Gender Differences in the Risk of Ischemic Stroke and Peripheral Embolism in Atrial Fibrillation: The AnTicoagulation and Risk factors In Atrial fibrillation (ATRIA) Study
Open accessAbstract
BACKGROUND: Previous studies provide conflicting results about whether women are at higher risk than men for thromboembolism in the setting of atrial fibrillation (AF). We examined data from a large contemporary cohort of AF patients to address this question. METHODS AND RESULTS: We prospectively studied 13,559 adults with AF and recorded data on patients' clinical characteristics and the occurrence of incident hospitalizations for ischemic stroke, peripheral embolism, and major hemorrhagic events through searching validated computerized databases and medical record review. We compared event rates by patient sex using multivariable log-linear regression, adjusting for clinical risk factors for stroke, and stratifying by warfarin use. We identified 394 ischemic stroke and peripheral embolic events during 15,494 person-years of follow-up off warfarin. After multivariable analysis, women had higher annual rates of thromboembolism off warfarin than did men (3.5% versus 1.8%; adjusted rate ratio [RR], 1.6; 95% CI, 1.3 to 1.9). There was no significant difference by sex in 30-day mortality after thromboembolism (23% for both). Warfarin use was associated with significantly lower adjusted thromboembolism rates for both women and men (RR, 0.4; 95% CI, 0.3 to 0.5; and RR, 0.6; 95% CI, 0.5 to 0.8, respectively), with similar annual rates of major hemorrhage (1.0% and 1.1%, respectively). CONCLUSIONS: Women are at higher risk than men for AF-related thromboembolism off warfarin. Warfarin therapy appears be as effective in women, if not more so, than in men, with similar rates of major hemorrhage. Female sex is an independent risk factor for thromboembolism and should influence the decision to use anticoagulant therapy in persons with AF.
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Female AF patients who have additional stroke risk factors, particularly older age, are at greater risk than men of having a stroke, even those anticoagulated with warfarin.
“Female AF patients who have additional stroke risk factors (particularly older age) are also at greater risk than men of having a stroke, 48,49 even those anticoagulated with warfarin 50 (see Chapter 8 for details).”
From 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS (2016) · cites this paper as [49]
Bleeding risk on anticoagulation is similar in both sexes.
“Bleeding risk on anticoagulation is similar in both sexes, 49,50,53 but women appear less likely to receive specialist care and rhythm control therapy, 54 while the outcomes of catheter ablation or AF surgery are comparable to those in men.55,56”
From 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS (2016) · cites this paper as [49]
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Cites
Atrial fibrillation as an independent risk factor for stroke: the Framingham study
Wolf, P. A., Abbott, R. D., & Kannel, W. B. (1991) · Stroke · doi:10.1161/01.str.22.8.983 · Cited by 7,388 · see citing works
