Summary
Background
Several studies have shown gender differences in the management of cardiovascular risk factors and diseases. Whether the management of hypertension by cardiologists in France differs according to patient gender has not been fully investigated.
Aims
The main objective of this cross-sectional, multicentre study was to examine the management according to gender of hypertensive patients by office-based cardiologists in France.
Methods
Cardiologists were asked to include consecutively two men and two women attending a routine consultation for essential hypertension. Therapeutic management was evaluated by comparing cardiovascular investigations in the preceding 6 months and hypertension control according to gender and the patients’ global cardiovascular risk.
Results
Overall, data from 3440 adult patients (53% men) referred to 654 cardiologists were analysed. Hypertension was uncontrolled in 76% of both men and women and 69% were at high global cardiovascular risk (75% of men, 62% of women; P < 0.001). Significantly fewer cardiovascular investigations had been performed in the preceding 6 months in women (22.6% vs 44.2% in men; P < 0.001). The treatment regimen was changed by the cardiologist in approximately 50% of patients regardless of gender or global cardiovascular risk.
Conclusions
The PARITE study shows that in French office-based cardiology practice, the antihypertensive regimen is adjusted as often in female as in male patients. However, the results suggest that there is room for improvement in the investigation of cardiovascular disease in women. Healthcare providers could be encouraged to implement established guidelines on the prevention of cardiovascular disease in women.
Résumé
Contexte
Le risque cardiovasculaire est généralement sous-estimé chez la femme. La maladie cardiovasculaire peut se manifester différemment et nécessiter des stratégies thérapeutiques différentes chez l’homme et la femme.
Objectifs
L’objectif principal de cette étude française observationnelle, transversale, multicentrique, a été d’évaluer en fonction du sexe, la prise en charge par des cardiologues libéraux de l’hypertension artérielle (HTA) et du risque cardiovasculaire global.
Méthodes
Les cardiologues devaient inclure les deux premiers hommes et les deux premières femmes vus en consultation de routine pour une hypertension essentielle. La prise en charge était analysée en termes de décision thérapeutique à la fin de la visite, en fonction du sexe, du risque cardiovasculaire (CV) global et du contrôle de l’hypertension. Les examens CV complémentaires des six mois précédents étaient également analysés.
Résultats
Parmi les 3440 patients adultes (53 % hommes et 47 % femmes) inclus dans cette analyse par 654 cardiologues, 76 % de la population globale de l’étude, ainsi que des femmes et des hommes avaient une HTA non contrôlée et 69 % un risque cardiovasculaire global élevé (75 % des hommes, 62 % de femmes ; p < 0,001). Le traitement antihypertenseur a été modifié de la même manière dans les deux sexes pour 50 % des patients. Enfin, 44,2 % des hommes et 22,6 % des femmes ont bénéficié d’un dépistage de l’ischémie myocardique ( p < 0,001).
Conclusions
L’étude Parite montre qu’en France, dans une population d’hypertendus suivis par des cardiologues libéraux, l’adaptation du traitement antihypertenseur se fait de manière équivalente entre hommes et femmes, et reste conditionnée par le contrôle tensionnel et ce indépendamment du niveau de risque cardiovasculaire global. Une amélioration de la prise en compte des recommandations spécifiques dans le diagnostic et le traitement de la maladie cardiovasculaire chez la femme reste néanmoins nécessaire pour une prévention efficace.
Background
While there is a popular perception that women are less susceptible to cardiovascular disease (CVD), it is less well recognized that this is no longer true after menopause: in Europe, cardiovascular mortality is in fact higher in women than in men (55% compared with 43%) . However, CVD presents differently in men and women and there is evidence that treatment efficacy is different between genders; for example, compared with male patients, aspirin is more effective in female patients in preventing stroke whereas it is less effective in preventing myocardial infarction . However, it has been shown that antihypertensive treatment can be as effective in women as in men . In this context, the Women at Heart initiative was launched by the European Society of Cardiology in 2005 to highlight the growing burden and under-appreciation of heart disease in women and to improve the management of women at risk of CVD in clinical practice. This initiative focused on the evaluation of cardiovascular risk factors (CVRFs) (especially the weighting of the various different factors) and the prescription of adapted treatment regimens . Consequently, the newly released Proceedings of the European Society of Cardiology Workshop on Gender Differences in CVD emphasized the need to implement strategies that improve perspectives in women .
The percentage of patients being treated for hypertension in France rose from 19.6% of the population in 2000 to 22.8% in 2006 . It has been conclusively demonstrated that lowering high blood pressure (BP) by drug treatment reduces the incidence of fatal and non-fatal cardiovascular events . However, BP is just one of the major factors that affects cardiovascular risk . Therefore, to decide on the therapeutic approach to be adopted for a given patient, the current European guidelines recommend taking into account not only BP but also the patient’s global cardiovascular risk (GCVR) based on CVRFs, end-organ damage and intercurrent cardiovascular or renal disease . Similarly, the current French recommendations promote a holistic approach in which more aggressive pursuit of BP control is warranted in patients at higher cardiovascular risk .
