WHEP Scholar Krista Vadaketh
Drexel University College of Medicine, Class of 2021

Women with atrial fibrillation not only have an increased risk of stroke compared to men, but also experience more severe and disabling strokes. Factors that predispose women with atrial fibrillation to developing more thromboembolic events than their male counterparts include the pathophysiology of the condition (larger left atrial volumes, reduced atrial contractility, non-pulmonary vein triggers, increased parasympathetic responses, higher degree of fibrotic remodeling), modifiable and non-modifiable risk factors (e.g., hyperthyroidism, suboptimal blood pressure management), and differences in clinical presentation (atypical symptoms, such as weakness and fatigue are also more common in women) that may delay diagnosis and treatment. 

One of the leading reasons why women with atrial fibrillation experience more thromboembolic events than men is due to differences in treatment of the condition between the two genders. Despite women being more symptomatic with lower quality of life scores, they are less likely to be managed with rhythm control strategies, including less anti-arrhythmic medications, fewer electrical cardioversions and fewer catheter ablations.  Women with atrial fibrillation are also treated less often and less effectively with anticoagulation. For example, among patients with a CHA2DS2-VASc score of 2+, women are more likely than men to receive aspirin instead of oral anticoagulants, more likely than men to be prescribed a lower dose of dabigatran, and in those prescribed warfarin, more likely to be sub-therapeutic.

It is fundamental to acknowledge that women are more predisposed to this condition and may present differently than men. Physicians must be aware of atypical symptoms and should not dismiss these symptoms as stress, “hormones” or depression until atrial fibrillation has been properly ruled out.