Pharmacist Expert Adviser

Dr. Page is an associate professor of clinical pharmacy and physicalmedicine and a clinical specialist, Division of Cardiology, University ofColorado Health Sciences Center, Schools of Pharmacy and Medicine.

Women with Hypertension Face UniqueChallenges

Hypertension affects an estimated72 million Americans, 54% ofwhom are female. Whereas therisk of death from ischemic heart diseaseand stroke increases progressively andlinearly with escalating blood pressure(BP) in both women and men, morewomen still die from hypertension.^1,2 Agender dimorphism in BP appears toexist, in that women exhibit lower systolicBP than men during early adulthood,whereas the opposite is true after age54, when the prevalence of hypertensionin women exceeds that of men. 2,³ Datahave suggested that, when it comes tohypertension, women face unique risksfor developing hypertension and endurespecial challenges when attempting tokeep their BP under control.

Hypertension in Pregnancyand Menopause

Hypertension is 2 to 3 times more commonin women taking oral contraceptives.¹ Hypertension also is the mostcommon medical disorder of pregnancy,complicating 1 in 10 pregnancies.⁴ In orderto minimize both acute and chronic fetaland maternal risk, appropriate hypertensiondiagnosis should be made early inthe pregnancy in order to differentiatebetween preexisting (chronic) hypertensionand pregnancy-induced (gestational)hypertension and preeclampsia. TheAmerican Heart Association encourageswomen to use home blood pressure monitoring(HBPM) to accurately assist theirprovider with this important task.⁵

Treating hypertension during pregnancyrequires close observation, whichmay include HBPM. Many commonantihypertensive medications such asangiotensin-converting enzyme inhibitorsand angiotensin II receptor blockersare contraindicated because of reportsof fetal toxicity and death. This treatmentapproach reflects concerns aboutthe safety of antihypertensive treatmentduring pregnancy because studieshave shown a direct linear relationshipbetween treatment-induced reductions inmean arterial pressure and the proportionof small-for-gestational-age infants.¹

Although debatable, cohort studies suggesta relationship between menopauseand hypertension.⁶ Compared with menmatched by age and body mass index, postmenopausalwomen exhibit higher systolicBP and greater systolic BP increases (5 mmHg) over 5 years. Unique etiological factorscontributing to this phenomenon consistof genetic factors, hormonal changes, andenvironmental factors.⁶

Women Versus Men in BPControl

Finally, persistent gender disparities existin BP control, cardiovascular risk factors,and disease management. Based on datafrom the 1999-2004 National Health andNutrition Examination Study, hypertensivewomen aged 18 and older have a higherprevalence of elevated total cholesterol,lower high-density lipoprotein cholesterol,and greater central obesity (P <.05,for all variables), compared with men.⁷Furthermore, findings generated from the2005 National Ambulatory Medical Careand National Hospital Ambulatory MedicalCare Surveys suggest that women withhypertension are not receiving adequatequality of care, compared with men.⁸

In the analysis of 7786 women and4275 men, women with hypertensionwere less likely to receive aspirin (P<.001), beta-blockers (P <.05), and statins(P <.05) for secondary prevention of cardiovasculardisease, compared with men.Furthermore, women were less likely tomeet BP control targets, compared withmen (P <.02).

Based on the data, health care providersneed to be mindful of the salient differencesthat exist between genders whenmanaging patients with hypertension.

References

• 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.
• American Heart Association Web site. Heart Disease and Stroke Statisitics-2008 Update. www.americanheart.org. Accessed October 6, 2008.
• Reckelhoff JF, Fortepiani LA. Novel mechanisms responsible for postmenopausal hypertension. Hypertension. 2004;43(5):918-923.
• Podymow T, August P. Update on the use of antihypertensive drugs in pregnancy. Hypertension. 2008;51(14):960-969.
• 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.
• Coylewright M, Reckelhoff JF, Ouyang P. Menopause and hypertension: an age-old debate. Hypertension. 2008;51(4):952-959.
• 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.
• 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 positionedhealth care professionals whocan make a significant impact onhealth outcomes and public health. Notonly are pharmacists easily accessibleto patients, but they are highly trained inevidence-based pharmacotherapy so asto deliver high-level medication diseasestate management. Regarding cardiovascularoutcomes, pharmacist-led interventionsin various health system settingshave been shown to reduce adverse drugevents, improve medication adherence,and in some cases even reduce mortalityand hospitalization.^1-3

Hypertension is one of the leadingcauses of death worldwide, and almost1 in 3 Americans carries a diagnosis ofhypertension,defined as a blood pressure(BP) of 140/90 mm Hg or higher.^4-6Therefore, disease state managementprograms targeting this chronic conditionthrough community pharmacist interventionshould significantly impact outcomeswithin this patient population. Recentmeta-analyses of quality improvementtactics have shown significant improvementsin lowering BP in hypertensivepatients, particularly when a pharmacistwas added to the health care team, comparedwith other strategies.^7,8

Pharmacist InterventionHelps Control Patients' BP

In the Electronic Communications andHome Blood-Pressure Monitoring study,Green and colleagues randomized 778patients with uncontrolled essential hypertensionand Internet access from an integratedgroup practice in Washington Stateto one of the following treatment strategies:usual care, home BP monitoringthrough secure patient Web site trainingonly, or home BP monitoring and securepatient Web site training plus pharmacistcare management delivered through Webcommunications.⁹

Usual care consisted of suggesting thatpatients with hypertension work closelywith their provider. In the pharmacistinterventiongroup, pharmacists reviewedpatient histories and were regularly providedpatients' BP measurements, medicationconcerns, and progress relatedto lifestyle goals through Internet-basedcommunication. Pharmacists respondedwith specific recommendations includingmedication changes. All clinical concernsor potential deviations from the medicationprotocol were referred back tothe patient's physician. After one yearof follow-up, those receiving pharmacistcare management had significantly betterBP control, compared with the otherinterventional strategies (P <.001).

Incorporate HBPM intoTreatment Plans

This study highlights not only the value ofpharmacist intervention, but also the criticalimportance of home blood pressuremonitoring (HBPM).¹⁰ Although the clinicalrelevance of office-measured BP hasbeen established in multiple outcomesstudies, BP measurement in this settinghas numerous shortcomings, includingloss of calibration of equipment, failureof physicians to follow measurementguidelines, and the white-coat effect.¹⁰Measurement of BP in the office settingtypically does not determine BP values12 to 24 hours after dosing of medicationsand cannot detect the presence andmagnitude of BP during sleep or duringthe post-awakening surge. Thus, in May2008, the American Heart Association, theAmerican Society of Hypertension, andthe Preventive Cardiovascular NursingAssociation issued a collaborative statementcalling for patients with hypertensionto incorporate HBPM as part of theirmanagement strategies.¹⁰

Pharmacists are uniquely positioned tomeet this call to action as they can assistpatients with selecting an appropriate monitorand provide the most accurate educationon how to properly use the device.

References

• 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.
• 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.
• 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.
• 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.
• 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.
• 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.
• Walsh JM, McDonald KM, Shojania KG, et al. Quality improvement strategies for hypertension management: a systematic review. Med Care. 2006;44(7):646-657.
• 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.
• 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.
• 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.