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TitleA Primer on Stroke Prevention and Treatment - L. Goldstein (Wiley-Blackwell, 2009) WW
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Page 2

A Primer on Stroke Prevention Treatment:
An Overview Based on AHA/ASA Guidelines

A Primer on Stroke Prevention Treatment: An Overview Based on AHA/ASA Guidelines, 1st Edition. Edited by
Larry B. Goldstein © 2009 American Heart Association. ISBN: 978-1-405-18651-3

Page 135

Chapter 9 Stroke in Women

127

study also assessed reported use of antidepressant
drugs, and this was again more common in women
than men [74]. The Sunnybrook Stroke Study evalu-
ated depression using the objective, observer-rated
scale (Montgomery Asberg Depression Rating Scale)
and a subjective scale (Zung Self-Rating Depression
Scale) in 436 patients with stroke [75]. The preva-
lence of self-reported depression at 3 months post-
stroke was 21%, whereas the objective measure was
27%, the majority of which was due to mild depres-
sion. These rates of depression were similar at 1 year
post-stroke. Consistent with other cited studies,
female sex was associated with depression measured
with both scales. The other important fi nding was
that depression was associated with worse functional
status, quantifi ed with the Functional Independence
Measure, and disability, measured with the Oxford
Handicap Scale (same as the mRS) [75]. In summary,
these studies have demonstrated that depression is
more common in women and is associated with
poorer functional status after stroke.

Another important reason to recognize depres-
sive symptoms following stroke is because its
presence is associated with increased mortality. A
randomized trial of treatment strategies for depres-
sion post-stroke screened for the presence of self-
reported mood symptoms within the PSE and the
General Health Questionnaire (GHQ)-28 (a measure
of general psychological distress) at 1 month and
then followed the cohort for 24 months. The inves-
tigators found that subjects in the highest quartile of
the GHQ-28 (signifying increased psychological dis-
tress) were at a 3-fold risk of death by 12 months
(OR 3.1; 95% CI 1.1–8.8; P = 0.037) and 2-fold risk
of death by 24 months (OR 2.2; 1.0–4.8; P = 0.048).
Interestingly, an International Classifi cation of
Diseases-10 diagnosis of major depression was not
associated with mortality.

Depression and psychological stress have also
been investigated as risk factors for incident stroke.
In a large study from the United Kingdom, there was
no signifi cant relationship between major depressive
disorder and incident stroke, but there was a signifi -
cant and positive association with psychological
stress [76]. Therefore, screening for psychological
distress may become an important aspect of risk
factor modifi cation.

A major knowledge gap in stroke outcomes is
how depression and psychological distress affect

stroke risk. Is this because it leads to reduced
physical activity, or weight gain and thus a worsen-
ing cardiovascular risk profi le? This is especially
important for women because they are at risk of
having depression prior to having a stroke, and
for having more depressive symptoms following
the stroke.

Physical activity
The patient described in the case study had a cere-
bellar stroke, which limited her mobility for several
months. Patients who have disability from ischemic
stroke should be considered for a supervised exercise
regimen. Not only have exercise programs been
shown to improve outcomes in physical function-
ing, but they have also been associated with improved
measures of QOL (higher ADL scores, improved
social function, and physical role function) [77] and
fewer depressive symptoms [78]. Specifi c recom-
mendations for physical activity for stroke survivors
are summarized in an AHA guidelines statement
[79]. These guidelines provide recommendations
for aerobic, strength training, fl exibility, and neuro-
muscular aspects of potential exercise programs,
depending on the goals and needs of the stroke
survivor [79].

With regards to sex differences, a recent random-
ized controlled trial of supervised versus unsuper-
vised exercise program reported that both men and
women improved in the 6-minute walking speed
and the SF-36 Physical Component summary score,
regardless of treatment assignment. However,
women made greater gains in the supervised pro-
grams, whereas men had greater gains in the unsu-
pervised programs (interaction term of gender by
treatment P = 0.01) [80]. The reasons for this
outcome are unclear but may relate to social
interactions.

Measuring exercise capacity is an opportunity to
optimize primary and secondary cardiovascular pre-
vention. This is important because poor exercise
capacity has been associated with cardiac death in
women [81]. This was shown in a study in which
women with and without coronary disease symp-
toms underwent symptom-limited treadmill tests
and were followed for cardiac outcomes. The percent
of predicted exercise capacity was measured with
exercise nomograms developed for women who
were active and those who were sedentary (Figure

Page 136

c09f007.eps


A Primer on Stroke Prevention Treatment: An Overview Based on AHA/ASA Guidelines

128

9.7) [81]. Regardless of the presence of symptoms,
women with an exercise capacity less than 85%
of the age-appropriate predicted value had a
2-fold increased risk of death from any cause and
a 2.4-fold risk of cardiac death [81]. Although
not specifi cally developed for stroke, this type of
exercise nomogram is useful for general cardiovas-
cular prevention screening and would help identify
women who would benefi t from exercise programs.
A major research gap related to physical activity for
women is how to motivate women who are at risk
for stroke to become active. In addition, given the
evidence that women are more likely to have worse
functional status and QOL than men post-stroke,
various exercise programs could be utilized to
improve function and QOL for women after stroke

and concomitantly reduce the risk of recurrent
stroke.

In summary, women have a greater lifetime risk
of stroke than men, and therefore we have many
opportunities and challenges to provide high-quality
preventive care. In addition, women may present
with unorthodox stroke symptoms, which requires
astute history taking to recognize a stroke and direct
treatment. During the acute stroke hospitalization,
we have an opportunity to improve outcomes by
recognizing and treating depression, providing
appropriate rehabilitation and exercise programs,
and initiating secondary prevention strategies.

References available online at www.wiley.com/go/
strokeguidelines.

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Fig. 9.7 Exercise nomogram for determining exercise capacity in active and sedentary women [81]. From Gulati M, et al. N Engl J Med.
2005;353:246–475.
MET, metabolic equivalent.

Page 269

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Page 270

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