Women and Hypertension: Beyond

the 2017 Guideline for Prevention,

Detection, Evaluation, and
Management of High Blood
Pressure in Adults
 HYPERTENSION IN WOMEN
• Cardiovascular disease (CVD) is the leading cause of death
in women Worldwide.

• Hypertension, the most common modifiable risk factor for

CVD, is estimated to occur in 85.7 million adults in the
United States (44.9 million women and 40.8 million men)

• Hypertension prevalence is higher in women than men

over the age of 65

• Menopause is associated with a two-fold increase in risk of

hypertension, with a prevalence of 75% in postmenopausal
women in the US Health Care Women Int. 2008 29:3–22
 CV RISK FACTOR PROFILES
• Although women and men with hypertension have a similar
prevalence of CVD, their risk factor profile is different.

• Hypertensive men have more traditional CV risk factors

compared to women, primarily due to increased rates of
smoking and dyslipidemia.

• In contrast, hypertensive women are older, with more non-

traditional risk factors such as abdominal obesity and kidney
disease

• However the screening strategies are similar for both genders.

J Clin Hypertens2014;16:309-12
 HYPERTENSION IN WOMEN

• Certain forms of hypertension occur exclusively in

women.
• Oral contraceptive–induced hypertension
• Pregnancy-related hypertension
• Postmenopausal hypertension
 OCP INDUCED HYPERTENSION
• Oral contraceptive (OCP) use is associated with increases in BP
and risk of cardiovascular events.

• It is generally reversible with discontinuation of the OCP.

• BP elevation in this group has been associated with concentration

of ethinyl estradiol in OCP

• The American College of Obstetricians and Gynecologists

recommends a trial of a low-dose combination OCP in women with
well-controlled and monitored hypertension.

• Patients with uncontrolled hypertension desiring OCP are

recommended to be treated with a progestin-only OCP.
.Obstet Gynecol. 2013;122:1122–1131
PREGNANCY RELATED HYPERTENSION
 CLASSIFICATION OF HYPERTENSION IN
PREGNANCY
Pre-existing hypertension (before 20 weeks)

Gestational hypertension (after 20 weeks)

1. Preeclampsia is the syndrome of new-onset hypertension

and proteinuria or, in the absence of proteinuria,
hypertension associated with target organ or new-onset
cerebral or visual disturbances.
2. Eclampsia is preeclampsia with seizures.

Pre-existing hypertension plus superimposed gestational

hypertension with proteinuria
FUTURE MATERNAL CV RISK

.Clin Card2018 Feb;41(2):239-246

 POSTMENOPAUSAL HYPERTENSION
• After menopause, there is an increase in SBP which is
thought to be secondary to the withdrawal of vasodilator
effects of endogenous estrogen, increased arterial stiffness
and salt sensitivity, diminished endothelial nitric oxide
production,

• The increase in both SBP postmenopausal women is

greater than in age-matched men, whereas DBP is similar in
both sexes. Importantly, isolated SBP elevation is a sensitive
predictor of future CVD in both genders

Am J Hypertens. 2007;20:1045–1050.
 DIAGNOSIS
• Meta-analyses have shown the superiority of ambulatory
blood pressure monitoring (ABPM) to in-office BP
measurements in diagnosing hypertension and predicting
cardiovascular outcomes (cardiovascular death, stroke,
and cardiac/coronary events).

• Night-time BP recorded by ABPM has emerged as a

better predictor of total mortality, stroke, and
cardiovascular death in patients with hypertension and a
history of CVD than either day-time ABPM or in-office BP
measurements

Hypertension. 2008; 51:55–61

 DIAGNOSIS
• Normally, BP varies with the circadian clock: it is higher
during the day time, and decreases by 10% to 20% during
sleep, a phenomenon known as dipping.

• Night-time BP recorded by ABPM has emerged as a better

predictor of total mortality, stroke, and cardiovascular death
in patients with hypertension

• Women younger than 30 years of age were less likely to have

nocturnal BP elevation than men (0% versus 20% men).

• Nocturnal BP elevation increased more rapidly in women,

such that the prevalences of nocturnal BP elevation and
nondipping were similar in men and women above the age
of 70 years Medicine (Baltimore). 2015; 94:e604.
 DIAGNOSIS

•
Basic and Optional Laboratory Tests for
Primary Hypertension
Basic testing Fasting blood glucose*
Complete blood count
Lipid profile
Serum creatinine with eGFR*
Serum sodium, potassium, calcium*
Thyroid-stimulating hormone
Urinalysis
Electrocardiogram
Optional testing Echocardiogram
Uric acid
Urinary albumin to creatinine ratio
 Best Proven Nonpharmacological Interventions for
Prevention and Treatment of Hypertension*
Nonpharmacologi Dose Approximate Impact on SBP
-cal Intervention
Hypertension Normotension
Weight loss Weight/body fat Best goal is ideal body weight, but aim -5 mm Hg -2/3 mm Hg
for at least a 1-kg reduction in body
weight for most adults who are
overweight. Expect about 1 mm Hg for
every 1-kg reduction in body weight.

