Review

Cardiovascular Risk in Women: Focus on Hypertension

Beth L. Abramson, MD, MSc, FRCPC, FACC, and Rochelle G. Melvin, BMSc
University of Toronto, Cardiac Prevention Centre and Womens Cardiovascular Health, St Michaels Hospital, Toronto, Ontario, Canada
ABSTRACT
Hypertension is a major concern in women, contributing to the risk for
morbidity and mortality and the development of cardiovascular dis-
ease (CVD), heart attack, and stroke. A womans risk for the devel-
opment of hypertension increases with age. Although it also affects
younger women, hypertension is prevalent in approximately 60% of
women >65 years of age. In addition to age, there are specic risk
factors and lifestyle contributors for the development of hypertension
in women, including obesity, ethnicity, diabetes, and chronic kidney
disease. Risk reduction strategies need to be used to help reduce
hypertension; maintaining a healthy body weight through diet and
exercise, reduced sodium intake, and lower alcohol intake are a few of
the approaches for hypertension risk reduction in women. There are
several proposed mechanisms for the development of hypertension
that are unique to women and pertain to the aging-related elevated
risk for hypertension resulting from falling estrogen levels during
menopause. Oral contraceptives, pre-eclampsia and polycystic ovary
syndrome are special considerations concerning the development and
progression of hypertension in women. There are signicant awareness
issues and care gaps in the treatment of hypertension in women.
Therefore, these problems must be faced and efforts need to be taken
to resolve the issues surrounding the treatment and control of hyper-
tension in women.
R

ESUM

E
Lhypertension art erielle qui est une pr eoccupation majeure chez les
femmes contribue au risque de morbidit e et de mortalit e, et au
d eveloppement de maladie cardiovasculaire (MCV), de crise cardiaque
et daccident c er ebral vasculaire. Le risque de d eveloppement de
lhypertension chez la femme augmente avec lge. Bien quelle se
manifeste egalement chez les plus jeunes femmes, lhypertension est
courante chez environ 60 % des femmes g ees de > 65 ans. En plus
de lge, il existe des facteurs de risque sp eciques et des causes li ees
au mode de vie dans le d eveloppement de lhypertension chez les
femmes, dont lob esit e, lethnicit e, le diabte et la n ephropathie
chronique. Des strat egies de r eduction du risque doivent tre utilis ees
pour aider r eduire lhypertension; le maintien dun poids sant e au
moyen du r egime et de lexercice, la r eduction de lapport en sodium et
la diminution de la consommation dalcool sont quelques-unes des
approches pour r eduire le risque dhypertension chez les femmes.
Plusieurs des m ecanismes propos es dans le d eveloppement de lhy-
pertension nexistent que chez les femmes et concernent le risque
elev e dhypertension li ee lge et provoqu ee par la chute de la
concentration en strognes au cours de la m enopause. Les contra-
ceptifs oraux, la pr e eclampsie et le syndrome des ovaires poly-
kystiques sont des aspects particuliers prendre en consid eration
concernant le d eveloppement et la progression de lhypertension chez
les femmes. Il y a dimportants problmes de sensibilisation et des
lacunes en matire de soins concernant le traitement de lhy-
pertension chez les femmes. Par cons equent, ces problmes doivent
tre surmont es et des efforts doivent tre d eploy es pour r esoudre les
problmes entourant le traitement et le contrle de lhypertension
chez les femmes.
Epidemiology: Patterns and Rates of Disease in
Women
Hypertension is a leading risk for cardiovascular disease
(CVD), heart attack, and stroke, and therefore indirectly
contributes to cardiovascular mortality.
1
Also, Canadian data
suggest that more deaths are caused directly by essential
hypertension and hypertensive renal disease in women.
2
In
2010, 17.1% of Canadians reported having high blood pres-
sure (BP), which is an increase from 2008.
3
Recent data indi-
cate that approximately one third of the US population >20
years of age has been diagnosed with hypertension (31.7%
of men and 32.8% of women).
4
In recent years (2007-2010),
half of patients (52.3% of men and 46.4% of women)
with hypertension continued to have uncontrolled high BP.
