Secondary Stroke Prevention in Women

Initial Assessment and Treatment

The American Heart Association recommends checking for atrial fibrillation via ECG, cardiac monitoring, or history in female patients with a history of ischemic stroke 1, 2
The American College of Cardiology suggests identifying if the stroke was cardioembolic or noncardioembolic based on prior workup 2, 3
The American Heart Association recommends confirming that the patient is not on hormone replacement therapy, which should be discontinued if present (Class III recommendation) 4, 5

The American College of Cardiology recommends oral anticoagulation as mandatory and superior to antiplatelet therapy in patients with atrial fibrillation 1, 2
The American Heart Association suggests direct oral anticoagulants (DOACs) are preferred over warfarin for nonvalvular atrial fibrillation 1
The American College of Chest Physicians recommends dabigatran 150 mg twice daily over warfarin (target INR 2.0-3.0) 2
The American Heart Association recommends clopidogrel 75 mg once daily as the preferred antiplatelet agent for long-term secondary prevention in patients without atrial fibrillation 1, 2, 6
The American College of Cardiology suggests clopidogrel over aspirin monotherapy (Grade 2B) for superior efficacy 2, 3

The American Heart Association recommends never using dual antiplatelet therapy (aspirin plus clopidogrel) for chronic secondary prevention beyond 21-30 days post-stroke (Class III recommendation) 4, 6, 7
The American College of Cardiology recommends avoiding postmenopausal hormone replacement therapy, as it increases stroke risk by 44-53% (Class III, Level A) 4, 5

The American College of Cardiology recommends atorvastatin 80 mg daily for patients with LDL-cholesterol >2.5 mmol/L (>100 mg/dL) 1
The American Heart Association suggests targeting LDL-cholesterol <1.8 mmol/L (70 mg/dL) for patients with atherosclerotic disease 1
The American College of Cardiology recommends targeting systolic blood pressure <140 mmHg, particularly important if intracranial stenosis is present 7
The American Heart Association recommends smoking cessation with counseling and pharmacotherapy (nicotine replacement, bupropion, or varenicline) 1
The American College of Cardiology suggests reducing salt intake to <2000 mg daily 1
The American Heart Association recommends limiting alcohol to ≤1 drink daily for women 1

The American College of Cardiology recommends monitoring lipid levels 1-3 months after treatment initiation, then every 3-12 months 1
The American Heart Association suggests ensuring medication adherence, as premature discontinuation increases cardiovascular event risk 7
The American College of Cardiology recommends screening for new-onset atrial fibrillation at each visit, as this would change management to anticoagulation 1, 2