Barriers to effective CVD management in women exist. Among these barriers, the American Heart Association has identified confusion as a result of mixed messages from the media, women not perceiving themselves to be at risk and healthcare providers failing to inform women of the value of prevention in CVD . A recent report of the EuroHeart project has shown that women are still under-represented in many cardiovascular clinical trials although there are important gender differences in most areas of heart disease .
Very little is known about how French cardiologists manage hypertension in the office or clinical setting, especially with respect to gender. The PARITE study was organized to gain insight into how French cardiologists are managing male and female hypertensive patients in an office setting.
Methods
In this cross-sectional, observational, French multicentre study, cardiologists were randomly selected from a geographically stratified database (IDREM) and invited to participate in the study. Those who agreed were asked to include, over a period of 3 months, the first four consecutive patients fulfilling the inclusion criteria (two men and two women, in no stipulated order). The patients included were adult outpatients with essential hypertension but no acute condition, attending for a routine consultation. Patients with secondary or malignant hypertension and pregnant women were excluded.
The primary endpoint was the therapeutic decision resulting from the visit, with a focus on changes in the patient’s treatment regimen according to both gender and GCVR status as defined by the French Health Authority recommendations .
CVD management was defined as the therapeutic decision made at the end of the visit coupled with an analysis of the complementary cardiovascular investigations (echocardiography, exercise stress testing, coronary angiogram and sleep apnoea test) performed within the previous 6 months.
CVD management was assessed in the patient population as a whole and broken down according to gender, GCVR, end-organ damage, hypertension control and geographic region.
All data were recorded at a single visit on the basis of a physical examination, the patient’s medical records and an interview. Systolic BP (SBP) and diastolic BP (DBP) were measured in line with current French guidelines: two readings were made at least 5 minutes apart with the patient in a sitting position (after a rest of at least 5 minutes); the result recorded was the mean of the two readings. BP control was defined as BP less than 140/90 mmHg, or less than 130/80 mmHg if the patient was diabetic or had impaired kidney function.
Data were acquired on: demographic details; body weight and height; medical and surgical history; family history of premature cardiovascular events; diabetes; blood lipid levels; smoking status; abdominal obesity; lifestyle; alcohol consumption; end-organ damage (microalbuminuria readings and left ventricular hypertrophy as measured by electrocardiography and echocardiography); concomitant cardiovascular and kidney disease; and any additional cardiovascular tests or procedures performed within 6 months prior to the study visit. Antihypertensive treatment details and other cardiovascular drugs were recorded. At the end of the visit, cardiologists recorded any change in the antihypertensive treatment regimen (i.e. an increase in dosage of the same drug, a change of drug within the same class, a change of class or the discontinuation of one or more drugs).
GCVR was classified according to French guidelines as low, medium or high based on BP and other CVRFs.
Statistical analysis
The results of statistical analyses are presented as mean and standard deviation values for quantitative variables and as frequencies for qualitative variables. Significance was estimated using the appropriate test (Wilcoxon for quantitative and chi-square for qualitative variables) with a confidence level of 5%.
Two multivariable analyses – one in patients at medium GCVR and one in patients at high GCVR – were carried out to identify factors that independently correlated with the prescription of any test designed to investigate myocardial ischaemia (exercise testing together with stress echocardiography, magnetic resonance imaging or scintigraphy), collectively referred to as “pooled tests”.
All statistical analyses were performed using SAS 8.2 software (SAS Institute, Cary, NC, USA).
Results
Between March and August 2010, 654 office-based cardiologists throughout France participated in the study. The physicians had a mean of 18.8 years of experience (median: 20 years). Out of a total of 3456 patients initially included, 16 were excluded from analysis because of missing key data (BP measurements in most cases). Thus, the analysed population consisted of 3440 hypertensive patients. Baseline social, demographic and clinical data are presented for this population as a whole and broken down according to gender (53% men, 47% women) ( Table 1 ). Compared with the female subpopulation, the mean age of the men was lower (because of a higher proportion of women aged over 75 years), with a higher body mass Index (BMI) and a higher frequency of presence of three or more CVRFs. In addition, more of the men were heavy drinkers (18% of men, 3% of women) and had end-organ damage (essentially left ventricular hypertrophy as measured by electrocardiography and echocardiography), documented CVD (myocardial infarction, coronary heart failure, aortic aneurysm or dissection and peripheral atherosclerosis) or kidney failure ( Table 1 ).