Healthy diet DASH dietary Consume a diet rich in fruits, -11 mm Hg -3 mm Hg

pattern vegetables, whole grains, and low-fat
dairy products, with reduced content
of saturated and total fat.
Reduced intake Dietary sodium Optimal goal is <1500 mg/d, but aim -5/6 mm Hg -2/3 mm Hg
of dietary for at least a 1000-mg/d reduction in
sodium most adults.
Enhanced Dietary Aim for 3500–5000 mg/d, preferably -4/5 mm Hg -2 mm Hg
intake of potassium by consumption of a diet rich in
dietary potassium.
potassium
 GENDER SPECIFIC FACTORS
• Salt restriction may benefit women given possible
upregulation of RAS after menopause
• DASH diet plus weight loss may have incremental
benefits on BP lowering
• Combined aerobic and resistance exercises
reduce arterial stiffness and BP in
postmenopausal women
 MANAGEMENT

• Treatment targets are not sex-specific either, as

a large meta-analysis evaluating
antihypertensive agents using similar cut-offs
for men and women, including 87,349 women,
showed no differences in CV outcomes.
Blood Pressure (BP) Thresholds and Recommendations for Treatment and Follow-Up
(continued on next slide)

BP thresholds and recommendations for treatment and follow-up

Normal BP Elevated BP Stage 1 hypertension

Stage 2 hypertension
(BP <120/80 (BP 120–129/<80 (BP 130–139/80-89
(BP ≥ 140/90 mm Hg)
mm Hg) mm Hg) mm Hg)

Clinical ASCVD
Nonpharmacologic
Promote optimal or estimated 10-y CVD risk
therapy
lifestyle habits ≥10%*
(Class I)

No Yes

Nonpharmacologic Nonpharmacologic therapy

Reassess in Reassess in Nonpharmacologic
therapy and and
1y 3–6 mo therapy
BP-lowering medication BP-lowering medication†
(Class IIa) (Class I) (Class I)
(Class I) (Class I)

Reassess in Reassess in
3–6 mo 1 mo
(Class I) (Class I)
 1y 3–6 mo therapy
BP-lowering medication BP-lowering medication†
(Class IIa) (Class I) (Class I)
(Class I) (Class I)

Reassess in Reassess in
3–6 mo 1 mo
(Class I) (Class I)

BP goal met

No Yes

Assess and Reassess in

optimize 3–6 mo
adherence to (Class I)
therapy

Consider
intensification of
therapy
 MANAGEMENT OF HYPERTENSION IN PREGNANCY
• Low-dose aspirin (100–150 mg daily) is recommended in women at
high or moderate risk of pre-eclampsia from week 12 to weeks 36–
37
• In women with gestational hypertension or pre-existing
hypertension superimposed by gestational hypertension, or with
hypertension and subclinical organ damage or symptoms, initiation
of drug treatment is recommended at SBP >140 mmHg or DBP >90
mmHg.
• In all other cases, initiation of drug treatment is recommended if
SBP >_150 mmHg or DBP >_95 mmHg.
• SBP >_170 mmHg or DBP >_110 mmHg in a pregnant woman is an
emergency, and hospitalization is recommended.
• Methyldopa , labetalol , and calcium antagonists are
recommended for the treatment of hypertension in pregnancy.
 MANAGEMENT OF HYPERTENSION IN
PREGNANCY
• In women with gestational hypertension or mild pre-
eclampsia, delivery is recommended at 37 weeks.
• It is recommended to expedite delivery in pre-eclampsia
and with adverse conditions such as visual disturbances
or haemostatic disorders.
• In pre-eclampsia associated with pulmonary oedema,
nitroglycerin given as an intravenous infusion is
recommended.
• In severe hypertension, drug treatment with
intravenous labetalol, or oral methyldopa or nifedipine,
is recommended.
 KEY POINTS
• Hypertension rates are higher in women than men over
the age of 65.
• Despite differences in CV risk factor profiles, there are
limited data on sex and gender specific screening
strategies for hypertension.
• Postmenopausal women are more likely to exhibit a non-
dipping pattern of BP, which is described as a <10% drop
in nocturnal BP which is related to poor CV outcomes and
target organ damage, especially in older women
compared to men
 KEY POINTS
• Results from Blood Pressure Lowering Treatment
Trialists' Collaboration, suggest a greater percentage
of stroke among hypertensive women compared to
men, whereas a higher percentage of coronary
heart disease and heart failure was observed among
men compared to women.
• Treatment targets are not sex-specific using similar
cut-offs for men and women, showed no differences
in CV outcomes(META-ANALYSIS)
 KEY POINTS
• There is currently no substantial evidence for
differential effects of antihypertensive therapy
based on gender.
• One meta-analysis suggests that calcium
channel blockers may be more beneficial in
women than ACE inhibitors for stroke
prevention.
THANK YOU FOR YOUR ATTENTION!
 2017 Hypertension Guideline

