Atrial fibrillation-related stroke in women: Evidence and inequalities in epidemiology, mechanisms, clinical presentation, and management

Clin Cardiol. 2020 Jan;43(1):14-23. doi: 10.1002/clc.23284. Epub 2019 Nov 6.


Background: Atrial fibrillation (AF) is the most common clinical arrhythmia and one of the major causes of stroke, heart failure, sudden death, and cardiovascular morbidity. Despite substantial advances in (interventional) rhythm control treatment during the last decade, anticoagulation for stroke prevention remains a major component of AF treatment.

Hypothesis: There are important sex-specific differences in AF-related stroke, resulting from sex-specific mechanisms and therapeutic differences.

Methods: This review summarizes available data on sex differences in risk assessment and prevention of stroke and highlights current knowledge gaps in AF-related stroke mechanisms, prevention and management that warrant further research.

Results: Increased thrombotic risk in women is multifactorial, involving hormonal changes after menopause, structural, endocrine and lifestyle/social factors and their interactions. It is clear from randomized studies that women benefit from anticoagulant treatment and that their bleeding risk is similar to men. Women should therefore receive equivalent treatment to men, based on the validated criteria for anticoagulation therapy. However, women are not represented equally in the large randomized studies and sex-related information in many fields is lacking.

Conclusions: Female sex is an established risk factor for stroke in AF patients. The evidence for sex-specific differences in stroke risk assessment and stroke prevention is accumulating. However, the underlying biological mechanisms remain incompletely understood and further studies are required in order to decrease AF-related morbidity and mortality.

Keywords: anticoagulation; atrial fibrillation; hemorrhage; menopause; sex differences; stroke.

Publication types

  • Review

MeSH terms

  • Anticoagulants / therapeutic use*
  • Atrial Fibrillation / complications*
  • Atrial Fibrillation / diagnosis
  • Atrial Fibrillation / epidemiology
  • Atrial Fibrillation / physiopathology
  • Female
  • Humans
  • Risk Assessment
  • Risk Factors
  • Sex Factors
  • Stroke / diagnosis*
  • Stroke / epidemiology*
  • Stroke / etiology
  • Stroke / prevention & control


  • Anticoagulants