| Men ( n = 1819) | Women ( n = 1621) | Total ( n = 3440) | P | ||||
|---|---|---|---|---|---|---|---|
| Data | Missing data ( n ) | Data | Missing data ( n ) | Data | Missing data ( n ) | ||
| Social and demographic data | |||||||
| Age (years) | 64.60 ± 11.62 | 2 | 67.30 ± 12.18 | 2 | 65.80 ± 11.96 | 2 | < 0.001 a |
| Age classes (years) | |||||||
| < 50 | 184 (10.1) | 138 (8.5) | 322 (9.4) | ||||
| 50–65 | 694 (38.2) | 485 (30.0) | 1179 (34.3) | ||||
| 65–75 | 549 (30.2) | 493 (30.5) | 1042 (30.3) | ||||
| ≥ 75 | 390 (21.5) | 503 (31.1) | 893 (26.0) | < 0.001 b | |||
| BMI (kg/m 2 ) | 28.00 ± 4.11 | 9 | 27.00 ± 5.04 | 14 | 27.50 ± 4.60 | 23 | < 0.001 a |
| BMI classes (kg/m 2 ) | |||||||
| < 25 | 413 (22.8) | 625 (38.9) | 1038 (30.4) | ||||
| 25–30 | 930 (51.4) | 591 (36.8) | 1521 (44.5) | ||||
| ≥ 30 | 467 (25.8) | 391 (24.3) | 858 (25.1) | < 0.001 b | |||
| GCVR | |||||||
| Low | 20 (1.1) | 81 (5.0) | 101 (2.0) | ||||
| Medium | 441 (24.2) | 528 (32.6) | 969 (28.2) | ||||
| High | 1358 (74.7) | 1012 (62.4) | 2370 (68.9) | < 0.001 b | |||
| CVRFs | |||||||
| Age > 50 (men) or > 60 (women) | 1600 (88.1) | 2 | 1170 (72.3) | 2 | 2770 (80.6) | 4 | < 0.001 b |
| Family history of CV events | 400 (23.5) | 116 | 317 (20.9) | 104 | 717 (22.3) | 220 | 0.078 |
| Diabetes (treated or untreated) | 538 (29.7) | 8 | 406 (25.2) | 10 | 944 (27.6) | 18 | 0.003 b |
| High cholesterol c | 1173 (65.6) | 27 | 933 (58.2) | 18 | 2106 (62.0) | 45 | < 0.001 b |
| Smoker | 442 (24.5) | 15 | 188 (11.7) | 15 | 630 (18.5) | 30 | < 0.001 b |
| Number of risk factors | |||||||
| 0 | 44 (2.4) | 144 (8.9) | 188 (5.5) | ||||
| 1 or 2 | 1040 (57.2) | 1042 (64.3) | 2082 (60.5) | ||||
| ≥ 3 | 735 (40.4) | 435 (26.8) | 1170 (34.0) | < 0.001 b | |||
| Other relevant conditions | |||||||
| Abdominal obesity | 799 (44.4) | 1 | 672 (41.9) | 18 | 1471 (43.3) | 39 | 0.139 b |
| Sedentary lifestyle | 1090 (60.1) | 5 | 1131 (70.1) | 8 | 2221 (64.8) | 13 | < 0.001 b |
| Excessive alcohol consumption | 314 (17.8) | 53 | 42 (2.6) | 21 | 356 (10.6) | 74 | < 0.001 b |
| End-organ involvement | |||||||
| At least one organ | 741 (40.7) | 538 (33.2) | 1279 (37.2) | < 0.001 b | |||
| Left ventricular hypertrophy | 669 (37.2) | 21 | 452 (28.4) | 30 | 1121 (33.1) | 51 | < 0.001 b |
| Microalbuminuria | 199 (15.4) | 527 | 162 (14.8) | 526 | 361 (15.1) | 1053 | 0.680 b |
| CV and kidney disease | |||||||
| At least one CV or kidney disease | 739 (40.6) | 453 (27.9) | 1192 (34.7) | < 0.001 b | |||
| Kidney failure (GFR < 60 mL/minute) or proteinuria > 500 mg/day | 157 (8.9) | 56 | 142 (9.0) | 45 | 299 (9.0) | 101 | 0.916 b |
| TIA or stroke | 147 (8.1) | 8 | 139 (8.6) | 8 | 286 (8.4) | 16 | 0.597 b |
| MI | 196 (10.8) | 12 | 64 (4.0) | 9 | 260 (7.6) | 21 | < 0.001 b |
| Coronary heart failure (without MI) | 248 (13.8) | 18 | 144 (8.9) | 11 | 392 (11.5) | 29 | < 0.001 b |
| Peripheral atherosclerosis | 261 (14.6) | 29 | 85 (5.3) | 17 | 346 (10.2) | 46 | < 0.001 b |
| Aortic aneurysm or dissection | 77 (4.3) | 37 | 20 (1.3) | 28 | 97 (2.9) | 65 | < 0.001 b |
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