Women and Hypertension

• Kathleen Drinan DO, FACC, FACOIHypertension in Women

Hypertension Increases With Age,Faster for WomenNHANES 1999–2000100Popu ulation, %80604020Males (n=22.3 million)Females (n=35.6 million)020–34 35–44 45–54 55–64 65–74 75+Age, yearsAdapted from American Heart Association. Heart Disease and Stroke Statistics—2006 Update. Dallas,TX: American Heart Association; 2006.

Heart Disease Is the Leading Cause of Death inWomenActual Cause of Death of U.S. Women (2003)De eaths, tho ousands60050040030020010038,74845,058 65,6720Diabetes Alzheimer’s COPD267,902Cancer483,842CVD51% of women cite cancer as their greatest health problem—only 13% cite heart diseaseCVD=cardiovascular disease; COPD=chronic obstructive pulmonary disease.Adapted from American Heart Association. Heart Disease and Stroke Statistics—2006 Update. Dallas,TX: American Heart Association; 2006.Mosca L et al. Circulation. 2004;109:573–579.

Women and Hypertension: Perception vs. RealityPERCEPTION: Women perceive hypertension as a minor health threat1Top Perceived Threats to Women’s Health in the U.S.Total(n=820)Cancer (Net)Breast cancer90%54%Cancer (unspecified)33%Ovarian cancer9%Cervical cancer9%Lung cancer8%Cardiovascular-Related Diseases/Conditions (Net)87%Heart disease (unspecified)/Heart conditions (unspecified) 69%Heart attack16%Hypertension, or high BP5%Hypercholesterolemia, or high blood cholesterol1%Diabetes19%Stroke (unspecified)12%Obesity11%Osteoporosis 9%REALITY: 39% of the women surveyed said they have been diagnosedwith hypertension by a physician or other health professionalIn a survey of 820 women >40, only 5% cite hypertension or high BP as one of the top threats towomen’s health.1Harris Interactive. Quick Query Dealing With Women’s Top Health Concerns. August 2006;1–3.

Hazard RatioSBP Is a Strong Predictor of CVD EventsAmong Middle-aged and Older WomenThe Women’s Antioxidant Cardiovascular Study (WACS) 6-YearResults76543210N=5,218RR* of CVD Events According to SBPSBP, mmHg*Adjusted for age, randomization, body mass index, smoking, alcohol use, exercisefrequency, enc diabetes, history of elevated cholesterol, antihypertensive tensi e therapy, priormyocardial infarction, prior stroke, and prior revascularization.Mason PJ et al. Circulation. 2004;109:1623–1629.

Post‐MI Risks Are Substantial for WomenPercent5040302038% of women will diewithin one year post-MIFemalesMales1002 nd HeartAttackSuddenDeathDisabled—Heart FailureStrokeMI=myocardial infarction.Adapted from Thom T et al. Circulation. 2006;113:e85–e151.

Hypertension Mortality Is Greater for AfricanAmerican Women*Overall Mortality Rates From Causes Related to HypertensionOvera all Mortal ityRate, %504030201014.540.80WhiteWomenAfrican AmericanWomen*Compared to whites.Adapted from American Heart Association. Heart Disease and Stroke Statistics—2006 Update.Dallas, TX: American Heart Association; 2006.

We Are Facing a Heart Failure EpidemicHospital Discharges for HF, 1979–2003:174% IncreaseDischargees in Tho ousands600Females500400Males30020010001979 1983 1987 1991 1995 1999 2003YearAdapted from American Heart Association. Heart Disease and Stroke Statistics—2006 Update.Dallas, TX: American Heart Association; 2006.

HF Is A Major Concern for Women• 75% of HF cases have antecedent hypertension• At age 40, the lifetime risk of developing HF for women is 1 in 5• 46% of female MI victims will be disabled with HF within 6 years• After HF is diagnosed:• the one year mortality rate is 1 in 5• 70% of women under age 65 will die within 8 years• fewer than 15% of women will survive more than 8−12 yearsAdapted from American Heart Association. Heart Disease and Stroke Statistics—2006 Update.Dallas, TX: American Heart Association; 2006.

Some Factors Contributing to gHypertension Among Women

BP Rises After Menopause—Risk of Hypertension TriplesSBP,Δ FromBaselinemmHgChanges in SBP From Baseline to Follow-up (Mean 5.2 Years)WomenControls6Premenopausal5(n=166)4† *Perimenopausal(n=44)3Postmenopausal2(n=105)1–1.9 19 –0.1 0100.4 3.3 3.80.2–1–2–3*P≤0.05.†P=0.07.Baseline SBP: Pre=121.4 ± 13mmHg; 1.3 Peri=122.0 ± 18mmHg; 1.8 Post=126.5 ± 17 1.7mmHg; Controls: men matched by age and BMI.Staessen JA et al. J Hum Hypertens. 1997;11:507–514.

Menopause and Hypertension• Menopause increases incidence of hypertension and CV disease• interruption of estrogen—a potent vasodilator—contributes to postmenopausalhypertension• loss of estrogen activates the renin‐angiotensin‐aldosterone system throughupregulation of both ACE activity and AT 1 receptors• BP becomes salt‐sensitive after menopause• female sex hormones appear to protect against salt‐induced increases in BPNickenig G et al. Circulation. 1998;97:2197–2201.Oparil S, Miller AP. J Clin Hypertens (Greenwich). 2005;7:300–309.

