The American Heart Association (AHA) published new guidelines for stroke prevention in women. Why do women need their own stroke prevention guidelines? While there are well known risk factors for both men and women, the new guidelines highlight other risk factors that are unique to or are more commonly seen in women. According to the new guidelines, women-specific stroke risk factors that involve pregnancy include preeclampsia and gestational diabetes. Other gender-specific risk factors are oral contraceptive use, hormonal changes, and postmenopausal hormone use. Risk factors that are not gender-specific but most commonly seen in women include high blood pressure, migraine with aura, atrial fibrillation (a heart rhythm disorder), diabetes, depression, and psychosocial stress.
High blood pressure is a common condition we receive prescriptions for in the pharmacy. As a pharmacist I often come across patients who do not take their blood pressure medication regularly because the benefits of taking these types of medications are not immediately seen. However it is important to keep your blood pressure under control as the new guidelines state that hypertension is particularly important among women since it is one of the most common and treatable risk factors. Data analysis has revealed that treating hypertension in women was associated with a 38% risk reduction in fatal and nonfatal stroke events and a 25% reduction in fatal and nonfatal cardiovascular events. In this article I will be focusing on high blood pressure and what the guidelines recommend for getting your blood pressure under control to reduce your risk of stroke.
According to the new AHA guidelines, the risk of stroke is higher in pregnant women in comparison to non-pregnant young women. The risk is greatest during the third trimester and postpartum period. Women of childbearing age who have chronic high blood pressure will be at an increased risk for preeclampsia, eclampsia, and stroke during pregnancy. Preeclampsia is worsening high blood pressure in pregnancy that occurs in the setting of proteinuria (protein in the urine). Eclampsia is preeclampsia that has progressed to seizures.
Prevention of Preeclampsia1
- Low-dose aspirin. The new guidelines recommend that women with chronic high blood pressure take low-dose aspirin (81 mg) from the 12th week of gestation until delivery to prevent preeclampsia. Preeclampsia is associated with increased platelet-derived thromboxane levels which could lead to blood clots, and aspirin is an anti-platelet agent.2
- Calcium supplementation. Oral calcium supplementation (at least 1 gram per day) should also be considered for women with low dietary intake of calcium (less than 600 mg per day) to prevent preeclampsia. If you have adequate calcium intake, there will be no benefit from taking additional calcium supplementation.
Treatment for High Blood Pressure1
While there is no data from large trials comparing the effectiveness of antihypertensive medications in pregnancy, the guidelines have noted that alpha blockers, beta blockers, calcium channel blockers, hydralazine, and thiazide diuretics have been used safely in pregnancy. More specifically, the guidelines state that severe hypertension should be treated with safe and effective medications such as methyldopa (Aldomet),labetalol (Normodyne, Trandate), and nifedipine (Procardia). Read the list below for more information on blood pressure medication that may be used in pregnant women.
- Alpha-blockers. Methyldopa (Aldomet) is safe to use in pregnancy and has no teratogenicity or fetal/neonatal adverse effects. Side effects for the mother may include sedation and depression.
- Beta-blockers. The guidelines noted that pindolol and metoprolol appear safe, however atenolol (Tenormin) should be avoided due to fetal growth restriction. The main maternal side effect is headache.
- Combined alpha-/beta-blockers. Labetalol can possibly cause neonatal bradycardia (slow heart rate) and may worsen asthma flare-ups in the mother.
- Calcium channel blockers. Nifedipine (Procardia) is the most commonly used calcium channel blocker and is safe to use in pregnancy. Maternal side effects include headache, possible interaction with magnesium sulfate, and it may interfere with labor.
- Diuretics (thiazide). Thiazide diuretics such as Microzide (hydrochlorothiazide) are safe to use in pregnancy and the main side effect for the mother is hypokalemia (low potassium).
- Hydralazine. Hydralazine is a vasodilator that may cause fetal bradycardia (slow heart rate) and low neonatal platelet count. Side effects for the mother include reflex tachycardia (fast heart rate in response to decreased blood pressure) and delayed hypotension (low blood pressure).
Blood pressure medications that are contraindicated and should be avoided in pregnancy include ACE-inhibitors (e.g., lisinopril, enalapril, ramipril, etc.); Angiotensin II Receptor Blockers (ARBs) such as Benicar (olmesartan), Cozaar (losartan), Diovan (valsartan); and the direct renin inhibitor Tekturna (aliskiren). These drugs are teratogenic and can cause adverse fetal outcomes such as skeletal and cardiovascular abnormalities, abnormal kidney development, and incomplete development of the lungs.
Natural Ways to Reduce Blood Pressure
One effective way to reduce blood pressure is to reduce your salt intake. Follow the DASH diet which focuses on increasing fruits, vegetables, and fat-free or low-fat dairy products. Reduce your saturated fat and cholesterol intake. Other ways to reduce your blood pressure and risk of stroke? Exercise regularly, and if you smoke, quit.
The content this article provides is for informational purposes only. It is not medical advice and should not be substituted for regular consultation with your health care provider. If you have any concerns about your medication or health, please contact your health care provider’s office.
- Guidelines for the Prevention of Stroke in Women: A Statement for Healthcare Professionals From the American Heart Association/American Stroke Association.
- UpToDate: Prevention of preeclampsia.