Gender and Blood Pressure Control
To the Editor:
We read with interest the article by Keyhani et al1 about gender disparities in blood pressure control in ambulatory practices across the United States. In this study, a total of 12 064 patient visits were identified (7786 women and 4278 men). Hypertension was identified by physicians in 4435 visits. Among patients with hypertension, women were less likely than men to meet blood pressure control targets (54.0% versus 58.7%; P<0.02), and this was confirmed by the multivariate analysis. Notably, there was no association between gender and the use of any antihypertensive medication or initiating a new therapy among patients with uncontrolled hypertension.
Although these findings are very interesting, they could not be largely applicable to other populations with a different risk profile. Thus, in a survey performed in the primary care setting in Spain that included 12 954 patients (6468 women and 6486 men) with hypertension, 49.1% of men versus 50.9% of women (P=0.049) attained blood pressure control, and, in the multivariate analysis, blood pressure control were not influenced by gender.2 With regard to antihypertensive therapy, no differences were found in the number of agents according to gender. A total of 70.2% of women versus 72.1% of men were taking ≥2 antihypertensive drugs. Concerning the type of agents, only diuretics (36.9% in females versus 30.4% in males; P<0.001) and β-blockers (9.7% in women versus 14.5% in men; P<0.001) were different between genders.
Despite the substantial risk of developing or dying from coronary heart disease or stroke in patients, available data reveal that American women with hypertension are less likely than men to receive recommended preventive therapies.1,3 However, it may not be the same in other countries. This might be influenced by the fact that, in United States, the most important cause of cardiovascular death in both genders is coronary heart disease, whereas in other countries, such as Spain, this differs.3 Thus, in this Mediterranean country, ischemic heart disease is the most frequent cause of death in men, whereas in women the main cause is stroke.4
This different cardiovascular risks of death may influence in the differences between blood pressure controls. The worse rates in women found in United States could be at least partially promoted by the confidence in the well-known cardioprotective effect of the feminine hormones.5 However, taking into account that this protective effect is less obvious in the prevention of stroke and that stroke is the most important cause of death in females in Spain, Spanish physicians could be more aware of attaining blood pressure goals in women. This might at least partly explain that blood pressure control rates are similar between genders in Spain.
These data suggest that, although some studies have reported that women have worse blood pressure control than men, this could be mainly caused by a lesser perception by physicians about the risk that hypertension represents in women more than because blood pressure objectives are specifically more difficult to achieve in females.
Source of Funding
The present study was supported by an unrestricted grant from Almirall-Prodesfarma Pharmaceuticals, Barcelona, Spain. All data have been recorded and analyzed independently to prevent bias.
Keyhani S, Scobie JV, Hebert PL, McLaughlin MA. Gender Disparities in blood pressure control and cardiovascular care in a national sample of ambulatory care visits. Hypertension. 2008; 51: 1–7.
Rosamond W, Flegal K, Friday GFK, Go A, Greenlund K, Haase N, Ho M, Howard V, Kissela B, Kittner S, Lloyd-Jones D, McDermott M, Meigs J, Moy C, Nichol G, O'Donnell CJ, Roger V, Rumsfeld J, Sorlie P, Steinberger J, Thom T, Wasserthiel-Smoller S, Hong Y. Heart disease and stroke statistics–2007 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation. 2007; 115: e69–e171.
Redón J, Cea-Calvo L, Lozano JV, Martí-Canales JC, Llisterri JL, Aznar J, González-Esteban J. PREV-ICTUS Study. Differences in blood pressure control and stroke mortality across Spain: the Prevención de Riesgo de Ictus (PREV-ICTUS) Study. Hypertension. 2007; 49: 799–805.
Mosca L, Banka CL, Benjamin EJ, Berra K, Bushnell C, Dolor RJ, Ganiats TG, Gomes AS, Gornik HL, Gracia C, Gulati M, Haan CK, Judelson DR, Keenan N, Kelepouris E, Michos ED, Newby LK, Oparil S, Ouyang P, Oz MC, Petitti D, Pinn VW, Redberg RF, Scott R, Sherif K, Smith SC Jr, Sopko G, Steinhorn RH, Stone NJ, Taubert KA, Todd BA, Urbina E, Wenger NK. Evidence-based guidelines for cardiovascular disease prevention in women: 2007 update. Circulation. 2007; 115: 1481–1501.