4
This has implications because event rates are higher with
elevated BP.
5
Estimates suggest that hypertension contributed
to 12.8% of deaths worldwide, with an even greater impact
on women (14.3% in women vs 11.4% in men).
6
In addition,
women and men aged 20 years with hypertension had higher
all-cause mortality than did those without hypertension.
7
Received for publication January 31, 2014. Accepted February 23, 2014.
Corresponding author: Dr Beth L. Abramson, Cardiac Prevention Centre
and Womens Cardiovascular Health, St. Michaels Hospital, 30 Bond St
6 -050 Queen Wing, Toronto, Ontario M5B-1W8, Canada. Tel.: 1-416-
864-5424; fax: 1-416-864-5974.
E-mail: abramsonb@smh.ca
See page 557 for disclosure information.
0828-282X/$ - see front matter 2014 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.cjca.2014.02.014
Canadian Journal of Cardiology 30 (2014) 553e559
Given the consequences associated with high and uncontrolled
BP, it is essential that measures be taken to diagnose, treat, and
control hypertension in women.
CVD, heart attack, and stroke are leading causes of death
and disability in women in North America.
8
Statistics Canada
reported 68,342 deaths attributable to CVD in 2009, half of
which were in women.
2
Recent US data (2010-2011) showed
that the prevalence of heart disease is similar in men and
women (12.4% for men, 10.2% for women).
4
Heart disease
accounted for a staggering 307,384 deaths in men and 290,305
deaths in women in the United States alone.
4
Contemporary
data suggest that cerebrovascular disease is even more deadly in
women. In both the United States and Canada, death tolls
from stroke are higher in women than in men. Of the 14,105
stroke deaths in Canada in 2009, the majority were in women
(5823 men, 8282 women).
2
Although stroke prevalence is
similar in men and women (2.6% in the United States),
4
death
rates from stroke are higher in women (52,367 men, 77,109
women in 2010).
4
However, age-adjusted death rates were
similar in both sexes for stroke.
4
Fortunately, age-adjusted
death rates among men and women have been declining in
the past decadedstroke and heart disease declined 37% and
30%, respectively, for men and declined 35% and 32%,
respectively, for women.
4
This is partially because of better
detection and treatment of risk factors.
With an aging population, hypertension is a risk factor that
will become an increasing problem. The prevalence and
incidence of diagnosed hypertension increases with increasing
age.
7
Even in younger women, high BP is an issue. Hyper-
tension is seen in 8% of women aged 20-44 years.
9
National
Health and Nutrition Examination Survey (NHANES) data
from the past decade (1999-2008) showed that the prevalence
of hypertension rose signicantly with age, from 2.7% in
women aged 20-34 years to 18.4% in women aged 40-44
years.
9
Younger women with hypertension have a higher
chance of CVD developing, which partially explains the
observation that rates of CVD in young women have
increased.
10
In individuals <60 years of age, the prevalence of
hypertension is similar between men and women; however,
among individuals aged 60 years, the prevalence is higher
among women.
7
In the 2010 Canadian Community Health
Survey, men <65 years had higher rates of hypertension,
whereas women >64 years of age had higher BP.
3
The high
prevalence of hypertension in older women has enormous
implications given the consequences of hypertension.
3,11
Risk Factors for Hypertension in Women
In large cohorts comparing patients with uncontrolled BP
and those with controlled BP, women had more risk factors
than did men.
12
Higher total cholesterol and not having had
BP readings checked by a physician within the previous 6
months were signicantly linked to uncontrolled BP in
women but not in men.
12
Central obesity, high total
cholesterol, and low high-density lipoprotein concentrations
are concurrent risk factors found to be more prevalent in
women than in men.
12
Abdominal adiposity is a risk factor
linked to hypertension, coronary heart disease, and diabetes
mellitus.
13
Aging is a primary risk factor for hypertension in
women, especially on reaching the postmenopausal years.
Progressive chronological and ovarian age may be the cause of
the increase in waist circumference and fat mass seen in
middle-aged women.