Gage, B. F., Waterman, A. D., Shannon, W., Boechler, M., Rich, M. W., & Radford, M. J. (2001) · JAMA · doi:10.1001/jama.285.22.2864 · Cited by 4,832 · see citing works
Risk Factors for Stroke and Efficacy of Antithrombotic Therapy in Atrial Fibrillation
(1994) · Archives of Internal Medicine · doi:10.1001/archinte.154.13.1449 · Cited by 2,593 · see citing works
A Method to Determine the Optimal Intensity of Oral Anticoagulant Therapy
Rosendaal, F. R., Cannegieter, S. C., van der Meer, F. J. M., & Briët, E. (1993) · Thrombosis and Haemostasis · doi:10.1055/s-0038-1651587 · Cited by 2,070 · see citing works
Risk Factors for Stroke and Efficacy of Antithrombotic Therapy in Atrial Fibrillation
(1994) · Archives of Internal Medicine · doi:10.1001/archinte.1994.00420130036007 · Cited by 2,066 · see citing works
Effect of Estrogen Plus Progestin on Stroke in Postmenopausal Women
Wassertheil-Smoller, S. W., Hendrix, S. L., Limacher, M. C., HEISS, G. M., Kooperberg, C. L., Baird, A. E., Kotchen, T. A., Curb, J. D., Black, H. R., Rossouw, J. E., et al. (2003) · JAMA · doi:10.1001/jama.289.20.2673 · Cited by 1,159 · see citing works
Hemorrhagic Complications of Anticoagulant Treatment
Levine, M. N., Raskob, G. E., Landefeld, S., & Kearon, C. (2001) · CHEST Journal · doi:10.1378/chest.119.1_suppl.108s · Cited by 1,129 · see citing works
Left Atrial Size and the Risk of Stroke and Death
Benjamin, E. J., D’Agostino, R. B., Belanger, A. J., Wolf, P. A., & Levy, D. A. (1995) · Circulation · doi:10.1161/01.cir.92.4.835 · Cited by 1,058 · see citing works
Risk Factors for Intracranial Hemorrhage in Outpatients Taking Warfarin
Hylek, E. M., & Singer, D. E. (1994) · Annals of Internal Medicine · doi:10.7326/0003-4819-120-11-199406010-00001 · Cited by 921 · see citing works
Self-citationWang, T. J., Massaro, J. M., Levy, D. A., Vasan, R. S., Wolf, P. A., D’Agostino, R. B., Larson, M. G., Kannel, W. B., & Benjamin, E. J. (2003) · JAMA · doi:10.1001/jama.290.8.1049 · Cited by 779 · see citing works
Accuracy of ICD-9-CM Codes for Identifying Cardiovascular and Stroke Risk Factors
Birman-Deych, E., Waterman, A. D., Yan, Y., Nilasena, D. S., Radford, M. J., & Gage, B. F. (2005) · Medical Care · doi:10.1097/01.mlr.0000160417.39497.a9 · Cited by 723 · see citing works
Anticoagulation Therapy for Stroke Prevention in Atrial Fibrillation
Go, A. S., Hylek, E. M., Chang, Y., Phillips, K. A., Henault, L. E., Capra, A. M., Jensvold, N. G., Selby, J. V., & Singer, D. E. (2003) · JAMA · doi:10.1001/jama.290.20.2685 · Cited by 705 · see citing works
Self-citationGo, A. S., Hylek, E. M., Borowsky, L. H., Phillips, K. A., Selby, J. V., & Singer, D. E. (1999) · Annals of Internal Medicine · doi:10.7326/0003-4819-131-12-199912210-00004 · Cited by 586 · see citing works
Self-citationLeft atrial volume as an index ofleft atrial size: a population-based study
Pritchett, A. M., Jacobsen, S. J., Mahoney, D. W., Rodeheffer, R. J., Bailey, K. R., & Redfield, M. M. (2003) · Journal of the American College of Cardiology · doi:10.1016/s0735-1097(02)02981-9 · Cited by 578 · see citing works
Antithrombotic Therapy in Atrial Fibrillation
Singer, D. E., Albers, G. W., Dalen, J. E., Go, A. S., Halperin, J. L., & Manning, W. J. (2004) · CHEST Journal · doi:10.1378/chest.126.3_suppl.429s · Cited by 547 · see citing works
