Stroke threatens more women than breast cancer does

Host Amber Smith: Upstate Medical University in Syracuse, New York, invites you to be The Informed Patient, with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith.

Stroke kills about twice as many women as breast cancer does every year. And yet, surveys show women are more afraid of a breast cancer diagnosis. Here to discuss how stroke affects women is Michelle Vallelunga. She's a nurse at Upstate and also the stroke program data coordinator.

Welcome to "The Informed Patient," Ms. Vallelunga.

Michelle Vallelunga: Thanks for having me.

Host Amber Smith: Why do you think women are more concerned about breast cancer?

Michelle Vallelunga: In general, it's definitely, I think, more on the radar of people, out in the media. And stroke, I think, sometimes it's been linked to, like, heart disease in general. And so I feel like there's just a greater heightened awareness out there about breast cancer, as it should be, and the importance of screening for that, a little different public perception out there about stroke and, specifically, women's risk for stroke.

And that's why I wanted to talk today about this topic, to just raise some awareness for folks.

Host Amber Smith: Why do women face a higher risk of stroke overall?

Michelle Vallelunga: I think that in general, the simple way to look at this is that some higher stroke risk may occur in the younger ages of women due to some unique risk factors. And then, as specifically for women in the older ages, like over age 75, for example. So it's like those two potentially coming together for women kind of ups their risk.

And then you add to those unique risk factors, some more general risk factors that affect both men and women. things like high blood pressure in general, obesity, lack of exercise, those kinds of things.

So when you take all three of those components together, it can lead to a higher stroke risk for women.

Host Amber Smith: Do women have more strokes than men have?

Michelle Vallelunga: About 85,000 women a year die from a stroke. And it actually has been increased to the third leading cause of death for women overall. It used to be the fourth leading cause. We just pulled up some recent information from American Heart and American Stroke Association. So that's really going to be the key where we can get some of these statistics.

Host Amber Smith: So it sounds like the strokes for women may be becoming more deadly.

Michelle Vallelunga: Yes, it is. I think that women, again, just have some of these unique risk factors that come into play that would cause them to be a little bit more at risk.

Host Amber Smith: Well, let's talk more about the risk factors that women and men have, but women have some unique risk factors.

So let's go over those, if you would.

Michelle Vallelunga: Sure So, women and high blood pressure: Certainly high blood pressure is a risk for men as well, but women are generally a little bit more likely to have high blood pressure. For women, it often comes after menopause and in high-risk populations like African American women, who are at greater risk for high blood pressure. For them, that also is a combined factor and can be unique to them.

But the good news for high blood pressure is that (controlling) it gives you the biggest bang for your buck in terms of lowering your stroke risk. So if you're very careful about monitoring your blood pressure, knowing what those numbers are, both men and women, if they take really good steps and get that blood pressure in the acceptable ranges, they can really hit their stroke risk by about 30 to 40%.

The second factor for women that is unique is pregnancy, just the state of pregnancy. When a woman is pregnant, there's more blood volume, and the blood tends to form clots more easily. It goes into sort of what we call a hypercoagulable state or, again, the ability to more easily form clots. And when those clots form, obviously, they can cause a blockage in the brain that then leads to stroke.

I just want to be clear that stroke after pregnancy is relatively rare. You're talking 25 to 35 for every, like, 100,000 deliveries. So it's kind of a rare thing, but I have seen it here in my career. And we've taken care of women who have had strokes post-pregnancy. But we're just trying to get the word (out) that these effects, the effect that pregnancy has and that rapid change after delivery, could make a perfect storm for a stroke.

Also related in pregnancy is something many of us have heard about, called preeclampsia, which is the state of high blood pressure during pregnancy. So you're probably picking up on a common theme here. We talked about high blood pressure normally now, high blood pressure during pregnancy. Many women have this condition, so we encourage them to really get monitored carefully during pregnancy and after, because if you have preeclampsia during pregnancy, later on in your life gives you a little bit higher risk for a stroke as well.

So those are unique to women.

Host Amber Smith: I've heard that oral contraceptive use can increase the risk of stroke, but can you tell us how that is and what can be done about it?

Michelle Vallelunga: Yes. The use of oral contraceptives, particularly combined with smoking -- so if a woman uses the oral contraceptive and smokes -- really increases their risk for stroke.