Hypertension in Patients With Comorbidities

 Management of Hypertension in Patients With SIHD
Hypertension With SIHD

Reduce BP to <130/80 mm Hg with

GDMT beta blockers*, ACE inhibitor, or ARBs†
(Class I)

BP goal not met

Angina
pectoris

Yes No

Add
Add
dihydropyridine CCBs,
dihydropyridine CCBs
thiazide-type diuretics,
if needed
and/or MRAs as needed
(Class I)
(Class I)

Colors correspond to Class of Recommendation in Table 1.

*GDMT beta blockers for BP control or relief of angina include carvedilol, metoprolol tartrate, metoprolol succinate, nadolol,
bisoprolol, propranolol, and timolol. Avoid beta blockers with intrinsic sympathomimetic activity. The beta blocker atenolol
should not be used because it is less effective than placebo in reducing cardiovascular events.
†If needed for BP control.
•ACE indicates angiotensin-converting enzyme; ARB, angiotensin receptor blocker; BP, blood
pressure; CCB, calcium channel blocker; GDMT, guideline-directed management and therapy;
and SIHD, stable ischemic heart disease.
 Heart Failure With Reduced Ejection Fraction

Recommendations for Treatment of Hypertension in

COR LOE
Patients With HFrEF
Adults with HFrEF and hypertension should be prescribed GDMT
I C-EO titrated to attain a BP of less than 130/80 mm Hg.

Nondihydropyridine CCBs are not recommended in the

III: No treatment of hypertension in adults with HFrEF.
B-R
Benefit
 Heart Failure With Preserved Ejection Fraction

Recommendations for Treatment of Hypertension in

COR LOE
Patients With HFpEF
In adults with HFpEF who present with symptoms of volume
I C-EO overload, diuretics should be prescribed to control
hypertension.
Adults with HFpEF and persistent hypertension after
management of volume overload should be prescribed ACE
I C-LD
inhibitors or ARBs and beta blockers titrated to attain SBP of
less than 130 mm Hg.
Management of Hypertension in Patients With CKD
Treatment of hypertension in patients with CKD

BP goal <130/80 mm Hg
(Class I)

Albuminuria
(≥300 mg/d or ≥300 mg/g
creatinine)

Yes No

ACE inhibitor Usual “first-line”

(Class IIa) medication choices

ACE inhibitor
intolerant

Yes No

ARB* ACE inhibitor*

(Class IIb) (Class IIa)
•Colors correspond to Class of Recommendation in Table 1.
•*CKD stage 3 or higher or stage 1 or 2 with albuminuria ≥300 mg/d or ≥300 mg/g creatinine.
•ACE indicates angiotensin-converting enzyme; ARB, angiotensin receptor blocker; BP blood
pressure; and CKD, chronic kidney disease.
.
 Hypertension After Renal Transplantation

Recommendations for Treatment of Hypertension After

COR LOE
Renal Transplantation
SBP: After kidney transplantation, it is reasonable to treat patients
with hypertension to a BP goal of less than 130/80 mm Hg.
IIa B-NR
DBP:
C-EO
After kidney transplantation, it is reasonable to treat patients
with hypertension with a calcium antagonist on the basis of
IIa B-R
improved GFR and kidney survival.
Management of Hypertension in Patients With Acute ICH

Acute (<6 h from symptom onset)

spontaneous ICH

SBP 150–220 mm Hg SBP >220 mm Hg

SBP lowering with

SBP lowering to
continuous IV infusion and
<140 mm Hg
close BP monitoring
(Class III:Harm)
(Class IIa)

Colors correspond to Class of Recommendation in Table 1.

