European Society of Cardiology thinks preventing strokes in women is too complicated

But with cha2ds2-vasc you give OAC if greater than 2 for male or 3 for female according to ESC guidelines. Having the female category then makes it a bit pointless. Just remove it and make it above 2 for everyone? Acronym isn't as pretty but surely it's simpler for clinicians?

Two German Podcasters, Kiarash Hossainpour and Philip Hopf, to face jail term with €250,000 for calling a transwoman a man.

I've no idea how they phrased it. Earlier reports of the law (ratified earlier this year) said that the misgendering would need to be intentional. However, I'm so accustomed to mission creep that I'm apprehensive about healthcare workers who would become wary of asking about sex in case it's interpreted as a hostile act of misgendering.

A rant on Reddit from a male who identifies as a woman complaining that a 999 call handler asked for his sex (described at 'gender assigned at birth') when discussing symptoms.

https://www.mumsnet.com/talk/womens_rights/5158576-sex-differences-in-asthma

I do very genuinely wonder how the intersection of disability rights & trans rights will play out in Germany - well, disabled people will get the shitty end of the stick, but will it be enough to effect change? People are absolutely going to start referencing the Nazis & Aktion T4 - with a sight more accuracy than all the Trans Holocaust nonsense^ - if the German state starts arresting blind people/people with severe learning disabilities/post-ictal epileptics/people with TBIs/people with dementia (etc etc) for correctly sexing people 🤦‍♀️

^ the Nazis had no coherent policy towards trans people, let alone a plan to exterminate them

because countries (like Germany) are making it illegal, iirc, to identify the sex of a trans identified person?

Say what now? 😡

As a woman with AF I can tell you that I was treated with care and attention. My Chad score included age at diagnosis and sex as mentioned, well at that time it did!

They were on to it straight away, every test under the sun, cardioversion, the lot. The problem with me though, was that I was approaching 65 and could not take anticoagulants due to bleeding risk from another issue. So they watched and waited. When it came to my 64th birthday I was put on a list for a Watchman device, which is designed to stop clots (stroke) in those who cannot take blood thinners. I was duly treated and had the device the day before my 65th birthday!. The cardiologist/electrophysiologist was determined that I would have this protection at age 65, so maybe he hadn't read the memo about age 75!

Anyway, just saying that the thought of a stroke initially terrified me, as my mother had Afib and it was undiagnosed, she had three devastating strokes one after the other and suffered greatly, she had her strokes at age 63, so naturally I was concerned.

I cannot believe that report, but I am not surprised. I hope those women with Afib are treated according to risk going forward.

I wonder if ESC opted for this because countries (like Germany) are making it illegal, iirc, to identify the sex of a trans identified person?
However, there have been national studies and systematic reviews that provide new data. There also seem to have been differences between the use of scoring systems. It may be that ESC looks to resolve these by opting to standardise on a scoring system that doesn't use contested categories because it's more straightforward to deliver this scoring system and set of guidelines and then adopt them to local (i.e., national) pragmatic service delivery that reflects the available therapies.

I absolutely agree with them that including the made up concept of "gender" in their clinical assessment tool is unhelpful. SO DON'T INCLUDE IT, just like you wouldn't include religion. What is this so difficult?

Yes, that's the nub of it.
Is it possible they're dropping female=1 point because data, but putting out press statements saying mumble..gender identity..bumble for, well, woke points?

I'm afraid I've not attempted to read the paper yet, but my DH has AF and my understanding of the score is that it's an overall stroke risk analysis - so factors such as diabetes come in as well as age. That's what matters from the point of view of treatments such as should this person be on anticoagulants, not just the additional stroke risk due to AF.

The experts comment in the Twitter link doesn't say 'Atrial fibrillation causes a greater increase in stroke.risk in women than it does in men' , it says that women with AF face a higher stroke risk than men - these aren't the same thing, the latter sounds like the total stroke risk.

I guess what I want to understand is why they did it then and can abandon it now?

Yes they were adding a point for being a woman. I saw a cardiologist 2 months ago after being diagnosed with Atrial Fibrillation. I had one point purely for being a woman (age 50).

(sorry derail strand of thread)

re. ageist sexist comments - I certainly remember when younger hospital consultants were still treated as highly superior beings. And particularly male consultants. I remember one being so rude to me that after he left one of his worshipping trainees came back and she whispered was I alright.

I later attended some sort of patient feedback session. Not a big turn out. Most of the patients said nothing. So I went through my prepared comment and the platform just said thank you.

But what was worse was when the meeting finished the other patients stopped me in the hall to congratulate me, but didn't seem to realise by not even saying I agree or something I could be written of as an hysterical women.

I thought the era of consultants being a law under themselves had died out. But maybe some still have a god complex and aren't challenged..

Yeah, there's the klaxon, right there.

WTF? Medics are rotten at doing research on and dealing with women and now they can't even be bothered to mention us on the scale? Gahhh come the Glorious Revolution I have my list for first up against the wall, and I'm going to need a very long wall 🤯

No, I mean did they add a point in the past as described , and why did they do that? @Ozanj - it's a genuine question, was the risk model based on now outdated research?

