Pharmacist Expert Adviser

Robert Lee Page II, PharmD, FCCP, FAHA, BCPS, CGP
Published Online: Sunday, February 1, 2009
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Dr. Page is an associate professor of clinical pharmacy and physical medicine and a clinical specialist, Division of Cardiology, University of Colorado Health Sciences Center, Schools of Pharmacy and Medicine.


Women with Hypertension Face Unique Challenges

Hypertension affects an estimated 72 million Americans, 54% of whom are female. Whereas the risk of death from ischemic heart disease and stroke increases progressively and linearly with escalating blood pressure (BP) in both women and men, more women still die from hypertension.1,2 A gender dimorphism in BP appears to exist, in that women exhibit lower systolic BP than men during early adulthood, whereas the opposite is true after age 54, when the prevalence of hypertension in women exceeds that of men. 2,3 Data have suggested that, when it comes to hypertension, women face unique risks for developing hypertension and endure special challenges when attempting to keep their BP under control.

Hypertension in Pregnancy and Menopause

Hypertension is 2 to 3 times more common in women taking oral contraceptives.1 Hypertension also is the most common medical disorder of pregnancy, complicating 1 in 10 pregnancies.4 In order to minimize both acute and chronic fetal and maternal risk, appropriate hypertension diagnosis should be made early in the pregnancy in order to differentiate between preexisting (chronic) hypertension and pregnancy-induced (gestational) hypertension and preeclampsia. The American Heart Association encourages women to use home blood pressure monitoring (HBPM) to accurately assist their provider with this important task.5

Treating hypertension during pregnancy requires close observation, which may include HBPM. Many common antihypertensive medications such as angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers are contraindicated because of reports of fetal toxicity and death. This treatment approach reflects concerns about the safety of antihypertensive treatment during pregnancy because studies have shown a direct linear relationship between treatment-induced reductions in mean arterial pressure and the proportion of small-for-gestational-age infants.1

Although debatable, cohort studies suggest a relationship between menopause and hypertension.6 Compared with men matched by age and body mass index, postmenopausal women exhibit higher systolic BP and greater systolic BP increases (5 mm Hg) over 5 years. Unique etiological factors contributing to this phenomenon consist of genetic factors, hormonal changes, and environmental factors.6

Women Versus Men in BP Control

Finally, persistent gender disparities exist in BP control, cardiovascular risk factors, and disease management. Based on data from the 1999-2004 National Health and Nutrition Examination Study, hypertensive women aged 18 and older have a higher prevalence of elevated total cholesterol, lower high-density lipoprotein cholesterol, and greater central obesity (P <.05, for all variables), compared with men.7 Furthermore, findings generated from the 2005 National Ambulatory Medical Care and National Hospital Ambulatory Medical Care Surveys suggest that women with hypertension are not receiving adequate quality of care, compared with men.8

In the analysis of 7786 women and 4275 men, women with hypertension were less likely to receive aspirin (P <.001), beta-blockers (P <.05), and statins (P <.05) for secondary prevention of cardiovascular disease, compared with men. Furthermore, women were less likely to meet BP control targets, compared with men (P <.02).

Based on the data, health care providers need to be mindful of the salient differences that exist between genders when managing patients with hypertension.

References

  1. Chobanian AV, Bakris GL, Black HR, et al. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA. 2003;289(19):2560-2571.
  2. American Heart Association Web site. Heart Disease and Stroke Statisitics-2008 Update. www.americanheart.org. Accessed October 6, 2008.
  3. Reckelhoff JF, Fortepiani LA. Novel mechanisms responsible for postmenopausal hypertension. Hypertension. 2004;43(5):918-923.
  4. Podymow T, August P. Update on the use of antihypertensive drugs in pregnancy. Hypertension. 2008;51(14):960-969.
  5. Pickering TG, Miller NH, Ogedegbe G, Krakoff LR, Artinian NT, Goff D. Call to action on use and reimbursement for home blood pressure monitoring: executive summary: a joint scientific statement from the American Heart Association, American Society Of Hypertension, and Preventive Cardiovascular Nurses Association. Hypertension. 2008;52(1):1-9.
  6. Coylewright M, Reckelhoff JF, Ouyang P. Menopause and hypertension: an age-old debate. Hypertension. 2008;51(4):952-959.
  7. Ong KL, Tso AW, Lam KS, Cheung BM. Gender difference in blood pressure control and cardiovascular risk factors in Americans with diagnosed hypertension. Hypertension. 2008;51(14):1142-1148.
  8. 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(4):1149-1155.