Self-citationFang, M. C., Chang, Y., Hylek, E. M., Rosand, J. M., Greenberg, S. M., Go, A. S., & Singer, D. E. (2004) · Annals of Internal Medicine · doi:10.7326/0003-4819-141-10-200411160-00005 · Cited by 532 · see citing works
Self-citationFactors Associated With Ischemic Stroke During Aspirin Therapy in Atrial Fibrillation
Hart, R. G., Pearce, L. A., McBride, R., Rothbart, R. M., & ASINGER, R. W. (1999) · Stroke · doi:10.1161/01.str.30.6.1223 · Cited by 532 · see citing works
Hemorrhagic Complications of Anticoagulant Treatment
Levine, M. N., Raskob, G. E., Beyth, R. J., Kearon, C., & Schulman, S. (2004) · CHEST Journal · doi:10.1378/chest.126.3_suppl.287s · Cited by 514 · see citing works
(1998) · Annals of Internal Medicine · doi:10.7326/0003-4819-128-8-199804150-00005 · Cited by 510 · see citing works
Prevalence of atrial fibrillation and eligibility for anticoagulants in the community
Sudlow, M., Thomson, R., Thwaites, B. C., Rodgers, H., & Kenny, R. A. (1998) · The Lancet · doi:10.1016/s0140-6736(98)01401-9 · Cited by 382 · see citing works
New-Onset Atrial Fibrillation: Sex Differences in Presentation, Treatment, and Outcome
Humphries, K. H., Kerr, C. R., Connolly, S. J., Klein, G., Boone, J. A., Green, M., Sheldon, R., Talajic, M., Dorian, P., & Newman, D. (2001) · Circulation · doi:10.1161/01.cir.103.19.2365 · Cited by 378 · see citing works
Benesch, C. G., Witter, D. M., Wilder, A. L., Duncan, P. W., Samsa, G. P., & Matchar, D. B. (1997) · Neurology · doi:10.1212/wnl.49.3.660 · Cited by 331 · see citing works
Coagulation factors and the increased risk of stroke in nonvalvular atrial fibrillation.
Gustafsson, C., Blombäck, M., Britton, M., Hamsten, A., & Svensson, J. E. (1990) · Stroke · doi:10.1161/01.str.21.1.47 · Cited by 309 · see citing works
Frequency and predictors of stroke death in 5,888 participants in the Cardiovascular Health Study
Longstreth, W. T., Bernick, C. B., Fitzpatrick, A. L., Cushman, M., Knepper, L. E., Lima, J. A. C., & Furberg, C. D. (2001) · Neurology · doi:10.1212/wnl.56.3.368 · Cited by 245 · see citing works
Go, A. S., Hylek, E. M., Phillips, K. A., Borowsky, L. H., Henault, L. E., Chang, Y., Selby, J. V., & Singer, D. E. (2000) · Circulation · doi:10.1161/01.cir.102.1.11 · Cited by 200 · see citing works
Self-citationThe Efficacy of Aspirin in Patients With Atrial Fibrillation
(1997) · Archives of Internal Medicine · doi:10.1001/archinte.1997.00440320143013 · Cited by 161 · see citing works
The California Automated Mortality Linkage System (CAMLIS).
Arellano, M., Petersen, G. R., Petitti, D. B., & Smith, R. E. (1984) · American Journal of Public Health · doi:10.2105/ajph.74.12.1324 · Cited by 156 · see citing works
Markers of Thrombin and Platelet Activity in Patients With Atrial Fibrillation
Feinberg, W. M., Pearce, L. A., Hart, R. G., Cushman, M., Cornell, E. S., Lip, G. Y. H., & Bovill, E. G. (1999) · Stroke · doi:10.1161/01.str.30.12.2547 · Cited by 139 · see citing works
Atrial Fibrillation and the Prothrombotic State in the Elderly
Conway, D., Heeringa, J., van der Kuip, D. A. M., Chin, B., Albert Hofman, D., Witteman, J. C. M., & Lip, G. Y. H. (2003) · Stroke · doi:10.1161/01.str.0000051728.85133.32 · Cited by 93 · see citing works