12
When women of reproductive age were assessed in the
NHANES cohort, it was shown that advancing age, ethnicity,
diabetes, chronic kidney disease, and obesity were indepen-
dently associated with hypertension,
9
with obesity as the most
signicant modiable risk factor. This is important because
obesity affects >30% of young women in the United States.
9
Women with class I obesity (body mass index [BMI], 30-35
kg/m
2
) and women with class II/III obesity (body BMI M 35
kg/m
2
) were, respectively, 4-fold and 6-fold more likely to be
hypertensive compared with women of normal weight.
9
As
BMI increased, the prevalence of hypertension rose to a point
of plateau at a BMI of 40.
9
In another contemporary large prospective cohort (n
14,822), normotensive women 45 years were monitored for
hypertension over 8 years. The best predictor model for
incident hypertension included age, BP, ethnicity, BMI, total
grain intake, and levels of apolipoprotein B, apolipoprotein A,
and C-reactive protein.
14
In Japanese women aged 35-54
years, obesity, alcohol consumption, high triglyceride levels,
and high low-density lipoprotein cholesterol levels were linked
to prehypertension and hypertension.
15
In 2 independent
cohorts of women (Nurses Health Study I and II), those who
used non-narcotic analgesics were at higher risk for the
development of hypertension compared with nonusers.
16
Hypertension-Related Complications in Women
Target organ damage, such as microalbuminuria and left
ventricular hypertrophy (LVH), have been shown to be more
likely to develop in hypertensive premenopausal women than in
men.
17
In addition, postmenopausal hypertension can lead to
the progression of LVH and is the main factor causing coronary
artery disease, chronic heart failure, and stroke in older women.
11
Therefore, in relation to hypertensive men, women with high BP
have a higher risk of LVH, heart failure, a steep age-related in-
crease in arterial stiffness, and diastolic dysfunction.
18
In women with established hypertension, stroke risk is
greater with increasing weight. Large observational data (n
41,837 women aged 55-69 years) have demonstrated that the
chance of stroke was increased 1.6 times for the highest tertile
of waist-to-hip ratio, 1.3 times for the highest tertile of BMI,
and 2.1 times for those in the highest tertiles of both.
13
NHANES data from 1999-2004 showed a concerning
increase in the prevalence of diabetes among hypertensive
women.
12
This may lead to increased cardiovascular event
rates. In a prospective population-based cohort in Sweden, it
was determined that diabetic hypertensive women have an
increased risk of CVD compared with men (relative risk [RR],
3.18 and 1.64, respectively).
19
Overall, in terms of RR, the
cardiovascular risk linked to high BP is higher for women
compared with men; 20 mm Hg higher systolic BP demon-
strated a RR of 1.32 in women and 1.22 in men.
19
Risk Reduction Strategies in Women
There are several different lifestyle approaches to reducing
and preventing hypertension in women. In the Nurses Health
Study II, 6 modiable lifestyle and dietary factors for hyper-
tension and 6 low-risk categories were dened. They consist of
554 Canadian Journal of Cardiology
Volume 30 2014
a daily mean of 30 minutes of vigorous exercise, a Dietary
Approaches to Stop Hypertensionestyle diet,
20
a BMI 25
kg/m
2
, modest alcohol intake up to 10 g/d, non-narcotic
analgesic use less than once per week, and intake of 400 mg/d or
more of supplemental folic acid.
16
Diet and exercise are
cornerstones of prevention. A population-based, cross-
sectional study in Sweden that assessed the differing risk
proles for newly diagnosed hypertension in women and
men found that regular physical exercise 3 times a week or
more was signicantly protective only in women.
21
High
physical activity levels were associated with a 15% reduction
in the risk of hypertension in the CARDIA (Coronary
Artery Risk Development in Young Adults) study.
22
In the
Trials of Hypertension Prevention (TOHP) study, weight
loss intervention was associated with a 42% reduction in
incident hypertension.
23
Maintaining a healthy and realistic
body weight is a goal that can be achieved through gradual
changes in lifestyle and behaviour. Reducing portion size,
supplementing high-fat foods with healthier food choices,
and committing to physical activity are all sensible daily
routine alterations.