And the reason: The contraceptive action, again, is having an effect on those various clotting factors in the blood, and they just increase the body's ability to form clots. It increases those clotting factor activities and interestingly, though, that the clotting factors are actually, like, after pregnancy and when affected through the use of hormones is really almost like a protective, like the body's own protective barrier, for, like, postpartum bleeding or postpartum hemorrhages. So it's kind of a good thing, but in certain women under certain conditions, it can be a bad thing where the clots form and then leads to a stroke.

Host Amber Smith: So is there concern for postmenopausal hormone use? Does that affect a stroke risk, too?

Michelle Vallelunga: Yeah, it could in the same manner as oral contraceptives, having an effect on those clotting factors. So we just encourage women who are considering the postmenopausal hormones to really sort of look at their entire health history and, certainly, review that with their doctors and look at sort of the whole picture.

That's what we encourage.

Host Amber Smith: How big of a threat are stress and depression in leading to stroke? And I wonder if this is a bigger problem for women than for men?

Michelle Vallelunga: I'm not aware of a lot of statistics on this, but we do know, in general, both high stress levels and particularly depression are linked to risk factors for stroke for both men and women.

But in the case of women, we tend to report higher stress levels than men, sort of subjectively, and I think we are also a little bit more likely to experience depression and anxiety. And I think just in general, the stress on women as caregivers -- particularly recently we read a lot about being caregivers for elderly parents, of other family members -- just in general can heighten that stress.

So I feel like they're in a little bit of a unique situation there to cause high stress levels.

Host Amber Smith: What about migraine headaches? Are those a risk factor for stroke?

Michelle Vallelunga: Yes, those are listed as a risk factor for women, and particularly migraine, the type of migraine, that has an aura precede it, so they have sort of symptoms coming on before the actual headache. This type of migraine is really more like vasculature, so it really is going to affect the arteries in the brain and could sort of cause them to spasm, very simply, in some cases.

And so this, over time, women are very likely to have migraines with aura, and also they say migraines with aura and smoking again, that "lovely" smoking is not great for you (chuckles). When combined with a lot of other things, can increase the risk for having stroke.

Host Amber Smith: Now, if I understand correctly, most strokes are caused by a blockage in a blood vessel, but some happen when a blood vessel bursts and blood escapes.

Do you see one type over the other affecting women more than men?

Michelle Vallelunga: No. I mean, I think just in general, ischemic strokes are more common, so the kind of stroke that you mentioned, where the blood clot is formed, versus the bleeding stroke. About 80% or so of all strokes are that ischemic type, that clot type.

And about 15% or so are the bleeding type. I don't really see, actually, not that I'm aware of, you know, an increase of one or the other of those type of strokes. But the, bleeding type of stroke is generally for women caused by long-standing, not treated, high blood pressure. That is probably the biggest factor.

So we circle back to high blood pressure being a factor in so much of one's health, related to stroke.

Host Amber Smith: Now, what about trans-ischemic attacks, that are known as TIAs or mini-strokes? Are those more common in women?

Michelle Vallelunga: I would say no, I think it's probably about the same, but it is very dependent, as you would think, on, one's own health history and what individual risk factors a person has.

And the TIA, as you mentioned, is transient, so which means it comes, and then it goes, and the stroke symptoms are equally as important. If you feel you're having stroke symptoms and they disappear. we encourage everyone to call 911, go to a hospital anyway, even though they're temporary.

Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith, and I'm talking with Michelle Vallelunga. She's a nurse at Upstate and the Stroke Program data coordinator.

I'm curious about stroke treatment and how women compare with men. Do you know if the clot-busting medications, which have to be given very early in the stroke, are as effective in women as in men?

Michelle Vallelunga: They are as effective. Like you mentioned, the clot-busting medication that we use here at Upstate, which is called tenecteplase or TNK. It's a type of tPA (tissue plasminogen activator). I think many people know that term out there. It has to be given within three hours or up to four and a half hours of the patient last being well, or, usually, when their symptoms are first noticed, to be very effective. and this obviously can be effective for both men and women.

The other form of treatment that we offer is a clot retrieval or a clot removal procedure called a thrombectomy. and that can be done in some cases up to 24 hours of last known well. Time is the key word here. If you feel as though you're having any stroke symptoms, whatsoever, the treatments are very time sensitive, as we've mentioned. So your best chances of getting the treatment, and ultimately your recovery, is to get here as quickly as possible.

