Abstract
Introduction: There are apparent sex differences in stroke, with women having a higher lifetime risk and worse outcomes. However, there remain critical gaps in our understanding of sex differences in risk, treatment response and outcomes following stroke. We conducted the first systematic summary of the role of sex on stroke-related conditions using a registry of clinical prediction models (CPMs). Methods: The Tufts PACE CPM Registry is based on a systematic review of cerebrovascular and cardiovascular CPMs published in English-language articles from 1/1990-5/2012, and includes 585 unique CPMs extracted from 506 articles. All included CPMs permit calculation of outcome probabilities from information provided in the form of an equation, point score or nomogram. We calculated the proportion of models with coefficients for the effect of sex on stroke incidence or prognosis, and summarized the directionality (harmful vs. protective) of the coefficients for sex. Results: Out of 75 CPMs with stroke as either an index condition or outcome, 23 (31%) contained a coefficient for sex or presented sex-stratified models. Only 8/48 (17%) models of stroke prognosis included sex or presented sex-specific models, as compared to 14/24 (58%) of models predicting stroke incidence. In models categorized by unique index-outcome pairs, sex was most commonly included in models predicting stroke among a general population (67%). Female sex was associated with reduced risk of mortality after ischemic stroke and a higher risk of stroke from arrhythmias or CABG/PCI. In a general population, women typically had a lower risk of stroke, although stratified models suggest this depends on the presence or absence of other risk factors. Conclusions: Sex is an important prognostic factor in CVD but is inconsistently included in stroke CPMs. Sex is more frequently included in models of stroke incidence than models of prognosis. Being female seems protective for some outcomes, but harmful for others.
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