Yes. Stroke risk due to AF is only for women over 75. Read the guidelines.

I can't find those figures, do you have a source for them, please? I've seen several organisations state this:

By the age of 75, 1 in 5 women and 1 in 6 men will have a stroke.

https://www.stroke.org.uk/sites/default/files/state_of_the_nation_2016_110116_0.pdf

There are fluctuations in risk across lifetime, however, this is a general age-related point and not specific to ischaemic stroke.

Recent evidence suggests that young women (18–45 years) may be at higher risk of ischemic strokes than men of the same age. The goal of this systematic review is to reconcile and synthesize existing evidence of sex differences among young adults with ischemic strokes.
…
Overall, there were 44% more women ≤35 years with ischemic strokes than men. This gap narrows in young adults, 35 to 45 years, and there is conflicting evidence whether more men or women have ischemic strokes in the 35 to 45 age group.

Systematic Review of Sex Differences in Ischemic Strokes Among Young Adults: Are Young Women Disproportionately at Risk?
Author:
Michelle H. Leppert, James F. Burke, Lynda D. Lisabeth, Tracy E. Madsen, et al.
Publication:
Stroke
Publisher:
Wolters Kluwer Health, Inc.
Date:
Jan 24, 2022

https://www.ahajournals.org/doi/10.1161/STROKEAHA.121.037117

From the guidelines linked above:

Across Europe, the most popular risk score is CHA2DS2–VASc, giving points for congestive heart failure, hypertension, age ≥75 years (2 points), diabetes mellitus, prior stroke/TIA/thromboembolism (2 points), vascular disease, age 65–74 years and female sex. However, implementation has varied in terms of gender. Female sex is an age-dependent stroke risk modifier rather than a risk factor per se.112,256,257 The inclusion of gender complicates clinical practice both for healthcare professionals and patients.258 It also omits individuals who identify as non-binary, transgender, or are undergoing sex hormone therapy. Previous guidelines from the ESC (and globally) have not actually used CHA2DS2-VASc; instead providing different score levels for women and men with AF to qualify for OAC. Hence, CHA2DS2-VA (excluding gender) has effectively been in place (Table 10).78 This task force proposes, in the absence of other locally validated alternatives, that clinicians and patients should use the CHA2DS2-VA score to assist in decisions on OAC therapy (i.e. without a criterion for birth sex or gender). Pending further trials in lower risk patients (NCT04700826,259 NCT02387229260), OAC are recommended in those with a CHA2DS2-VA score of 2 or more and should be considered in those with a CHA2DS2-VA score of 1, following a patient-centred and shared care approach. Healthcare professionals should take care to assess for other thromboembolic risk factors that may also indicate the need for OAC prescription.

Refs for age and sex as raised by Ozanj

The female/male ischaemic stroke risk ratio varied with age. Only women aged >75 years had a higher risk, whereas women aged <65 years had a lower risk compared with men. These findings challenge the ‘sex category’ component of the CHA2DS2-VASc score, used to make decision regarding anticoagulation treatment in AF patients.
Wu VC, Wu M, Aboyans V, et al
Female sex as a risk factor for ischaemic stroke varies with age in patients with atrial fibrillation
Heart 2020;106:534-540.
https://doi.org/10.1136/heartjnl-2019-315065

Female sex was only associated with an increased risk of stroke for AF patients aged ≥ 75 years. Our study suggests that female sex should not be automatically included as an independent stroke/thromboembolic risk factor in guidelines or in the CHA2DS2‐VASc score, without careful prior consideration of the ‘age < 65 and lone AF’ criterion.
Female sex as a risk factor for stroke in atrial fibrillation: a nationwide cohort study
MIKKELSEN, A.P. et al. Journal of Thrombosis and Haemostasis, Volume 10, Issue 9, 1745 - 1751
https://doi.org/10.1111/j.1538-7836.2012.04853.x

"I only know about this because her response to such an overt case of age (and sex?) discrimination was on one level to just laugh as it confirmed everything some of us know about how women are treated."
This is what I too easily default to, and why I value FWR so much.

What?! They actually said that? Appalling doesn't even begin to cover it.

@ozanj

Was this the case though?

Atrial fibrillation causes a greater increase in stroke.risk in women than it does in men, so the scoring tool to assess risk adds a point for female sex.

The problem here is that men are 3 x more likely to have a stroke under 75. Women, while they have a higher risk, it’s over 75. While yes AF is a risk factor it isn’t one in women under 70.

I've only skimmed this but I think this is the link to the published guidelines

academic.oup.com/eurheartj/advance-article/doi/10.1093/eurheartj/ehae176/7738779?login=false

Wait, was she offered any treatment for it? My mum got sent to a specialist at 70.

If memory serves me right, when her immediate doctor who made the referral checked up on the progress of her treatment, found out what had happened then referred her to another hospital. And then there was Covid.

The problem may have been that the first hospital was said to be THE specialists, and were getting too many referrals. But if that was the case would have been more acceptable to say they can only take referrals from their catchment area.

I only know about this because her response to such an overt case of age (and sex?) discrimination was on one level to just laugh as it confirmed everything some of us know about how women are treated. But also worry of course. The potential for a stroke lurking there every day.