Primary prevention is the goal and the final step in our model, which is intrinsically dependent on access to care and adherence to treatment. In women, it has been shown that a healthy lifestyle, consisting of low body mass index, abstinence from smoking, moderate consumption of alcohol, and a healthy diet and regular exercise were associated with a lower incidence of ischemic and total stroke.1 This survey did not address health outcomes, but even in this patient population who seeks regular specialty care, there were still women smoking, not taking aspirin with no contraindication not to do so, and with poorly controlled hypertension and cholesterol. Most surprisingly, more than one third of our sample with atrial fibrillation reported not taking warfarin. This population may represent a mix of women with true contraindications to warfarin use as well as reflect patients for whom physicians are averse to prescribing anticoagulation therapy. This is despite evidence in that patients with a stroke and a history of atrial fibrillation, the majority are subtherapeutic or not taking warfarin at the time of their event.23 In addition, women with atrial fibrillation have higher rates of off-warfarin thromboembolic risk compared with men,24 placing them at higher risk.
There are several limitations of this study. Like in all survey studies, there was a selection bias for women who returned the survey. Women were predominately white and living in a suburban area, and whether these results can be extended to a more urban, ethnically diverse population is unknown. It would be expected that barriers to primary prevention would be greater in such populations. In addition, all women were asked to identify warning signs and risk factors without any prompting, which would tend to underreport what women actually know. The benefit of this method is that there is a sense of relationships that women have between health and behavior without cues. It is also possible that women do not identify medical terms such as “atrial fibrillation” unless they themselves have the condition.