New guidelines from the American Heart Association and the American Stroke Association provide the first evidence-based recommendations for stroke prevention in women, detailing for the first time the increased risk of stroke specific to women (pregnancy, hormone therapy, contraception, migraine, etc.). The guideline provides graded evidence on prevention strategies for multiple risk categories. This evidence is derived from analysis of data from dozens of studies and hundreds of thousands of female subjects. Women’s unique and gender-specific stroke risk factors should be recognized, and risk scores incorporating these factors should be used to identify women at risk for stroke. It is also important to increase stroke awareness and to provide more rigorous patient education to young women. In terms of pregnancy outcomes and pre-eclampsia-related stroke, the guideline makes recommendations based on evidence from 17 studies. For pregnant women with chronic primary or secondary hypertension, or a history of pregnancy-related hypertension, level A evidence supports the use of low-dose aspirin in mid- and late pregnancy. level A evidence also supports the use of calcium supplements for the prevention of preeclampsia in pregnant women with low dietary calcium intake. In addition, level A evidence supports the use of safe antihypertensive agents (methyldopa, labetalol, and nifedipine) for the treatment of severe hypertension during pregnancy. level B evidence supports the treatment of moderate hypertension. Atenolol, angiotensin receptor blockers, and direct renin inhibitors are contraindicated in pregnancy because of their teratogenic properties. Because preeclampsia increases lifetime stroke risk, the guideline also recommends that women within 1 year of childbirth be evaluated and may be considered for treatment of cardiovascular risk factors based on their personal and familial risk factors. Level A evidence does not support routine screening for prothrombotic mutations prior to initiation of oral contraceptive use. However, level B evidence suggests that oral contraceptives may be harmful to women with risk factors, including smoking and a history of thromboembolic events. Seven studies have examined the association between stroke and hormone therapy in approximately 37,000 women. The guideline authors made 2 recommendations based on level A evidence: 1. Hormone therapy should not be used for primary or secondary stroke prevention in postmenopausal women. 2. Selective estrogen receptor modulators (raloxifene, tamoxifen and tibolone) should not be used for primary prevention of stroke. Migraine with aura Only a small body of literature has examined the association between migraine with aura and stroke, although data do suggest that the overall risk may be doubled. If migraine with aura is associated with another risk factor (e.g., pregnancy or preeclampsia), the risk of stroke increases dramatically. Level B evidence supports smoking cessation in women with migraine with aura, and Level C evidence suggests that treatments to reduce the frequency of migraine attacks may also reduce stroke risk. Obesity and metabolic syndrome A healthy lifestyle of eating natural foods, exercising, and quitting tobacco has been shown to reduce stroke incidence in both men and women. However, subgroup analyses suggest that the benefits of a healthy lifestyle are greater for men. Studies in women have yielded inconsistent results regarding the efficacy of a healthy lifestyle in reducing stroke in women. A large number of additional studies are necessary to identify interventions that are particularly beneficial for women. Until these studies are available, Level B evidence supports a lifestyle that includes exercise, a healthy diet, nonsmoking, and moderate alcohol consumption (≤1 serving per day) in nonpregnant women. Atrial fibrillation Overall, the number of women who develop atrial fibrillation is comparable to that of men. However, the prevalence of atrial fibrillation increases significantly with age, and women have a longer life expectancy than men. Therefore, the authors noted that as the number of older women increases, atrial fibrillation becomes significantly more common. The authors recommend that primary care physicians actively screen women aged ≥75 years for atrial fibrillation. level B evidence supports the preference for pulse and, to a lesser extent, electrocardiogram as screening methods. There is no evidence to support the use of oral anticoagulants in women with atrial fibrillation aged ≤65 years with no other risk factors. level B evidence supports the administration of antiplatelet therapy.