Inoue, H., Nozawa, T., Okumura, K., Jong-Dae, L., Shimizu, A., & Yano, K. (2004) · CHEST Journal · doi:10.1378/chest.126.3.687 · Cited by 77 · see citing works
(1997) · Archives of Internal Medicine · doi:10.1001/archinte.157.11.1237 · Cited by 74 · see citing works
Plasma adenosine levels and platelet activation in patients with atrial fibrillation
Minamino, T., Kitakaze, M., Asanuma, H., Ueda, Y., Koretsune, Y., Kuzuya, T., & Hori, M. (1999) · The American Journal of Cardiology · doi:10.1016/s0002-9149(98)00823-6 · Cited by 45 · see citing works
Wang, T., Chen, W., Su, S., et al. (2001) · Journal of Cardiovascular Electrophysiology · doi:10.1046/j.1540-8167.2001.00877.x · Cited by 36 · see citing works
Ettinger, B. B., & Pressman, A. R. (1999) · PubMed · Cited by 32 · see citing works
Flagged first, then by citations
Cited by
Sorted by citations
Heart Disease and Stroke Statistics—2017 Update: A Report From the American Heart Association
Benjamin, E. J., Blaha, M. J., Chiuve, S. E., Cushman, M., Das, S. R., Deo, R., de Ferranti, S. D., Floyd, J., Fornage, M., Gillespie, C., et al. (2017) · Circulation · doi:10.1161/cir.0000000000000485 · Cited by 12,591 · see citing works
Heart Disease and Stroke Statistics—2020 Update: A Report From the American Heart Association
Virani, S. S., Alonso, A., Benjamin, E. J., Bittencourt, M. S., Callaway, C. W., Carson, A. P., Chamberlain, A. M., Chang, A. R., Cheng, S., Delling, F. N., et al. (2020) · Circulation · doi:10.1161/cir.0000000000000757 · Cited by 9,175 · see citing works
Heart Disease and Stroke Statistics—2019 Update: A Report From the American Heart Association
Benjamin, E. J., Muntner, P., Alonso, A., Bittencourt, M. S., Callaway, C. W., Carson, A. P., Chamberlain, A. M., Chang, A. R., Cheng, S., Das, S. R., et al. (2019) · Circulation · doi:10.1161/cir.0000000000000659 · Cited by 9,036 · see citing works
Heart disease and stroke statistics-2018 update: a report from the american heart association
Benjamin, E. J., Virani, S. S., Callaway, C. W., Chamberlain, A. M., Chang, A. R., Cheng, S., Chiuve, S. E., Cushman, M., Delling, F. N., Deo, R., et al. (2018) · Circulation · doi:10.1161/cir.0000000000000558 · Cited by 7,146 · see citing works
Lip, G. Y. H., Nieuwlaat, R., Pisters, R., Lane, D. A., & Crijns, H. J. G. M. (2010) · Chest · doi:10.1378/chest.09-1584 · Cited by 6,879 · see citing works
2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS
Kirchhof, P., Benussi, S., Kotecha, D., Ahlsson, A., Atar, D., Casadei, B., Castella, M., Diener, H.-C., Heidbuchel, H., Hendriks, J., et al. (2016) · European Heart Journal · doi:10.1093/eurheartj/ehw210 · Cited by 6,418 · see citing works
Heart Disease and Stroke Statistics—2022 Update: A Report From the American Heart Association
Tsao, C. W., Aday, A. W., Almarzooq, Z. I., Alonso, A., Beaton, A. Z., Bittencourt, M. S., Boehme, A. K., Buxton, A. E., Carson, A. P., Commodore-Mensah, Y., et al. (2022) · Circulation · doi:10.1161/cir.0000000000001052 · Cited by 5,987 · see citing works
Heart Disease and Stroke Statistics—2015 Update: A Report From the American Heart Association