BP indicates blood pressure; ICH, intracerebral hemorrhage; IV, intravenous;
and SBP, systolic blood pressure.
 Acute Ischemic Stroke
Recommendations for Management of Hypertension in
COR LOE
Patients With Acute Ischemic Stroke
Adults with acute ischemic stroke and elevated BP who are eligible
for treatment with intravenous tissue plasminogen activator should
I B-NR have their BP slowly lowered to less than 185/110 mm Hg before
thrombolytic therapy is initiated.

In adults with an acute ischemic stroke, BP should be less than

185/110 mm Hg before administration of intravenous tissue
I B-NR plasminogen activator and should be maintained below
180/105 mm Hg for at least the first 24 hours after initiating
drug therapy.
Starting or restarting antihypertensive therapy during
hospitalization in patients with BP greater than 140/90 mm Hg
IIa B-NR who are neurologically stable is safe and reasonable to
improve long-term BP control, unless contraindicated.
 Acute Ischemic Stroke (cont.)

Recommendations for Management of Hypertension in

COR LOE
Patients With Acute Ischemic Stroke
In patients with BP of 220/120 mm Hg or higher who did not
receive intravenous alteplase or endovascular treatment and have
no comorbid conditions requiring acute antihypertensive treatment,
IIb C-EO the benefit of initiating or reinitiating treatment of hypertension
within the first 48 to 72 hours is uncertain. It might be reasonable to
lower BP by 15% during the first 24 hours after onset of stroke.

In patients with BP less than 220/120 mm Hg who did not

receive intravenous thrombolysis or endovascular treatment
III: and do not have a comorbid condition requiring acute
No A antihypertensive treatment, initiating or reinitiating treatment of
Benefit hypertension within the first 48 to 72 hours after an acute
ischemic stroke is not effective to prevent death or
dependency.
Management of Hypertension in Patients With Acute Ischemic Stroke
Acute (<72 h from symptom onset) ischemic
stroke and elevated BP

Patient
qualifies for IV
thrombolysis
therapy

Yes No

Lower SBP to <185 mm Hg and

DBP <110 mm Hg before
initiation of IV thrombolysis
BP ≤220/110 mm Hg BP >220/110 mm Hg
(Class I)

And

Maintain BP <180/105 mm Hg for Initiating or reinitiating treatment of Lower BP 15%

first 24 h after IV thrombosis
(Class I)
hypertension within the first 48-72 during first 24 h
hours after an acute ischemic stroke is (Class IIb)
ineffective to prevent death or
dependency
(Class III: No Benefit)

For preexisting hypertension,

reinitiate antihypertensive drugs
after neurological stability
(Class IIa)

Colors correspond to Class of Recommendation in Table 1.

BP indicates blood pressure; DBP, diastolic blood pressure; IV, intravenous; and SBP, systolic blood
pressure.
 Secondary Stroke Prevention
Recommendations for Treatment of Hypertension for
COR LOE
Secondary Stroke Prevention
Adults with previously treated hypertension who experience a stroke
or transient ischemic attack (TIA) should be restarted on
I A antihypertensive treatment after the first few days of the index
event to reduce the risk of recurrent stroke and other vascular
events.
For adults who experience a stroke or TIA, treatment with a
thiazide diuretic, ACE inhibitor, or ARB, or combination
I A treatment consisting of a thiazide diuretic plus ACE inhibitor, is
useful.

Adults not previously treated for hypertension who experience

a stroke or TIA and have an established BP of 140/90 mm Hg
I B-R or higher should be prescribed antihypertensive treatment a
few days after the index event to reduce the risk of recurrent
stroke and other vascular events.
 Secondary Stroke Prevention (cont.)
Recommendations for Treatment of Hypertension for
COR LOE
Secondary Stroke Prevention
For adults who experience a stroke or TIA, selection of specific drugs
should be individualized on the basis of patient comorbidities and
I B-NR
agent pharmacological class.

For adults who experience a stroke or TIA, a BP goal of less

IIb B-R than 130/80 mm Hg may be reasonable.

For adults with a lacunar stroke, a target SBP goal of less than
IIb B-R 130 mm Hg may be reasonable.