Host Amber Smith: So time is of the essence. Have you noticed a difference among the genders in who gets to the hospital fastest?

Michelle Vallelunga: No, I actually don't have any data on that, although that would be a really good thing to look at.

Host Amber Smith: I just wonder what some of the reasons might be for a delay in coming to seek care?

Michelle Vallelunga: I think just very subjectively, from my own practice and my own experience, many people are very hesitant. even before COVID and the worries of coming to the hospital, people are just very hesitant to waste your time and to like, "But what if it's not a stroke?"

And I always tell people that If you come to the hospital, and it's not a stroke, we definitely want that. We want to be able to tell you, you have not had a stroke and to let them know, "Hey, this is OK. We are here to care for you," and not to be nervous about coming in, but that was generally one of the reasons that this was always told to me: "I, don't want to come in, I'm embarrassed," or "I'm going to waste your time if it's not a stroke."

Host Amber Smith: Well, stroke is the leading cause of adult disability. So I'd like to ask you to explain how this may impact women differently than men.

Michelle Vallelunga: I just think that with women being caregivers for, often, elderly parents, children, many, many other members of their family, I think that that can definitely have an impact. Because if a woman is disabled from a stroke or is suffering long-term effects from a stroke, the whole family unit is disrupted.

I think that that can really have a huge impact on the family and everything that takes place in that family.

Host Amber Smith: Is stroke something that is a concern, moreso for older people, older women and men, than for younger, and how common is it for you to see a younger woman in her 20s, 30s, 40s, 50s, with a stroke?

Michelle Vallelunga: It's definitely less common for a younger woman to have a stroke than in older women. I think obviously in general we see more strokes in, older women, older women and men. but really the information that I'd like to get out there is that even though it's rare, and obviously much less, prevalent out there, if you're, at a gathering in the holidays and, younger women start talking about, different risk factors that they have having been pregnant, being on oral contraceptives and smoking, high stress levels in their lives, they have a history of migraines with auras. If younger women are talking about these kinds of things to you.

Hopefully this will never happen, but should you be in a situation with a younger woman who maybe has just delivered a baby or has some of these risk factors and starts developing stroke symptoms, and tells you they're having stroke symptoms, the goal of my lecture is to definitely get these people to say, "Oh, wait a second. Let me put these factors together, and perhaps I should encourage this person to call 911 and get help for the stroke." So that's kind of my ultimate thing, is to get people to start thinking about stroke can happen in younger women.

For older women, largely, their risk is tied to atrial fibrillation, and women, especially over age 75, are at higher risk for stroke due to atrial fibrillation.

Host Amber Smith: So let's explain that a little bit more. Atrial fibrillation is a specific heart rhythm, and you may not know you have it unless a doctor diagnoses it, right?

Michelle Vallelunga: Right. A-fib is an interruption of the electrical impulses of the heart that really causes your heart to beat irregularly. Some people are symptomatic, so they kind of feel their heart racing, they're a little bit short of breath, but other people, as you say, are not symptomatic at all and never know that they have A-fib.

So in general, we recommend that all women over 75 get at least screened for A-fib, through their primary provider or cardiologist, if they're seeing one. Certainly they can help screen you for A-fib. In the condition of A-f ib, because the heart is not beating regularly, the blood tends to pool in the top of the heart, and clots have a greater tendency to form.

And so those clots can then be sent out of the heart and go up to the brain and then, cause a stroke. So that's the concern there with atrial fibrillation.

Host Amber Smith: So if a person knows they have that, but it's under control, either through a procedure or medications, that type of thing, does that remove their risk of stroke?

Michelle Vallelunga: Not entirely. Certainly it can still happen, but it's the best defense. The best defense is to definitely be in touch with your physician or your cardiologist about it and take the medications according to -- we see this all the time, where folks are not, really taking the medications the way they're prescribed.

Or if you have symptoms, even though you're taking the medication, don't ignore the symptoms. Give your doctor a call, talk to them about those symptoms because you want to try to manage yourself, along with your doctor, the best way you can.

Host Amber Smith: And I'm assuming that would apply to high blood pressure, as well. If you have it under control, that helps mitigate some of your risk.

But you still have to be aware, right?