24
The National Heart, Lung, and Blood
Institute recommends 9 useful steps to attain a healthy
weight: determine your BMI, measure your waist circum-
ference, know your risk factors, set realistic and useful goals,
make your goals short-term ones, monitor your weight, keep
a food diary, monitor your behaviour, and reward success.
25
In some prospective cohorts of women, the risk of incident
hypertension was reduced in women with a higher total folate
intake. However, these are only observational data and remain
to be proved.
26
Reduced sodium intake is another lifestyle
modication that is associated with lower BP.
27
In a recent
study with 3230 participants, a dose-response relation between
reduction in salt intake and the fall in systolic BP was evident; a
salt intake decrease of 6 g/d predicts a 5.8 mmHg fall in systolic
BP, after adjustment for age, ethnic group, and BP status.
28
These ndings illustrate the need for a reduction in popula-
tion salt intake, which would lower population BP and subse-
quently the incidence of major cardiovascular events.
28
Limiting alcohol intake is a particularly important non-
pharmaceutical approach for reducing hypertension in
women. In a meta-analysis of 15 randomized controlled trials
(total of 2234 participants), alcohol reduction was linked to a
signicant decrease in mean systolic BP by 3.31 mm Hg and
diastolic BP by 2.04 mm Hg.
29
Alcohol enhances sympathetic
nervous system activity and the reduced estrogen-mediated
inhibition of this system in postmenopausal years further
augments the alcohol-induced increase in BP in women.
15
A NHANES comparison of women and men from 1999-
2004 found that over the course of 6 months, more women than
men had their BP reading checked by doctors. This was signi-
cantly associated with good BP control.
12
This has important
implications as a risk reduction strategy in women, because
improved detection of hypertension can lead to both better con-
trol of BP and recognition of other cardiovascular risk factors.
12
Proposed Mechanisms Unique to Women
It is likely that the aging-related elevated risk for hyper-
tension specic to women is in part caused by falling estrogen
levels during menopause. Decline in estrogen contributes to a
rise in BP through activation of the renin-angiotensin system
(RAS) and the sympathetic nervous system.
11
Plasma renin
activity has been shown to be higher in postmenopausal
women than in men and premenopausal women.
30
The effect
of estrogen on renin levels in circulation is further illustrated
by the fact that women who receive estrogen replacement
during menopause demonstrated signicantly lower renin
levels than those who did not receive hormone replacement.
31
RAS activation causes high BP through several different
mechanisms. Angiotensin II (A-II), a major substrate in RAS,
is a potent vasoconstrictor that causes blood vessels
throughout the body to constrict. Furthermore, A-II stimu-
lates aldosterone and antidiuretic hormone release, which
enlarges extracellular blood volume through salt and water
reabsorption. A-II also increases systemic vascular resistance
through sympathetic nervous system stimulation.
32
Endothelin levels are upregulated in postmenopausal
women,
33
and this may be mediated by A-II or altered
androgen ratios that are associated with menopause.
34
It is
also known that estradiol inhibits endothelin synthesis; thus,
after menopause the reduced levels of estradiol lead to an
increased amount of endothelin.
30
Endothelin is a potent
vasoconstrictor that augments sodium reabsorption in the
kidney and ultimately increases BP on a long-term basis.
30
Endothelin causes hypertension through activation of the
endothelin type A receptor, which mediates vasoconstriction,
or blockade of the endothelin type B receptor, which is
coupled to nitric oxide (NO)-mediated vasodilation.
34
Furthermore, evidence has shown that endothelial dysfunc-
tion can arise from loss of estrogen at any age, and this can
lead to hypertension.
34
An acute estradiol-mediated increase
in intracellular calcium activates endothelial NO synthase to
produce NO, and estradiol chronically increases mRNA for
endothelial NO synthase.
35
Because NO promotes vasodila-
tion and consequently a reduction in BP, hypertension is a
plausible result of a decline in estrogen. Additionally, renin
gene polymorphisms are linked with hypertension in women
aged 40-70 years, yet not in men, which suggests that there
could be a genetic aspect to the contribution of RAS to
postmenopausal hypertension.
