to complain or report symptoms – even when we know we should.  Some women still see heart problems as ‘masculine’ and can feel awkward presenting cardiac symptoms, particularly to a male physician. Just watch the comedic video by Elizabeth Banks at the American Heart Association website for a very insightful rendition of how we can minimize symptoms (AHA, Go Red for Women, “Just a Little Heart Attack”).  It’s painfully funny….

Prepare for Your Electrophysiologist (EP) Appointment

Your physician may have limited time, so be prepared before going in for your appointment. It helps to take a list of questions or concerns to help you stay focused and make the best use of your time.  This also demonstrates the level of seriousness and concern that you bring to the session.

Importance of Blood Thinners for Women

Anticoagulation therapy is so basic to stroke prevention in A-Fib that any woman diagnosed with non-valvular A-Fib should make sure to discuss this with her physician at her first appointment.  But ‘Blood thinners’ carry the risk of bleeding, so your physician may check your risk on the HAS-BLED score.⁸ before prescribing blood thinners for you. The newer, novel anticoagulants such as Pradaxa and Xarelto can make adherence easier for women. This is because the lack of dietary restrictions suits the diet of the typically ‘dieting’ woman.  However, the new, novel anticoagulants do not yet have reversal agents and should be used with caution. The other option, warfarin, requires frequent blood monitoring, and women are often very reluctant to add more required tasks to their already busy schedules.  There is a procedure for those who cannot tolerate anticoagulation medication. This procedure involves closing off the left atrial appendage and involves a more detailed and complex risk-benefit analysis.

(Added 2018: The anticoagulants Pradaxa, Xarelto and Eliquis now have FDA-approved reversal agents or antidotes.)

Know the Symptoms of Stroke!

•  Sudden numbness or weakness of face, arm, leg—especially on one side of the body.
•  Sudden confusion, trouble speaking or understanding
•  Sudden trouble seeing in one or both eyes
•  Sudden trouble walking, dizziness, loss of balance or coordination
•  Sudden severe headache with no known cause

And the Other Symptoms Unique to women!

•  Sudden face and limb pain
•  Sudden hiccups
•  Sudden nausea
•  Sudden general weakness
•  Sudden chest pain
•  Sudden shortness of breath
•  Sudden palpitations

Call your emergency service (dial 911 in the US or 999 in the UK) if you have any of these symptoms, and make sure that your family and friends know that time is critical with stroke.  Everyone should know the simple test to act F.A.S.T.

F = FACE  Ask the person to smile. Does one side of the face droop?

A= ARMS  Ask the person to raise both arms. Does one arm drift down?

S= SPEECH  Ask the person to repeat a simple phrase. Is their speech slurred or strange?

T= TIME  If you observe any of these signs, call 911 immediately. ²

Aim to be A-Fib Free

Probably the best thing to know about A-Fib stroke prevention is to not have A-Fib!  As Steve Ryan points out so well in his book, “Beat Your A-Fib”, the best preventive for A-Fib stroke is get rid of your A-Fib, to ‘Beat Your A-Fib’.

Prevent an A-Fib stroke—first ‘treat’—then ‘beat’ your A-Fib!

Lynn Haye, PhD

LYNN HAYE, Ph.D.  is a clinical psychologist and former A-Fib patient. She studies and writes about current trends in the treatment and diagnosis of atrial fibrillation and has a special interest in women’s health issues. Dr. Haye and her family live in Orange County, CA.