Better blood pressure management needed for women after stroke

Following an acute stroke, adequate treatment of blood pressure is the most important way to reduce recurrent stroke in both men and women. Although no data currently exist that suggest blood pressure lowering after stroke should be done differently in women versus men, data do show areas of differences in blood pressure management for men and women.

One key area is treatment of blood pressure in the acute stroke setting. Data suggest that women are not receiving adequate blood pressure treatment in this setting and it could affect outcomes.

“Women present with higher blood pressures in the acute setting that disqualifies them for intravenous thrombolysis,” said Cheryl Bushnell, MD, professor of neurology and director of the Wake Forest Baptist Stroke Center for Wake Forest Baptist Health in Winston Salem, North Carolina. “This is important because women ultimately have better outcomes from tissue plasminogen activator (IV tPA) than men, so we should be doing everything we can to manage blood pressure better in women in the acute stroke setting.”

Speaking during the American Heart Association (AHA) Scientific Sessions in a session entitled “Blood Pressure Management after Acute Stroke in Women,” Bushnell highlighted the need for physicians to recognize that blood pressure in women may not be sufficiently controlled in the acute stroke setting and the need to do so.

Citing data from a 2010 study in Neurology, Bushnell emphasized a finding that highlights what she called the “gender treatment paradox.” The study showed no difference in who received IV tPA treatment, but that women had worse outcomes after stroke than men if they didn’t receive tPA. She also cited findings from a stroke registry at the Wake Forest Baptist Medical Center (WFBMC) showing that, among 952 patients (469 women and 483 men), women had worse outcomes without tPA than men, but had better outcomes with tPA than men. These data highlight the importance of women receiving tPA in the acute stroke setting.

Next: How to manage patients in the acute stroke

How to manage patients in the acute stroke setting remains challenging, Bushnell said, citing gaps in current AHA guidelines on acute stroke management that show no evidence to data on what the ideal blood pressure for patients should be after an acute ischemic stroke. In addition, she said the guidelines offer no recommendations for treatment that is specific to women. What the guidelines do show is that extreme blood pressures-systolic blood pressure (SBP) greater than 220 mmHg or less than 100 mmHg-are potentially detrimental.

Bushnell also talked about the differences between women and men in terms of tolerance to antihypertensive medications. She said that women may be more likely to be prescribed thiazide diuretics than men, and may be more likely to have side effects from antihypertensive medications (for example, cough related to angiotensin converting enzyme [ACE] inhibitors, electrolyte disturbances related to diurectics, and edema related to calcium channel blockers [CCBs]).

Unknown, she said, is whether sex differences in blood pressure regulation may be related to hormones and, if so, what impact this would have on treatment.

Overall, Bushnell highlighted the need for more evidence on the specific needs for blood pressure treatment for women to prevent a recurrent stroke. To that end she emphasized that “secondary prevention trials for hypertension treatment need to increase the recruitment of women.”