Hypertension Increases With Weight Gain in WomenNurses’ Health Study: Hypertension † According to Weight ChangeMultivar riate RR*7 Age

Smoking and Physical Inactivity Are Risk Factors forCardiovascular Disease• Smoking has been associated with 50% of all coronary events inwomen• Coronary risk is elevated even in women with minimal use(relative risk ik24f 2.4 for 1–4 cigarettes/day)• 66% of women reported never engaging in vigorous physicalactivity lasting ≥10 minutes per week• Another 12% reported minimal (

Smoking and Physical Inactivity Are Risk Factors forCardiovascular Disease• Smoking has been associated with 50% of all coronary events inwomen• Coronary risk is elevated even in women with minimal use(relative risk ik24f 2.4 for 1–4 cigarettes/day)• 66% of women reported never engaging in vigorous physicalactivity lasting ≥10 minutes per week• Another 12% reported minimal (

Hypertension ControlHypertension ControlAmong Women

Evolution of Antihypertensive Agents1950s1960s1970s1980s1990sVasodilatorsCentral 2 -agonistsAldosterone receptor blockersDiureticsβ-adrenergic blockersCalcium channel blockers (nondihydropyridines) 1 -blockers- β-blockersCalcium channel blockers (dihydropyridines)Angiotensin-converting i ienzyme inhibitorsAngiotensin receptor blockersScholz H. Z Kardiol. 2002;91:34−42.

Control of Hypertension Low in WomenAbout Half Are Treated; About a Quarter Are Controlled*olled*Women n, %8070605040302010075.1 73.671.260.160.062.029.127.429.61988–1991 1991–1994 1999–2000Awareness Treatment Control*Percentage of hypertensive patients controlled. Control=treatment with antihypertensivemedication and a measured BP of

Today, we have:increased knowledge about the prevalence of hypertension amongwomena better understanding of CV risks in womenmore aggressive hypertension treatment guidelinesmore effective drug optionsSo why are BP control rates among women as lowas they were nearly 20 years ago?

Why Are So Many Women Unaware ofTheir Hypertension?• Hypertension rarely causes noticeable symptoms —recognizedas “the silent killer”• Usually detected during routine physical examThe Women Take Heart ProjectUnacknowledged or unaware hypertensive women weresignificantly ifi younger as a group, had a lower mean BMI, and alower waist-toto-hip ratio than women who reported a history ofhypertension.However, their BP measures were similar:ilunaware hypertensive women (146/89 mmHg) vs.aware hypertensive women (147/88 mmHg).http://www. johnshopkinshealthalerts.com/reports/heart_health/136-1. html. Accessed August 10, 2006.Furumoto-Dawson AA et al. J Clin Hypertens. 2003;5:38−46.

AWARENESS• WTH – over one half of the hypertensive women were either undiagnosedor unaware or did not acknowledge their hypertension.

• “I walked into my doctor’s office complaining of heart palpitations My• I walked into my doctor s office complaining of heart palpitations. Myblood pressure was 180/90.”

• “My doctor gave me a grave look and said,• “you need to lose weight”.• “Tell me something I don’t know”, I thought smugly. I didn’t take heradvice seriously. After all, I’d been heavier and never felt my heart racing.“I’d had perfect blood pressure – 110/70 for years, even at my heaviest.

Blood Pressure Patternsin the General Population (NHANES III)MenWomen150150130110SBPPP130110SBPPP808070DBP70DBP30-3939 40-4949 50-5959 60-6969 70-7979 80Age30-3939 40-4949 50-5959 60-6969 70-7979 80AgeAdapted from Burt VL et al. Hypertension 1995;25:305-313. 313.

JNC 7*:Need for Prompt Aggressive Action• Current control rates unacceptable• Most patients can achieve goal (the majoritywill require >2 drugs)• Adjust therapy monthly or more frequentlyuntil goal is reached“Action to control BP is needed now and isa challenge that all must accept.”—Kottke T et al. JAMA. 2003*JNC 7=The Seventh Report on the Joint National Committee on Prevention, Detection,Evaluation, and Treatment of High Blood Pressure.Chobanian AV et al. Hypertension. 2003;42:1206–1252.Kottke T et al. JAMA. 2003;289:2573–2575.

Aggressively Lowering BPPrevents Clinical i l EventsRe eduction in BP, mm mHgEach 5 mmHg reductionin DBP reduces*0–1 Stroke by 34%–2Ischemic heartdisease by 21%–3–4–5–6–7IMPORTANT NOTE: The medicinesdiscussed are approved to treat high–8BP and are not approved to prevent–9ischemic heart disease or stroke–10resulting from high BP.Each 10 mmHg reductionin DBP reduces*Stroke by 56%Ischemic heartdisease by 38%*From any pretreatment level; no threshold. Estimated from 9 large cohort studies.Law M et al. Health Technol Assess. 2003;7:1–94.

JNC 7: Management of BPLifestyle Modification: JNC 7 encourages lifestyle modification for patients whohave normal BP, and recommends lifestyle modification for patients who areprehypertensive, or are stage 1 or stage 2 hypertensive.Normal

PREVENTIONThe prevalence of hypertension is very lowin women