Sex Differences in Poststroke Outcomes Among Middle Aged and Older Stroke Survivors

Abstract

Over 7 million US adults are stroke survivors, and approximately 4.1 million are women. As the population ages, number of stroke survivors will rise to a projected 10 million by 2030, impacting the prevalence of stroke recurrence and underscoring the growing need for enhanced secondary stroke prevention and access to high quality poststroke care to optimize stroke survivorship. Although women face a disproportionate burden of stroke prevalence, number of deaths after stroke, and physical disability when compared with men, little is known about sex differences in secondary and tertiary stroke prevention and important contributors to sex differences. To address these gaps, this dissertation examined sex differences in stroke recurrence and post-recurrence mortality, poststroke medication adherence, and social participation restrictions, and identified factors contributing to these differences. Chapter 2 (the first aim) delineated sex differences in trends in stroke recurrence and post-recurrence mortality in the population-based biethnic Brain Attack Surveillance in Corpus Christi (BASIC) project. Short- and long-term risks of recurrence declined during 2000-2020 among both sexes, with women experiencing a larger decline. However, short- and long-term risks of post-recurrence mortality increased over the study period, with women experiencing a larger increase. Therefore, ongoing surveillance of stroke outcomes and continued efforts to prevent recurrent stroke and reduce post-recurrence mortality among both sexes are needed. Chapter 3 (the second aim) investigated how social, behavioral, and clinical factors contributed to sex differences in recurrence and all-cause mortality after first-ever ischemic stroke in BASIC. Marital status, obesity, stroke severity, prestroke depression, and prestroke disability were identified as common contributors to sex differences in recurrence and poststroke mortality. Education and coronary artery disease contributed only to the sex difference in mortality, while routine physician access contributed only to the sex difference in recurrence. Given sex differences in these factors, future interventions to prevent recurrence and mortality should consider a sex-specific approach. Chapter 4 (the third aim) examined sex differences in poststroke medication adherence and the contributors in BASIC. At 90-days poststroke, women were more likely to report nonadherence to cholesterol-lowering drugs and antiplatelets. Adjustment for obesity attenuated the disparities, while adjustments for age, marital status, insurance type, routine physician access, smoking and alcohol consumption accentuated the disparities. Race-ethnicity modified the sex disparities such that the sex differences were larger in Mexican Americans (MA) than non-Hispanic whites. MA women, women with obesity, men with unhealthy lifestyles, and men without access to care may be targeted subgroups in medication adherence interventions. Chapter 5 (the fourth aim) evaluated sex differences in social participation restrictions among community dwelling stroke survivors identified from the National Health and Aging Trends Study. Women were more likely than men to report participation restrictions in overall social activities (OR 1.90; 95% CI 1.21, 2.99) and in attending religious services (OR 1.80; 95% CI 1.08, 3.02). These sex differences were explained away by several prestroke factors including marital status, living arrangements, driving frequency, comorbidities, physical capacity, and activity limitations. Future social or clinical interventions aimed at promoting poststroke social participation need to consider sex-specific approaches. Collectively, this dissertation uncovers significant sex differences across various aspects of secondary and tertiary stroke prevention, which can be explained by sex differences in social, behavioral, and clinical factors. Future interventions designed to improve poststroke outcomes need to consider a sex-specific approach and prioritize targeting social factors.