Michelle Vallelunga: You should be aware. We do encourage, if you've been diagnosed with high blood pressure, even sort of early high blood pressure, along with maybe other heart related risk factors. We do encourage folks to check their blood pressure on a regular basis, record those down, report them back to their doctor. Because we know that, you know, you can get your blood pressure taken like once every six months or three months or so when you see your physician, but blood pressure does vary throughout the day, so we do encourage people that if you have high blood pressure, even if you're not necessarily on medication for it yet, if you're in conversation with your doctor about that to, go ahead and self-monitor it. And there's different resources out there for folks to get blood pressure cuffs and things like that.

Host Amber Smith: Well, we've covered pretty well atrial fibrillation and high blood pressure, but I want to ask you about some of the other risk factors that might affect people's risk for stroke. Is diabetes a concern? If you have diabetes, are you at higher risk for stroke?

Michelle Vallelunga: It is, yes, it is. The overall presence of diabetes, really, in general, causes your vascular (sytem), your blood, to be at risk. Basically, it causes the blood vessels to be very stressed, along with high blood pressure for long periods of time, not diagnosed, and other factors related to diabetes, like, obesity, lack of exercise.

Just in general, heart-healthy habits are also healthy habits for the brain. So we say heart-healthy habits are brain-healthy habits as well. So those are some of the general risk factors that people should pay attention to.

Host Amber Smith: What is it about smoking, or vaping, that increases a person's risk? What does the act of smoking do to your body?

Michelle Vallelunga: It's really, again, we keep circling back to the effect on the blood vessels. So anything that's going to either cause the blood vessels to spasm or cause it to constrict, where that normal blood flow is interrupted, through the use of like tobacco products and the effect that they have, is really what the concern is.

Over time, the effect on the blood vessels is what could cause a clot to become lodged, could cause the vessel to burst. So, we really obviously caution people certainly not to smoke -- lessen if you can, but certainly go towards not smoking.

Host Amber Smith: So in terms of prevention or things that we can do to help reduce our risk, we've talked about exercise, maintaining a healthy body weight, not smoking. Do you have any dietary recommendations?

Michelle Vallelunga: I think that most of our stroke patients are, recommended for a low-sodium diet. There's a lot of information out there on the low-sodium diet, which is in general a diet called the DASH diet (dietary approaches to stop hypertension), and people can look that up, but in general it's low sodium, higher intake of vegetables, fruit, and just less red meat. I mean, just a general heart-healthy diet works for stroke as well.

Host Amber Smith: And what we are talking about applies to men as well as women, right?

Michelle Vallelunga: Yes.

Host Amber Smith: So before we wrap up, I want to go over the typical warning signs of stroke, because I believe there's some that maybe apply a little more to women than men.

Is that right?

Michelle Vallelunga: In general, they can all be applied to both men and women, yes.

So, to review the signs of stroke, we usually think of the acronym FAST-ED, and we've added a couple letters. Most people are very familiar with FAST, or at least I hope so, but to review them for everyone: FACE, so if you have like a droop, you see someone with a facial droop on one side or the other, that could be a sign of stroke. ARM weakness, either side. SPEECH, slurred speech. T is TIME , so time to call 911. And we've added a couple of others now that we like folks to be aware of.

And we work with our local EMS agencies, too, to talk to them about our newest ones that we've added:

E for EYES, eye deviation or vision problems. So if you see someone sort of looking to one side or the other, or they report that suddenly their vision has changed, either sudden blurred vision or sudden loss of vision in one section of what they can see.

The last letter is D, for DENIAL or DIZZINESS. The denial refers to someone who may not really be aware of one side of their body or the other. This happens a lot, in some large, -vessel strokes that we see, or a dizziness. And a dizziness is pretty profound in folks that are having strokes, where it really may affect their ability to walk. They may be walking like they're drunk, in that sense, so they're very dizzy.

So we want to think FAST-ED for our stroke symptoms.

Host Amber Smith: Well, Michelle, Vallelunga, I appreciate you making time for this interview.

Michelle Vallelunga: Thank you, Amber. It was a pleasure being here.

Host Amber Smith: My guest has been Michelle Vallelunga. She's a nurse at Upstate and the Stroke Program data coordinator.

"The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe. Find our archive of previous episodes at upstate.edu/informed.

This is your host, Amber Smith, thanking you for listening.