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. Author manuscript; available in PMC: 2019 Sep 1.
Published in final edited form as: Stroke. 2018 Sep;49(9):e291. doi: 10.1161/STROKEAHA.118.021980

Response by Demel and Rexrode to Letter Regarding Article, “Stroke risk factors unique to women”

Stacie L Demel DO 1, Kathryn M Rexrode 2
PMCID: PMC6205747  NIHMSID: NIHMS1500367  PMID: 30355009

Dear Editor,

Please find our response to comments from Mr. Shahid and Dr. Lip.

Thank you very much for your thoughtful response to our recent publication Stroke Risk Factors Unique to Women.1 We agree that atrial fibrillation (AF) is a common and important stroke risk factor, with higher risk of for stroke for women than men with AF; this risk was highlighted in the review by Madsen et al.2

As you are aware, there is not a consensus as to the reasons for which women with AF have higher stroke rates than men with AF.3 Postmenopausal hormone use may be a factor, as is suggested by the SPAF trial post hoc analysis,4 although as you note, this was not confirmed in your manuscript which used data from the AFFIRM trial, and does not explain all of the observed increased risk.5 Genetic, environmental, and hormonal factors, as well as other co-morbidities, may play a role in the increased stroke risk in women with AF compared to men.3 We propose that further research, testing these hypotheses, is needed to bring more clarity to this issue.

Ultimately, we also agree with your statement that in the case of a patient with AF, the default should be to anticoagulate women greater than 65 years of age, with AF and a CHA2DS2VASc = 1 unless the risks are outweighed by a high risk of bleeding.

Sincerely,

Drs. Demel and Rexrode

Footnotes

Conflicts of Interest Statements: KM Rexrode: currently supported by NIH grant HL088521; SL Demel: receives compensation as a member of the Speaker’s Bureau for Genentech

References

  • 1.Demel SL, Kittner S, Ley SH, McDermott M, Rexrode KM. Stroke risk factors unique to women. Stroke. 2018;49:518–523 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2.Madsen TE, Howard VJ, Jimenez M, Rexrode KM, Acelajado MC, Kleindorfer D, et al. Impact of conventional stroke risk factors on stroke in women: An update. Stroke. 2018;49:536–542 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 3.Cheng EY, Kong MH. Gender differences of thromboembolic events in atrial fibrillation. Am J Cardiol. 2016;117:1021–1027 [DOI] [PubMed] [Google Scholar]
  • 4.Hart RG, Pearce LA, McBride R, Rothbart RM, Asinger RW. Factors associated with ischemic stroke during aspirin therapy in atrial fibrillation: Analysis of 2012 participants in the spaf i-iii clinical trials. The stroke prevention in atrial fibrillation (spaf) investigators. Stroke. 1999;30:1223–1229 [DOI] [PubMed] [Google Scholar]
  • 5.Apostolakis S, Sullivan RM, Olshansky B, Lip GY. Hormone replacement therapy and adverse outcomes in women with atrial fibrillation: An analysis from the atrial fibrillation follow-up investigation of rhythm management trial. Stroke. 2014;45:3076–3079 [DOI] [PubMed] [Google Scholar]

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