36
Oxidative stress markers are more prevalent in post-
menopausal women.
37
This stress, which may be augmented
by endothelin and A-II, subsequently causes a reduction in the
vasodilator NO and thus results in an increase in BP.
34
Endothelin upregulates the production of the reduced form
of nicotinamide adenine dinucleotide phosphate oxidase
subunits and superoxide, and therefore promotes oxidative
stress.
30
Reckelhoff et al.
30
used the aging female spontane-
ously hypertensive rat (SHR) to illustrate that postmenopausal
rats have an increase in oxidative stress because this animal
model displays many of the features found in postmenopausal
women. The contribution of oxidative stress to post-
menopausal hypertension in the SHR is further demonstrated
by the fact that chronic treatment with vitamin E and vitamin
C has been shown to reduce BP.
30
Moreover, endothelin both
causes oxidative stress and increases the reaction to oxidative
stress, perpetuating a cycle that can lead to hypertension.
30
Several studies have reported an increase in androgen levels
during the postmenopausal years, which may play a role in
causing hypertension. This trend is consistent with premen-
opausal women with polycystic ovary syndrome or virilizing
tumours, who have elevated serum androgen levels and
Abramson and Melvin 555
Cardiovascular Risk and Hypertension in Women
increased BP.
30
Reckelhoff et al.
30
used the SHR to show this
hyperandrogenic state, demonstrating a 4-fold increase in
serum testosterone levels in the postcycling SHR compared
with young female rats. Testosterone administration in rats
has been shown to stimulate production of angiotensinogen,
which activates the RAS and subsequently increases BP.
30
Additionally, plasma endothelin is increased after androgen
supplementation in women, and cultured mesangial cells from
the SHR show an increase in oxidative stress and angiotensin
type 1 receptor expression subsequent to dihydrotestosterone
administration.
30
It is common for women to put on weight after menopause
or have a change in their waist-hip ratio. With menopause, a
womans body habitus may become modied; obesity may
take on more of an android, as opposed to gynecoid, pattern
and waist-to-hip ratio may change. The waist-to-hip ratio is
related to the quantity of visceral adipose tissue, and conse-
quently abdominal adiposity has been shown to positively
correlate with hypertension prevalence.
13
Mechanistic expla-
nations for this link include the observation that obesity is
concurrent with an increase in sympathetic activity, which is
demonstrated by an elevation of renal noradrenaline spillover
and an increase in muscle sympathetic nerve activity.
38
This is
associated with a reduced hepatic clearance of insulin in in-
dividuals with abdominal adiposity, which leads to a build up
of plasma insulin concentrations.
13
Insulin augments the risk
of hypertension by causing sodium reabsorption in the
proximal tubule of the kidney and elevated plasma catechol-
amine concentrations.
13
As mentioned, weight gain is linked
to high BP.
30
Obesity often results from a fault in dietary
thermogenesis or excessive dietary intake. Dietary-mediated
insulin release leads to the growth of hypertrophic adipo-
cytes throughout upper regions of the body and abdomen.
Hyperinsulinemia is associated with upper body obesity, and
subsequently insulin has been shown to predispose to hy-
pertension by stimulating the sympathetic nervous system in
addition to renal sodium reabsorption.
39
High renal sympa-
thetic tone causes hypertension by stimulating renin release in
the kidneys and causing renal tubular sodium reabsorption.
38
Because obesity is also associated with other risks for vascular
disease, such as insulin resistance and hyperinsulinemia, this
compounds a postmenopausal womans risk for vascular
events.
Special Considerations in Women
Oral contraceptives
There is often an idiosyncratic response to BP in women
taking oral contraceptive medications.
40
The Nurses Health
Study demonstrated that women taking oral contraceptives
had a signicantly increased risk of hypertension. This trend is
reversible: 3 months after discontinuation of oral contracep-
tive use, BP was shown to return to pretreatment levels.
41
Progesterone, rather than estrogen, is thought to be the fac-
tor contributing to this contraceptive-mediated hypertension.
