Addressing Gender Disparities in Acute Stroke Care

Comments

Despite having worse stroke symptoms and living within comparable distances from comprehensive stroke centers, women with acute ischemic strokes with large vessel occlusion are less likely to be referred to centers compared with men, according to a new study from UTHealth Houston.

Led by corresponding author Sunil Sheth, MD, associate professor of neurology and director of the vascular neurology program with McGovern Medical School at UTHealth Houston, and senior author Youngran Kim, PhD, assistant professor of management, policy and community health with UTHealth Houston School of Public Health, the study was published in the Journal of the American Heart Association .

Large vessel occlusion stroke occurs when a major artery in the brain becomes blocked. They are considered one of the most serious types of strokes, accounting for 24% to 46% of acute ischemic strokes.

“Timely stroke treatment is incredibly important; The faster a doctor can open the glass, the better the patient’s chances of having a good outcome. “These routing systems in hospitals are designed to get patients to the best care as quickly as possible,” Sheth said. “We don’t know exactly why women were less likely than men to be sent to comprehensive stroke centers, but we do know that gender is an implicit bias. Getting to the granular level of what was included in a hospital’s routing decision will be very important for future studies.”

Researchers identified consecutive patients with acute ischemic stroke due to large vessel occlusion from a prospectively collected multi-hospital registry for the Houston metropolitan area from January 2019 to June 2020. They compared prehospital routing of men and women with centers capable of performing therapy. endovascular to remove the clot blocking the artery. Among 503 patients, 82% were sent to comprehensive stroke centers. Women made up 46% of the study participants.

Compared with men, women with acute ischemic stroke with large vessel occlusion were older (73 vs. 65) and had a higher National Institutes of Health Stroke Scale (NIHSS) score. (14 vs. 12), meaning their symptoms were worse. After adjusting for differences in stroke type, age, distance traveled, and other relevant factors, women with acute ischemic stroke with large vessel occlusion were approximately 9 % less likely than men to be referred to Comprehensive stroke centers.

"The higher NIHSS score in women may be partly attributed to their older age, as age itself is a known factor contributing to sex differences in stroke severity," Kim said. “In addition, older women are more likely to live alone and experience social isolation, which can lead to a delay in recognizing stroke symptoms and subsequent delays in seeking medical care.”

Additionally, patients who lived within 10 miles of the nearest comprehensive stroke center were 38% more likely to be referred to one.

Stroke is the fifth leading cause of death among women, according to the Centers for Disease Control and Prevention, and because women generally live longer than men, more women suffer strokes throughout their lives.

Previous studies have shown that women with acute ischemic stroke were less likely than men to receive anticoagulant treatment with intravenous tissue plasminogen activator (tPA) , and that women with stroke are 33% more likely to receive being misdiagnosed for problems not related to the stroke, such as headache or dizziness.

"Older age at onset and severe stroke in women, combined with a higher likelihood of age-related risk factors, may contribute to a higher rate of death from stroke and a higher risk of disability after stroke." in women," Kim said. “Therefore, appropriate triage and prehospital pathway may be even more critical for women. "There is a need to investigate whether large vessel occlusions in women are less likely to be identified with current screening tools due to older age, premorbidity, or nontraditional symptoms."

Clinical Perspective

What’s new?

We identified sex differences in the likelihood of prehospital referral of patients with acute ischemic stroke with large vessel occlusion to centers capable of performing endovascular therapy.

What are the clinical implications?

Timely intervention is essential for patients with acute ischemic stroke.

Identifying and eliminating disparities in prehospital referral will help ensure optimal treatment outcomes.

Endovascular therapy (EVT) for large vessel occlusion (LVO) and acute ischemic stroke (AIS) can dramatically reduce disability, but its effectiveness is highly time-sensitive. As a result, many urban stroke care systems have adopted referral paradigms in the prehospital setting, in which patients with suspected LVO AIS are preferentially referred to comprehensive stroke centers (CSCs) rather than primary stroke centers. potentially closer cerebrovascular arteries without EVT capability. (PSC). Although previous studies have shown that a major delay in the initiation of EVT is interhospital transfer from a PSC to a CSC, the frequency with which direct routing to the CSC occurs and the factors associated with direct transport to the CSC are unknown. .

Stroke affects more women than men, but disparities in treatment persist.

Previous studies have found lower rates of intravenous tissue plasminogen activator (tPA) treatment and longer door-to-image and door-to-needle times associated with worse outcomes. Some previous data also suggested lower rates of VTE in women, and inequities in prehospital CSC routing in women versus men remain undetermined.

Here, we determined the referral rate of CSC in a multi-hospital registry in a metropolitan city covering a large geographic area. Among patients with LVO AIS, we examined rates of prehospital referral to PSC versus CSC and identified differences based on sex. We hypothesize that distance to the CSC, stroke severity, and sex are associated with direct prehospital referral to the CSC.

Muhammad Tariq, MD, chief resident in the Department of Neurology at McGovern Medical School, was the study’s first author. Other co-authors from the McGovern Medical School neurology department included student Iman Ali, BS; resident Sergio Salazar-Marioni, MD; research coordinator Ananya Iyyangar, BSA; research coordinator Hussain Azeem, BS; resident Swapnil Khose, MD; research assistant Rania Abdelkhaleq, MPH; and Louise McCullough, MD, PhD, professor and department chair and Roy M. and Phyllis Gough Huffington Distinguished Chair at McGovern Medical School. Abdelkhaleq is also a student at the UTHealth Houston School of Public Health. McCullough is a member of the University of Texas MD Anderson Cancer Center, UTHealth Houston Graduate School of Biomedical Sciences. Also co-author of the study was Dr. Victor Lopez, a resident at Emory School of Medicine.