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Sex differences in intensity of care and outcomes after acute ischemic stroke across the age continuum

Yu AYX, Austin PC, Rashid M, Fang J, Porter J, Vyas MV, Smith E, Joundi RA, Edwards J, Reeves M, Kapral MK. Neurology. 2022; Sep 30 [Epub ahead of print]. DOI:

Background and Objectives — Sex differences in stroke care and outcomes have been previously reported, but it is not known if these associations vary across the age continuum. We evaluated whether the magnitude of female-male differences in care and outcomes varied with age.

Methods — In a population-based cohort study, we identified patients hospitalized with ischemic stroke between 2012 and 2019 and followed through 2020 in Ontario, Canada using administrative data. We evaluated sex differences in receiving intensive care unit services, mechanical ventilation, gastrostomy tube insertion, comprehensive stroke centre care, stroke unit care, thrombolysis, and endovascular thrombectomy using logistic regression and reported odds ratios (OR) and 95% confidence intervals (CI). We used Cox proportional hazard models and reported the hazard ratios (HR) and 95% CI of death within 90 or 365 days. Models were adjusted for covariates and included an interaction between age and sex. We used restricted cubic splines to model the relationship between age and care and outcomes. Where the p-value for interaction was statistically significant (p<0.05), we reported age-specific OR or HR.

Results — Among 67,442 patients with ischemic stroke, 45.9% were females and the median age was 74 years [64, 83]. Care was similar between both sexes, except female patients had higher odds of receiving endovascular thrombectomy (OR 1.35, 95% CI [1.19, 1.54] comparing female to male), and these associations were not modified by age. There was no overall sex difference in hazard of death (HR 95% CI 0.99 [0.95, 1.04] for death within 90 days; 0.99 [0.96, 1.03] for death within 365 days), but these associations were modified by age with the hazard of death being higher in female than male patients between the ages of 50-70 years (most extreme difference around age 57, HR 95% CI 1.25 [1.10, 1.40] at 90 days, p-interaction 0.002; 1.15 [1.10, 1.20] at 365 days, p-interaction 0.002).

Discussion — The hazard of death after stroke was higher in female than male patients aged 50 to 70 years. Examining overall sex differences in outcomes without accounting for the effect modification by age may miss important findings in specific age groups.