In adults previously untreated for hypertension who experience

an ischemic stroke or TIA and have a SBP less than 140 mm
IIb C-LD
Hg and a DBP less than 90 mm Hg, the usefulness of initiating
antihypertensive treatment is not well established.
Management of Hypertension in Patients With a Previous History of Stroke
(Secondary Stroke Prevention)
Stroke ≥72 h from symptom onset and stable
neurological status or TIA

Previous
diagnosed or treated
hypertension

Yes No

Restart
antihypertensive
Established Established
treatment
SBP ≥140 mm Hg or SBP <140 mm Hg and
(Class I)
DBP ≥90 mm Hg DBP <90 mm Hg

Aim for
BP <130/80 mm Hg
(Class IIb) Initiate Usefulness of starting
antihypertensive antihypertensive
treatment treatment is not
(Class I) well established
(Class IIb)
Aim for
BP <130/80 mm Hg
(Class IIb)

Colors correspond to Class of Recommendation in Table 1.

DBP indicates diastolic blood pressure; SBP, systolic blood pressure; and TIA, transient ischemic
attack.
 Diabetes Mellitus

Recommendations for Treatment of Hypertension in

COR LOE
Patients With DM
SBP: In adults with DM and hypertension, antihypertensive drug
B-RSR treatment should be initiated at a BP of 130/80 mm Hg or higher
I with a treatment goal of less than 130/80 mm Hg.
DBP:
C-EO
In adults with DM and hypertension, all first-line classes of
I ASR antihypertensive agents (i.e., diuretics, ACE inhibitors, ARBs,
and CCBs) are useful and effective.
In adults with DM and hypertension, ACE inhibitors or ARBs
IIb B-NR may be considered in the presence of albuminuria.

SR indicates systematic review.

 Atrial Fibrillation

Recommendation for Treatment of Hypertension in

COR LOE
Patients With AF
Treatment of hypertension with an ARB can be useful for
prevention of recurrence of AF.
IIa B-R
 Valvular Heart Disease

Recommendations for Treatment of Hypertension in Patients

COR LOE
With Valvular Heart Disease
In adults with asymptomatic aortic stenosis, hypertension should be
treated with pharmacotherapy, starting at a low dose and gradually
I B-NR titrating upward as needed.

In patients with chronic aortic insufficiency, treatment of systolic

hypertension with agents that do not slow the heart rate (i.e.,
IIa C-LD avoid beta blockers) is reasonable.
 Pregnancy

Recommendations for Treatment of Hypertension in

COR LOE
Pregnancy
Women with hypertension who become pregnant, or are planning to
become pregnant, should be transitioned to methyldopa, nifedipine,
I C-LD and/or labetalol during pregnancy.

Women with hypertension who become pregnant should not be

III: treated with ACE inhibitors, ARBs, or direct renin inhibitors.
C-LD
Harm
Diagnosis and Management of a Hypertensive Crisis
SBP >180 mm Hg and/or
DBP >120 mm Hg

Target organ damage new/

progressive/worsening

Yes No

Hypertensive
Markedly elevated BP
emergency

Admit to ICU
(Class I) Reinstitute/intensify oral
antihypertensive drug therapy
and arrange follow-up

Conditions:
• Aortic dissection
• Severe preeclampsia or eclampsia
• Pheochromocytoma crisis

Yes No

Reduce SBP to <140 mm Hg Reduce BP by max 25% over first h†, then
during first h* and to <120 mm Hg to 160/100–110 mm Hg over next 2–6 h,
in aortic dissection† then to normal over next 24–48 h
(Class I) (Class I)

Colors correspond to Class of Recommendation in Table 1.

*Use drug(s) specified in Table 19.
†If other comorbidities are present, select a drug specified in Table 20.
BP indicates blood pressure; DBP, diastolic blood pressure; ICU, intensive care unit; and
SBP, systolic blood pressure.
DRUGS FOR HYPERTENSIVE CRISES
 KEY POINTS
• Hypertension rates are higher in women than men
over the age of 65.
• Despite differences in CV risk factor profiles, there
are limited data on sex and gender specific screening
strategies for hypertension.
• Postmenopausal women are more likely to exhibit a
non-dipping pattern of BP, which is described as a
<10% drop in nocturnal BP. There is evidence for poor
CV outcomes and target organ damage with this type
of BP pattern, especially in older women compared to
men
 KEY POINTS
• Results from Blood Pressure Lowering Treatment
Trialists' Collaboration, suggest a greater
percentage of stroke among hypertensive women
compared to men, whereas a higher percentage
of coronary heart disease and heart failure was
observed among men compared to women.
• Treatment targets are not sex-specific using
similar cut-offs for men and women, showed no
differences in CV outcomes(METAANALYSIS)
 KEY POINTS
• There is currently no substantial evidence for
differential effects of antihypertensive therapy
based on sex or gender
• One meta-analysis suggests that calcium
channel blockers may be more beneficial in
women than ACE inhibitors for stroke
prevention.