Regarding risk of hypertension with oral contraceptives, a
womans family history of hypertension, occult renal disease,
obesity, middle age (>35 years), and length of oral contra-
ceptive use were all found to contribute to a propensity for
hypertension.
41
In contrast with nonusers, women with 6 or
more years of oral contraceptive use were found to be at the
highest risk for hypertension.
18
Furthermore, the type of
contraceptive has an impact on ones risk of future hyper-
tension. Monophasic combination pills have demonstrated an
increased hypertensive threat compared with biphasic or tri-
phasic combination pills.
18
Although the reaction is idiosyn-
cratic and reversible, The World Health Organization
contraindicates oral contraceptive use if a womans BP is
>160/100 mm Hg.
18
Pre-eclampsia
In the United States, hypertension is estimated to
complicate up to 5% of the estimated 4 million pregnancies a
year.
9
Complications associated with hypertension during
pregnancy are a main contributor to maternal and fetal
morbidity. The risk of superimposed pre-eclampsia and
placental abruption are increased in pregnant women with
hypertension, as are the maternal outcomes of stroke, renal
failure, pulmonary edema, and death. Chronic hypertension
can also affect fetal outcomes, including preterm birth and
intrauterine growth restriction.
9
The increased risk of gesta-
tional complications for older pregnant women may in part be
attributable to elevations in BP with advanced age.
9
There-
fore, BP evaluation and monitoring during pregnancy are
integral parts of maternal-fetal care. Importantly, women with
pre-eclampsia are at an increased risk for cardiovascular events
and overall mortality in the long run.
42
This has implications
for hypertension screening and long-term follow up.
Polycystic ovary syndrome
Premenopausal women with polycystic ovary syndrome or
virilizing tumours are hyperandrogenic and thus are more
prone to elevations in BP.
30
As mentioned, high levels of an-
drogens have been linked to hypertension.
30
In a population-
based cohort study in Sweden between 1995 and 2007, poly-
cystic ovary syndrome was found to be strongly associated with
pre-eclampsia (adjusted odds ratio, 1.45; 95% condence in-
terval, 1.24-1.69).
43
As mentioned, women with pre-eclampsia
are at higher risk for future cardiovascular events. These nd-
ings suggest that women with polycystic ovary syndrome
should be screened for hypertension at a younger age.
Awareness Issues, Care Gaps, and Closing the
Gaps for Treatment of Hypertension in Women
Hypertension continues to be inadequately controlled in
the general population, and women are especially vulnerable.
Data suggest this is a problem for women everywhere. Two
population-based studies were performed with men and
women older than 20 years in the Netherlands. The percent of
strokes ascribed to treated yet uncontrolled BP were 3.1% for
men and 4.1% for women. Untreated hypertensive in-
dividuals had an even higher number of incident strokes, with
22.8% for men and 25.4% for women.
44
Improvement in the
detection and management of hypertension is important in
the prevention of incident strokes, especially among untreated
hypertensive women.
Studies suggest that women are knowledgeable about
having hypertension; however, this does not seem to translate
into adequate control rates of this disease. In the 1999-2004
556 Canadian Journal of Cardiology
Volume 30 2014
NHANES, 68% and 67% of hypertensive women and men,
respectively, were aware of their high BP. The control rates for
treated hypertensive individuals were 66% for men and
62.5% for women.
41
In this cohort, women (along with the
elderly and Mexican Americans) had the lowest rates of BP
control.
45
Data from the Canadian Health Measures Survey,
collected at 15 sites across Canada from March 2007 through
February 2009, found that hypertension was uncontrolled in a
signicantly higher percentage of women (30%) than men
(17%).
46
When age, socioeconomic status, anthropometry,
comorbidity, category of medication, and other connections
to hypertension were considered, the odds of uncontrolled
hypertension were still nearly twice as high in women.
46
Paradoxically, women are more likely than men to have
their BP checked and to adhere to their medication regimen,
yet their control rates are still lower. This implies that there
are either biological factors or bias at play, ie, sex differences in
the mechanisms causing hypertension or the possibility that
women are not being treated as aggressively as men for their
hypertension.
