Text-based Document. Women are Different!: Gender Specific Protocols for Treatment of Hypertension. Authors Whiffen, Rebecca J.

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1 The Henderson Repository is a free resource of the Honor Society of Nursing, Sigma Theta Tau International. It is dedicated to the dissemination of nursing research, researchrelated, and evidence-based nursing materials. Take credit for all your work, not just books and journal articles. To learn more, visit Item type Format Title Presentation Text-based Document Women are Different!: Gender Specific Protocols for Treatment of Hypertension Authors Whiffen, Rebecca J. Downloaded 13-May :53:43 Link to item

2 Gender Specific Protocols for Treatment of Hypertension in Women BJ Whiffen, DNP, FNP-BC, ACNP-BC Associate Professor, Southeast Hospital College of Nursing Saint Francis Medical Center Cape Cardiology Group

3 Hypertension Affects one out of four Americans Affects one out of three adults worldwide (WHO, 2012 Report) 2/3 of treated hypertensive women have uncontrolled hypertension Leading cause of death in women in every major developed country Major risk factor for cardiovascular disease, diabetes mellitus, cerebrovascular accident, chronic renal failure, heart failure and peripheral vascular disease

4 Research in Women In 1970, 9% of clinical trials included women In 2006, 34% included women National Institutes of Health Revitalization Act WISE study, WHI study

5 Gender specific research WISE-Women s Ischemic Syndrome Evaluation WHI-Women s Health Initiative SWAN-Study of Women s Health Across the Nation American Heart Association CVD preventative guidelines

6 Literature Review Gender differences Blood pressure is less prevalent in younger women when age-matched with men, but become similar when >65years of age and older Sex-linked patterns of disease have been identified Women have a more intense immune response Proposal of microvascular coronary disease in women Age-matched rats differ in exercise response The renin-angiotension system may play a significant role

7 Racial differences Chinese patients were found to have a different response to propranolol than Caucasian patients due to a more rapid metabolism of the drug Asian Indians and Koreans were found to have an increased sensitivity to nifedipine African Americans are found more responsive to thiazide diuretics and less responsive to ACE Inhibitors and Beta Blockers Hispanic Americans response to medication similar to Caucasians

8 Age and Menopausal Status Blood pressure increases after age 65 for women. Until that age, HTN more prevalent in men (70% in age > 65 years, 80% in age>75 years) There is no firm evidence that menopause is a risk factor, although some studies have found differences between postmenopausal and premenopausal renin-angiotensin systems

9 Evaluation of Best Practices JNC-7 - Key points B/P <140/90 Guidelines utilized Thiazide-type diuretics used first in uncomplicated HTN, alone or combined with drugs from other classes ACE or ARB should be used initially in DM, usually need two or more drugs to achieve target B/P Most patients will need two or more drugs to achieve target B/P

10 Evaluation of Best Practices Guidelines, continued Effectiveness Based Guidelines for the Prevention of Cardiovascular Disease in Women :2011 Update-Key Points Drug therapy indicated when B/P is > 140/90 ( >130/90 in the setting of CRF or DM) Thiazides are recommended first line Beta-blockers and/or ACE/ARB recommended initial treatment of high risk women with CAD, with the addition of thiazides, if needed.

11 Study Design Sample: 100 women, convenience sample Setting: cardiovascular practice in Southeast Missouri Inclusion criteria: DX of essential hypertension, benign (ICD-9 code 401); on anti-hypertensive medication, female Exclusion criteria: renal artery stenosis, inability to ascertain menopausal status or race

12 Outcome Measures Outcome measures: to evaluate for best practices utilizing current guidelines B/P controlled -140/90 or less Diabetic patients on an ACE or ARB, if no contraindications Development of gender specific guidelines for treatment of HTN in women

13 Data collection Retrospective chart review A convenience sample of the first 100 charts that met the inclusion criteria were examined and data reviewed. DX: Essential Hypertension, benign (ICD-9 code 401) Treatment with antihypertensive medications: Beta-Blocker, ARB, ACE Inhibitor, CCB, Alpha Blockers, and Diuretics. Variables: age, race, menopausal status, and comorbidities of CAD and DM.