Pharmacists, Cardiovascular Outcomes, and Home Blood Pressure Monitoring

Pharmacists are ideally positioned health care professionals who can make a significant impact on health outcomes and public health. Not only are pharmacists easily accessible to patients, but they are highly trained in evidence-based pharmacotherapy so as to deliver high-level medication disease state management. Regarding cardiovascular outcomes, pharmacist-led interventions in various health system settings have been shown to reduce adverse drug events, improve medication adherence, and in some cases even reduce mortality and hospitalization.1-3

Hypertension is one of the leading causes of death worldwide, and almost 1 in 3 Americans carries a diagnosis of hypertension, defined as a blood pressure (BP) of 140/90 mm Hg or higher.4-6 Therefore, disease state management programs targeting this chronic condition through community pharmacist intervention should significantly impact outcomes within this patient population. Recent meta-analyses of quality improvement tactics have shown significant improvements in lowering BP in hypertensive patients, particularly when a pharmacist was added to the health care team, compared with other strategies.7,8

Pharmacist Intervention Helps Control Patients' BP

In the Electronic Communications and Home Blood-Pressure Monitoring study, Green and colleagues randomized 778 patients with uncontrolled essential hypertension and Internet access from an integrated group practice in Washington State to one of the following treatment strategies: usual care, home BP monitoring through secure patient Web site training only, or home BP monitoring and secure patient Web site training plus pharmacist care management delivered through Web communications.9

Usual care consisted of suggesting that patients with hypertension work closely with their provider. In the pharmacistintervention group, pharmacists reviewed patient histories and were regularly provided patients' BP measurements, medication concerns, and progress related to lifestyle goals through Internet-based communication. Pharmacists responded with specific recommendations including medication changes. All clinical concerns or potential deviations from the medication protocol were referred back to the patient's physician. After one year of follow-up, those receiving pharmacist care management had significantly better BP control, compared with the other interventional strategies (P <.001).

Incorporate HBPM into Treatment Plans

This study highlights not only the value of pharmacist intervention, but also the critical importance of home blood pressure monitoring (HBPM).10 Although the clinical relevance of office-measured BP has been established in multiple outcomes studies, BP measurement in this setting has numerous shortcomings, including loss of calibration of equipment, failure of physicians to follow measurement guidelines, and the white-coat effect.10 Measurement of BP in the office setting typically does not determine BP values 12 to 24 hours after dosing of medications and cannot detect the presence and magnitude of BP during sleep or during the post-awakening surge. Thus, in May 2008, the American Heart Association, the American Society of Hypertension, and the Preventive Cardiovascular Nursing Association issued a collaborative statement calling for patients with hypertension to incorporate HBPM as part of their management strategies.10

Pharmacists are uniquely positioned to meet this call to action as they can assist patients with selecting an appropriate monitor and provide the most accurate education on how to properly use the device.

References

  1. Koshman SL, Charrois TL, Simpson SH, McAlister FA, Tsuyuki RT. Pharmacist care of patients with heart failure: a systematic review of randomized trials. Arch Intern Med. 2008;168(7):687-694.
  2. Viktil KK, Blix HS. The impact of clinical pharmacists on drug-related problems and clinical outcomes. Basic Clin Pharmacol Toxicol. 2008;102(3):275-280.
  3. McConnell KJ, Denham AM, Olson KL. Pharmacist-led interventions for the management of cardiovascular disease: Opportunities and obstacles. Disease Management & Health Outcomes. 2008;16(3):131-144.
  4. Kearney PM, Whelton M, Reynolds K, Muntner P, Whelton PK, He J. Global burden of hypertension: analysis of worldwide data. Lancet. 2005;365(9455):217-223.
  5. Fields LE, Burt VL, Cutler JA, Hughes J, Roccella EJ, Sorlie P. The burden of adult hypertension in the United States 1999 to 2000: a rising tide. Hypertension. 2004;44(4):398-404.
  6. Chobanian AV, Bakris GL, Black HR, et al. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA. 2003;289(19):2560-2572.
  7. Walsh JM, McDonald KM, Shojania KG, et al. Quality improvement strategies for hypertension management: a systematic review. Med Care. 2006;44(7):646-657.
  8. Walsh JM, Sundaram V, McDonald K, Owens DK, Goldstein MK. Implementing effective hypertension quality improvement strategies: barriers and potential solutions. J Clin Hypertens (Greenwich). 2008;10(4):311-316.
  9. Green BB, Cook AJ, Ralston JD, et al. Effectiveness of home blood pressure monitoring, Web communication, and pharmacist care on hypertension control: a randomized controlled trial. JAMA. 2008;299(24):2857-2867.
  10. Pickering TG, Miller NH, Ogedegbe G, et al. Call to action on use and reimbursement for home blood pressure monitoring: executive summary: a joint scientific statement from the American Heart Association, American Society Of Hypertension, and Preventive Cardiovascular Nurses Association. Hypertension. 2008;52 (1):1-9.


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