BP classification
SBP (mmHg)
DBP (mmHg)
Normal
<120
and <80
Prehypertension
120–139
or 80–89
Stage 1 hypertension
140–159
or 90–99
Stage 2 hypertension
>160
or >100
Practical Points in Diagnosis and Treatment
Epidemiological Differences Between Women and Men
Differences in blood pressure between the sexes exist bimodally in adulthood and in later age. In early adulthood men generally have higher systolic blood pressures, while in later age women’s pressures are higher starting at age 60 [1]. Women typically are less hypertensive than men until age 50, where at that age the incidence of newly diagnosed hypertension in women exceeds that of men. Older African-American women above the age of 75 years are the most prevalent hypertensives, with 75 % of them diagnosed by this age. Again, women are thought to be more aware of their hypertension diagnosis than men, and have it treated and better controlled (according to NHANES III data). This is possibly due to more doctor encounters and primary care opportunities in women [1]. There is also an increased incidence of diastolic dysfunction and diastolic heart failure in women, especially older women greater than 70 years, when compared to men. Diastolic dysfunction occurs when there is impaired relaxation of the left ventricle, and when fully developed can lead to diastolic heart failure, or heart failure with preserved ejection fraction. Older women greatly outnumber men in diastolic heart failure, and they have higher rates of hypertension pre-diagnosis. Older women who develop diastolic heart failure with preserved ejection fraction have also higher rates of hypertension than women without diastolic failure, and less incidence of myocardial infarction than do patients with systolic heart failure [4].
Diagnosis
The diagnosis of hypertension in men and women is the same. Table 12.1 shows the classification of blood pressure according to The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood pressure (JNC-7). Hypertension is appropriately diagnosed after two separate blood pressure readings in the seated position after two or more separate office visits. The inclusion of a “prehypertensive” category, defined as a systolic blood pressure of 120–139 mmHg or diastolic blood pressure of 80–89 mmHg was created to support targeted lifestyle interventions in this group to avoid escalation in the blood pressure to hypertensive levels in the future. Unless other indications are present to prompt treatment to lower the blood pressure (other risk factors such as diabetes or evidence of target organ damage such as chronic renal insufficiency), the prehypertensive category is useful to encourage providers to prescribe exercise and additional lifestyle modifications such as weight loss and diet modification that may be warranted at that point. In women, review of additional contributors, such as oral contraceptive therapy in younger women or hormonal therapy in perimenopausal women, should be discussed should evidence of prehypertension be found.
Ideally, measurement of blood pressure should involve both right and left arms to evaluate for any significant discrepancies between the two which may herald a larger problem such as vascular stenosis or aortic coarctation. When using a manual cuff, care should be taken to ensure the right size is used (the cuff bladder itself should encircle 80 % of the arm).
Thorough history and physical examination should follow with careful search for identifiable reversible causes of secondary hypertension. In women in particular these may include Cushingoid features suggestive of glucocorticoid excess, variable extremity blood pressures indicative of possible coarctation of the aorta, obesity with increased neck girth and fatigue or daytime somnolence suggestive of obstructive sleep apnea. Young women less than 35 years of age with resistant hypertension should be screened for renovascular hypertension/fibromuscular dysplasia with ultrasound of the renal arteries. Occult hypertension in the morbidly obese young woman could suggest a diagnosis of polycystic ovarian syndrome. Again, in young women consideration should be given to the use of oral contraceptives and elevated blood pressure readings. Women are more predisposed to developing certain rheumatologic and collagen vascular disorders including systemic sclerosis and systemic lupus which in themselves can promote hypertension. Other etiologies of secondary hypertension include untreated pheochromocytoma and thyroid disease, which should be considered based on clinical presentation.
Basic laboratory tests and procedures that are recommended after a diagnosis of hypertension is made include the 12-lead electrocardiogram to evaluate for presence of left ventricular hypertrophy or atrial enlargement which would suggest long-standing hypertension, urinalysis to evaluate for proteinuria and intrinsic renal dysfunction from hypertension, basic metabolic profile with glomerular filtration rate (GFR) to evaluate electrolytes and renal involvement, and routine lipid screening. Additional studies may be warranted should there be suspicion of the reversible causes described above (sleep study, thyroid secreting hormone (TSH), plasma metanephrines, renal ultrasound, cortisol levels, etc). There is some evidence that elevated C-reactive protein (CRP) in women with no other risk factors is associated with a higher cardiovascular event rate but in isolation its clinical utility remains unclear.