Mozaffarian, D., Benjamin, E. J., Go, A. S., Arnett, D. K., Blaha, M. J., Cushman, M., de Ferranti, S., Després, J.-P., Fullerton, H. J., Howard, V. J., et al. (2015) · Circulation · doi:10.1161/cir.0000000000000152 · Cited by 5,797 · see citing works
Self-citationFuster, V., Rydén, L. E., Cannom, D. S., Crijns, H. J., Curtis, A. B., Ellenbogen, K. A., Halperin, J. L., Le Heuzey, J.-Y., Kay, G. N., Lowe, J. E., et al. (2006) · Circulation · doi:10.1161/circulationaha.106.177292 · Cited by 2,805 · see citing works
January, C. T., Wann, L. S., Calkins, H., Chen, L. Y., Cigarroa, J. E., Cleveland, J. C., Ellinor, P. T., Ezekowitz, M. D., Field, M. E., Furie, K. L., et al. (2019) · Circulation · doi:10.1161/cir.0000000000000665 · Cited by 2,744 · see citing works
2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS
Kirchhof, P., Benussi, S., Kotecha, D., Ahlsson, A., Atar, D., Casadei, B., Castella, M., Diener, H.-C., Heidbuchel, H., Hendriks, J., et al. (2016) · European Journal of Cardio-Thoracic Surgery · doi:10.1093/ejcts/ezw313 · Cited by 1,403 · see citing works
Bushnell, C., McCullough, L. D., Awad, I. A., Chireau, M. V., Fedder, W. N., Furie, K. L., Howard, V. J., Lichtman, J. H., Lisabeth, L. D., Piña, I. L., et al. (2014) · Stroke · doi:10.1161/01.str.0000442009.06663.48 · Cited by 941 · see citing works
Fuster, V., Rydén, L. E., Cannom, D. S., Crijns, H. J., Curtis, A. B., Ellenbogen, K. A., Halperin, J. L., Kay, G. N., Le Huezey, J.-Y., Lowe, J. E., et al. (2011) · Circulation · doi:10.1161/cir.0b013e318214876d · Cited by 859 · see citing works
Atrial fibrillation in women: epidemiology, pathophysiology, presentation, and prognosis
Ko, D., Rahman, F., Schnabel, R. B., Yin, X., Benjamin, E. J., & Christophersen, I. E. (2016) · Nature Reviews Cardiology · doi:10.1038/nrcardio.2016.45 · Cited by 353 · see citing works
Du, X., Ninomiya, T., de Galan, B., Abadir, E., Chalmers, J., Pillai, A., Woodward, M., Cooper, M., Harrap, S., Hamet, P., et al. (2009) · European Heart Journal · doi:10.1093/eurheartj/ehp055 · Cited by 239 · see citing works
Pancholy, S. B., Sharma, P. S., Pancholy, D. S., Patel, T. M., Callans, D. J., & Marchlinski, F. E. (2014) · The American Journal of Cardiology · doi:10.1016/j.amjcard.2013.10.035 · Cited by 204 · see citing works
COCHET, H., MOURIES, A., NIVET, H., SACHER, F., DERVAL, N., DENIS, A., MERLE, M., RELAN, J., HOCINI, M., HAÏSSAGUERRE, M., et al. (2015) · Journal of Cardiovascular Electrophysiology · doi:10.1111/jce.12651 · Cited by 199 · see citing works
Gender-related differences in catheter ablation of atrial fibrillation
Forleo, G. B., Tondo, C., De Luca, L., Russo, A. D., Casella, M., De Sanctis, V., Clementi, F., Fagundes, R. L., Leo, R., Romeo, F., et al. (2007) · EP Europace · doi:10.1093/europace/eum144 · Cited by 189 · see citing works
Wagstaff, A. J., Overvad, T. F., Lip, G. Y. H., & Lane, D. A. (2014) · QJM · doi:10.1093/qjmed/hcu054 · Cited by 176 · see citing works
Female sex as a risk factor for stroke in atrial fibrillation: a nationwide cohort study
MIKKELSEN, A. P., LINDHARDSEN, J., LIP, G. Y. H., GISLASON, G. H., TORP‐PEDERSEN, C., & OLESEN, J. B. (2012) · Journal of Thrombosis and Haemostasis · doi:10.1111/j.1538-7836.2012.04853.x · Cited by 137 · see citing works
