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After Stroke, Genders Differ in Reasons for rtPA Treatment Exclusion

PROVIDENCE, RI – Does treatment with the common clot-dissolving drug, recombinant tissue plasminogen activator (rtPA) vary according to gender?

That question was explored by research published recently in the journal Stroke. The study team, led by researchers from Brown University and Rhode Island Hospital, analyzed stroke treatment records to determine that men and women just have different physiological reasons for being excluded from administration of rtPA.

Stroke is the third leading cause of death for women, but the fifth leading cause of death for men. Annually, 55,000 more women have strokes than men.

"Although men and women had similar overall eligibility rates for rtPA, women were more likely to have severe hypertension –a potentially treatable condition but a reason they can be excluded from receiving tPA," said primary author Tracy Madsen, MD, an emergency department physician at Rhode Island Hospital. "Interestingly, although the women were more likely to have severe hypertension, this treatable condition was often untreated.”

Women were also more likely to be excluded from rtPA treatment because of advanced age and because they tended to have more major strokes.

For the study, researchers looked at the records of all adult ischemic stroke patients at 16 hospitals in southwest Ohio and northern Kentucky in 2005. Patient eligibility for rtPA treatment and individual exclusion criteria was determined using the 2013 AHA and European Cooperative Acute Stroke Study (ECASS) III guidelines.

Of the 1,837 ischemic strokes identified, 58% were in women, with a median age of 72.2 compared to 66.1 for males, and 24% of the patients were black. In general, eligibility for r-tPA was found to be similar by sex –6.8% men and 6.1% women –even after adjusting for age. The percentage of patients arriving beyond the 3-4.5 hour time windows were similar across the genders, but more women had severe hypertension. More women were older than 80 and had National Institutes of Health Stroke Scale scores greater than 25.

“Within a large, biracial population, eligibility for r-tPA was similar by sex,” the authors conclude. “Women were more likely to have the modifiable exclusion criterion of severe hypertension but were not more likely to be treated. Women were more likely to have two of the five ECASS III exclusion criteria.”

They add that “under-treatment of hypertension in women is a potentially modifiable contributor to reported differences in r-tPA administration.”