Treatment
Once the diagnosis of hypertension is made, treatment of hypertension for women is essentially the same as that for men with the exception of the consideration of current reproductive goals. Care should be taken with determining where the woman is in terms of family planning and discussion of birth control should always be included if angiotensin converting enzyme (ACE) inhibitors or angiotensin-receptor blockers (ARBs) are being considered. ACE inhibitors and ARBs should be avoided in women actively planning a pregnancy or in women who are not reliably using birth control or similarly effective anti-contraceptive modalities.
Recent data shows that both the diagnosis and treatment of hypertension is suboptimal. In 2010, only 47 % of Americans with hypertension reported theirs as controlled, an actual increase from 29 % 10 years prior (NHANES study data). Women are more likely than men to report their blood pressure as being controlled (approximately 51 % compared to 43 %). Certain sub-populations, including the elderly, diabetic, those with chronic kidney disease, and African-Americans have higher rates of having treated, but uncontrolled, hypertension [5].
Overall trial data shows no difference between different antihypertensive classes in terms of effect on outcomes in women when compared to men. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood pressure (JNC-7) provides a step-wise method of therapy (see Fig. 12.1), beginning with lifestyle modifications including a balanced, low salt (2.4 g of sodium) and low fat diet, weight loss, smoking cessation, reduced alcohol intake, and exercise. Initial treatment goals are that of a systolic blood pressure (SBP) of less than 140 or 130 mmHg if the patient is diabetic or with renal insufficiency. Thiazide diuretics typically are first-line in therapy, with use of 12.5–25 mg of hydrochlorothiazide or even chlorthalidone (see Table 12.2). Should the patient have diabetes or chronic kidney disease, an ACE inhibitor or an ARB should be utilized with close monitoring of electrolytes and renal function to ensure stability in the first few weeks. Those with stage 2 hypertension (≥ 160/100) or above should be treated initially with two antihypertensives. A diagnosis of congestive heart failure or coronary disease warrants using ACE inhibitors and adding beta-blockers should blood pressure allow.
Fig. 12.1
Treatment Algorithm – JNC 7 (Source: National Heart, Lung, and Blood Institute; National Institutes of Health; U.S. Department of Health and Human Services [2]). ACEI Angiotensin converting enzyme (ACE) inhibitor, ARB angiotensin receptor blocker, BB beta blocker, CCB calcium channel blocker, SBP systolic blood pressure, DBP diastolic blood pressure, HF heart failure, MI myocardial infarction, CAD coronary artery disease, DM diabetes mellitus, CKD chronic kidney disease
Table 12.2
Oral antihypertensive drugs – JNC −7
Class | Drug (trade name) | Usual dose range (mg/day) | Usual daily frequency |
|---|---|---|---|
Thiazide diuretics | HCTZ | 12.5–25 | 1 |
Chlorthalidone | 12.5–25 | 1 | |
BBs | Atenolol (Tenormin) | 25–100 | 1 |
Bisoprolol (Zebeta) | 2.5–10 | 1 | |
Metoprolol (Lopressor) | 50–100 | 2 | |
Metoprolol XL (Toprol XL) | 50–100 | 1 | |
Combined α and BBs | Carvedilol (Coreg) | 12.52–50 | 2 |
Labetalol (Normodyne) | 200–300 | 2 | |
ACE-I | Benazepril (Lotensin) | 10–40 | 1 |
Captopril (Capoten) | 25–100 | 1 | |
Enalapril (Vasotec) | 5–40 | 1 | |
Lisinopril (Zestril) | 10–40 | 1 | |
Quinapril (Accupril) | 10–80 | 1 | |
Ramipril (Altace) | 2.5–20 | 1 | |
ARBs | Irbesartan (Avapro) | 150–300 | 1 |
Losartan (Cozaar) | 25–100 | 1–2 | |
Olmesartan (Benicar) | 20–40 | 1 | |
Telmisartan (Micardis) | 20–80 | 1 | |
Valsartan (Diovan) | 80–320 | 1–2 | |
CCBs | Amlodipine (Norvasc) | 2.5–10 | 1 |
Nicardipine SR (Cardene SR) | 60–120 | 2 | |
Nifedipine (Adalat, Procardia) | 30–60 | 1 | |
α agonists | Clonidine (Catapres) | 0.1–0.8 | 2 |
Clonidine patch | 0.1–0.3 | weekly | |
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