Female sex as an independent risk factor for stroke in atrial fibrillation: Possible mechanisms
Albert, C. M., Andreotti, F., Badimon, L., Van Gelder, I. C., Hylek, E. M., & Cove, C. L. (2014) · Thrombosis and Haemostasis · doi:10.1160/th13-04-0347 · Cited by 116 · see citing works
Self-citationBall, J., Carrington, M. J., Wood, K. A., Stewart, S., & the SAFETY Investigators (2013) · PLoS ONE · doi:10.1371/journal.pone.0065795 · Cited by 98 · see citing works
Gender differences in patients referred for atrial fibrillation management to a tertiary center
ROTEN, L., RIMOLDI, S. F., SCHWICK, N., SAKATA, T., HEIMGARTNER, C., FUHRER, J., DELACRÉTAZ, E., & TANNER, H. (2009) · Pacing and Clinical Electrophysiology · doi:10.1111/j.1540-8159.2009.02335.x · Cited by 73 · see citing works
Potpara, T. S., Marinkovic, J. M., Polovina, M. M., Stankovic, G. R., Seferovic, P. M., Ostojic, M. C., & Lip, G. Y. H. (2012) · International Journal of Cardiology · doi:10.1016/j.ijcard.2011.04.022 · Cited by 71 · see citing works
Cardiovascular Disease in Women
Stock, E. O., & Redberg, R. (2012) · Current Problems in Cardiology · doi:10.1016/j.cpcardiol.2012.07.001 · Cited by 65 · see citing works
Blomstrand, A., Blomstrand, C., Ariai, N., Bengtsson, C., & Björkelund, C. (2014) · BMJ Open · doi:10.1136/bmjopen-2014-005173 · Cited by 43 · see citing works
Are there gender differences in outcomes after the Cox-Maze procedure for atrial fibrillation?
Henry, L., Hunt, S., Holmes, S. D., Martin, L. M., & Ad, N. (2013) · Innovations Technology and Techniques in Cardiothoracic and Vascular Surgery · doi:10.1097/imi.0b013e3182a2306c · Cited by 17 · see citing works
- Authors
- Fang, M. C., Singer, D. E., Chang, Y., Hylek, E. M., Henault, L. E., Jensvold, N. G., & Go, A. S.
- Affiliations
- Boston University (US)
- Venue
- Circulation
- Published
- 2005-09-20
- Volume
- 112
- Issue
- 12
- Pages
- 1687-1691
- ISSN
- 0009-7322 (ISSN-L)
- 1524-4539
- PMC
- PMC3522521
- OpenAlex
- W2101535898
- Cited by
- 469
- References
- 34
- Citations by year
- 2026: 11 · 2025: 10 · 2024: 14 · 2023: 16 · 2022: 18 · 2021: 18 · 2020: 17 · 2019: 17 · 2018: 28 · 2017: 32 · 2016: 32 · 2015: 31 · 2014: 18 · 2013: 27 · 2012: 41
- FWCI
- 13.02
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- Circulation (publishedVersion)
- PubMed (publishedVersion)
- Europe PMC (PubMed Central) (acceptedVersion)
- PubMed Central (acceptedVersion)
- Funders
- AstraZeneca
- Massachusetts General Hospital
- National Institute on Aging (K23AG028978, AG 15478, R01AG015478)
- Topics
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Atrial Fibrillation Management and Outcomes
- Health Sciences › Medicine › Epidemiology › Acute Ischemic Stroke Management
- Health Sciences › Medicine › Internal Medicine › Venous Thromboembolism Diagnosis and Management
- Keywords
- atrial fibrillation, ischemic stroke, peripheral embolism, sex differences, thromboembolic risk, warfarin, anticoagulation, major bleeding
- MeSH terms
- Aged, Aged, 80 and over, Anticoagulants, Atrial Fibrillation, Female, Humans, Hypertension, Male, Middle Aged, Risk Factors, Sex Characteristics, Thromboembolism, Warfarin, Cohort Studies, Stroke
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