AHA and ASA Release First-Ever Guidelines on Stroke Prevention in Women

Guideline Watch |
February 24, 2014

AHA and ASA Release First-Ever Guidelines on Stroke Prevention in Women

  1. Hooman Kamel, MD

Despite numerous evidence gaps, this literature summary and practical set of recommendations will be a helpful guide for primary care physicians, obstetricians, and neurologists.

  1. Hooman Kamel, MD

Sponsoring Organization: American Heart Association/American Stroke Association

Background and Objective

Certain stroke risk factors occur only or more commonly in women. To address these risk factors, the AHA/ASA have released guidelines for stroke prevention in women.

Key Recommendations

  • During pregnancy, women with hypertension should take low-dose aspirin from 12 weeks of gestation until delivery (Class I, Level A). Prescribe appropriate antihypertensive drugs (e.g., methyldopa, labetalol, nifedipine) for severe hypertension (I, A) and consider them for moderate hypertension (IIa, B).

  • Consider screening for pre-eclampsia/eclampsia history and documenting it as a stroke risk factor (IIa, C).

  • Screen patients with cerebral venous thrombosis (CVT) for underlying prothrombotic conditions (e.g., infection, inflammatory disease, oral contraceptive use) (I, C). Test for primary hypercoagulable states, but not acutely or during warfarin use (IIa, B).

  • Warfarin therapy duration should be 3 to 6 months if CVT is provoked, 6 to 12 months if unprovoked, and lifelong if recurrent or if a primary hypercoagulable state is present (IIb, C).

  • Acute CVT during pregnancy can be treated with low-molecular-weight heparin (LMWH) rather than unfractionated heparin (IIa, C). LMWH should be continued throughout pregnancy and either LMWH or warfarin for ≥6 weeks postpartum, ≥6 months total (I, C).

  • Prior CVT does not contraindicate future pregnancy (IIa, B), although gestational and postpartum LMWH should be considered (IIa, C).

  • Measure blood pressure before initiating oral contraceptives (I, B).

  • Perform pulse palpation for atrial fibrillation (AF) in the primary care setting for women older than 75 (I, B).


To be effective, many of these recommendations — such as pulse screening for atrial fibrillation — will require diffusion into routine primary care practice. Other recommendations — such as guidelines on the management of cerebral venous thrombosis, which occurs much more commonly in women — are directly useful to neurologists. Ultimately, more-tailored treatment of these gender-specific factors may reduce the overall burden of stroke.

Editor Disclosures at Time of Publication

  • Disclosures for Hooman Kamel, MD at time of publication Consultant / Advisory board Genentech Grant / research support American Heart Association


Reader Comments (1)

Dr. V Kantariya MD Physician, Family Medicine/General Practice

Women who get migraines with aura are also at higher stroke risk. As for the risk of treatment with triptans (drugs of choice in migraine therapy) ,there are no sufficient data to intention of lowering risk of stroke. First, do No Harm! CHOOSING WISELY!

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