14 Descriptive Analytical Methods Bivariate Correlational Analyses

15 Results white black hispanic asian 100 women 95% White 5% African American

16 Mean age=72.5 years Results Menopausal=96% Diabetes Mellitus=33% CAD=57%

17 Results-medications utilized Beta Blocker ACE ARB CCB Diuretic Alpha Blocker

18 Evidence for Best Practices Out of 100 women, 76% were found to have controlled HTN, compared to the national rate of 64%, and the national rate of 23% in women aged 80 years or greater. Out of 100 women, 33 were diagnosed with DM; and 54% of those were on an ACE or ARB, as compared to the national rate of 43%. Out of 100 women, 73% were on two or more medications.

19 Limitations Little variation in race, ethnicity, or age in sample Race was ascertained by patient photo Retrospective study-subject to interpretive bias by investigator Small convenience sample Further research recommended on gender specific clinical trials

20 Gender Specific Protocols Non drug therapies Dietary sodium restriction Weight loss Smoking cessation

21 Gender Specific Protocols Women who are or have Initial adding if needed Uncomplicated HTN Thiazide diuretic Diabetes mellitus ACE/ARB Thiazide diuretic Over age 65 or menopausal CAD ACE/ARB Diuretic, beta-blocker ACE/ARB Thiazide diuretic, then beta blocker if CAD present African Thiazide diuretic, Calcium channel blocker ACE/ARB Asian Calcium channel Thiazide diuretic blocker Caucasian/Hispanic Thiazide diuretic Beta Blocker, ACE/ARB

22 References Bairey Merz, C. N., Shaw, L. J., Reis, S. E., Bittner, V., Kelsey, S. F., Olson, M., et al. (2006). Insights From the NHLBI-Sponsored Women's Ischemia Syndrome Evaluation (WISE) Study: Part II: Gender Differences in Presentation, Diagnosis, and Outcome With Regard to Gender-Based Pathophysiology of Atherosclerosis and Macrovascular and Microvascular Coronary Disease. [doi: DOI: /j.jacc ]. Journal of the American College of Cardiology, 47(3, Supplement 1), S21-S29. CDC. (2005). CDC. Racial/Ethnic Disparities in Prevalence, Treatment, and Control of Hypertension-United States, MMWR weekly,54(01),7-9. Chobanian, A., et al. (2003). JNC 7 Express-The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure. US Department of Health and Human Services, National Institutes of Health. NIH publication No , May 2003.

23 References Gudmundsdottir,H, et al. (2012) Hypertension in Women. Therapeutic Advances in Chronic Diseases. 2012; 3(3): Melloni, C., et al. (2010). Representation of Women in Randomized Clinical trials of Cardiovascular Disease Prevention. Circulation(3), Mosca, L., et al. (2011). Effectiveness-Based Guidelines for the Prevention of Cardiovascular Disease in Women 2011 Update: A Guideline from the American Heart Association. Circulation, E-pub date Feb 16, doi: /cir.0b013e31820faaf8. Ostchega, Y., Yoon, SS., Hughes, J., Louis, T.. (2008). Hypertension Awareness, Treatment and Control-Continued Disparities in Adults : United States, Palaniappan, L., et al. (2010). Call to Action: Cardiovascular Disease in Asian Americans. A Science Advisory From the American Heart Association. Circulation. Pinn, V. (2005). Research on Women's Health: Progress and Opportunities. JAMA, 294(11),

24 References Rossouw, J. E., et al. (2002). Risks and Benefits of Estrogen Plus Progestin in Healthy Postmenopausal Women. JAMA: The Journal of the American Medical Association, 288(3), WHO 2012 World Health Statistics. Xie, H.-G., Kim, R. B., Wood, A. J., & Stein, C. M. (2001). MOLECULAR BASIS OF ETHNIC DIFFERENCES IN DRUG DISPOSITION AND RESPONSE. Annual Review of Pharmacology and Toxicology, 41(1), Yanes, L. L., Romero, D. G., Iliescu, R., Zhang, H., Davis, D., & Reckelhoff, J. F. (2010). Postmenopausal Hypertension: Role of the Renin-Angiotensin System. Hypertension, 56(3),