47
In the Womens Health Initiative, BP control
rates among participants were inversely correlated with age.
Treated female hypertensive individuals in the oldest cohort
had lower control rates (46%) than did those in the younger
group (64%).
48
The rationale for this pattern could be
attributed to age-related resistance to antihypertensive agents
or a less aggressive treatment approach for the elderly.
48
This
philosophy of looser BP control in the elderly, as currently
emphasized in recent US guidelines, may have a greater
impact on older women, because they represent a larger per-
centage of the very elderly.
49
Risk awareness seems to have improved over time. A
telephone survey of a nationally representative random sample
of women conducted in June and July of 2003 were compared
with similar surveys from 2000 and 1997. Findings demon-
strate that awareness of heart disease as the leading cause of
morbidity and mortality in women improved over the 6 years,
yet there is still an inconsistency between perceived and actual
risk; less than a quarter of women cited heart disease as their
greatest health problem.
50
Education is an essential factor for
the management of hypertension. Patients should be thor-
oughly informed about their diagnosis and the importance of
adhering to their treatment plans and lifestyle modications.
In an online survey performed by members of the database of
WomenHeart: The National Coalition for Women with
Heart Disease, 24% of women reported that they do not
consistently take their BP medication.
47
Nonadherence was
attributed to forgetfulness (27%), medication expense (10%),
actual adverse effects (7%), and concerns about side effects
(7%). In this survey, women were presented with options for
lifestyle modication resources to improve BP control. Ideas
surrounding dietary planning and physical activity were the
leading suggestions chosen by women. Lists of useful websites,
local health and wellness programs, tracking sheets, access to
professionals for aid with lifestyle changes, better communi-
cation with health care professionals, and home BP cuffs were
the other options identied by women as possible means to
improve BP control.
47
Moreover, more than half of the
women in the survey indicated that local pharmacies would be
convenient places to check BP, and more than 25% of women
listed grocery stores, senior/community centres, or health
clubs as locations for this purpose.
47
These ndings suggest
that establishing accessible centres for women to measure BP
in their communities might improve self-management of
hypertension.
Closing care gaps in women is likely achieved through
multiple interventions. Emphasis on cardiac risk in routine
well woman physical examinations is another means by
which early detection of hypertension can be achieved. Home
BP monitoring systems are potentially another option to
improve treatment and adherence to hypertension control,
especially in elderly women, because they may have a harder
time reaching a physicians ofce.
47
The role of the health care
provider in closing care gaps for women is another essential
factor that must be addressed. The survey responses of
WomenHeart members found that only 28% of women re-
ported receiving educational materials on the effects of hy-
pertension, and 25% of women did not recall their health care
provider discussing important lifestyle changes or the detri-
ments of high BP.
47
It is important to note that differences were found in the
treatment patterns of hypertensive men and women. In a
prospective population-based cohort in Sweden, it was
determined that women were often prescribed older drugs,
such as diuretics or beta-blockers.
19
In comparison, men were
more frequently treated with newer drug classes, including
angiotensin-converting enzyme inhibitors or calcium channel
blockers.
19
Overall, detecting and treating hypertension can
make a difference. A systematic review of 11 randomized
controlled trials that merged data from a total of 23,00
women has shown that in women from all subgroups and
races, antihypertensive treatment provided a signicant
reduction in relative risk of cardiovascular events; there was a
38% decrease in fatal and nonfatal cerebrovascular events and
a 25% reduction in fatal and nonfatal cardiovascular events in
women aged 55 years and older.
18
These ndings demonstrate
the vital importance of treatment for helping to close the gaps
surrounding issues of hypertension control and management.
Conclusions
In summary, hypertension is a major issue for the female
population. It poses a serious risk for cardiovascular events in
women. There are several risk factors and proposed mecha-
nisms for hypertension development that are unique to
women. Care gaps exist and hypertension and stroke rates are
signicant for women. Efforts should be taken to face the
awareness issues as well as care gaps surrounding treatment
and control of hypertension unique to women.
Disclosures
The authors have no conicts of interest to disclose.
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