Sex differences in risk factor control of treated hypertensives: a national primary healthcare-based study in Sweden

Hypertension: sex-related differences in drug treatment, prevalence and blood pressure control in primary care

Antihypertensive treatment is equally beneficial for reducing cardiovascular risk in both men and women. Despite this, the drug treatment, prevalence and control of hypertension differ between men and women. Men and women respond differently, particularly with respect to the risk of adverse events, to many antihypertensive drugs. Certain antihypertensive drugs may also be especially beneficial in the setting of certain comorbidities - of both cardiovascular and extracardiac nature - which also differ between men and women. Furthermore, hypertension in pregnancy can pose a considerable therapeutic challenge for women and their physicians in primary care. In addition, data from population-based studies and from real-world data are inconsistent regarding whether men or women attain hypertension-related goals to a higher degree. In population-based studies, women with hypertension have higher rates of treatment and controlled blood pressure than men, whereas real-world, primary-care data instead show better blood pressure control in men. Men and women are also treated with different antihypertensive drugs: women use more thiazide diuretics and men use more angiotensin-enzyme inhibitors and calcium-channel blockers. This narrative review explores these sex-related differences with guidance from current literature. It also features original data from a large, Swedish primary-care register, which showed that blood pressure control was better in women than men until they reached their late sixties, after which the situation was reversed. This age-related decrease in blood pressure control in women was not, however, accompanied by a proportional increase in use of antihypertensive drugs and female sex was a significant predictor of less intensive antihypertensive treatment.

Arterial hypertension assessment in a population with chronic myeloid leukemia

Treatment of chronic myeloid leukaemia (CML) is based on tyrosine kinase inhibitors (TKI), whose introduction in 2001 improved the survival rate after 5 years from 40 to 90%. The longevity increase has been accompanied by a higher incidence of cardiovascular events (CVE) that can be explained due to the sum of cardiovascular risk factors (CVRF) together with the secondary effects of the TKI. The effect of the TKI over the blood pressure control is still unknown. An observational cross-sectional study of patients with CML under treatment with TKI (imatinib, dasatinib and nilotinib) was conducted. Blood pressure was analyzed through sphygmomanometer and 24-h ambulatory blood pressure monitoring (ABPM). A total of 73 patients were included, 57 treated with a single line of treatment. 32.9% of the total of individuals under this study showed uncontrolled blood pressure according to the ABPM. The factors related to uncontrolled BP were overweight, dyslipidemia, alcohol use, pulse wave velocity a high/very high cardiovascular risk. The subjects who received treatment with nilotinib did present worse control of their blood pressure in ABPM than those treated with imatinib and dasatinib (p = 0.041). This finding could indicate that an uncontrolled blood pressure is implied in the pro-inflammatory and pro-atherogenic mechanism underlying the development of the cardiovascular disease in those patients under treatment with nilotinib. The ABPM is a useful tool in the diagnosis and treatment of HT, being the reason why it should be included in the assessment of patients with CML whose HT diagnosis proves uncertain.

Gender Differences in Inhaled Pharmacotherapy Utilization in Patients with Obstructive Airway Diseases (OADs): A Population-Based Study

Purpose

Gender differences in the incidence, susceptibility and severity of many obstructive airway diseases (OADs) have been well recognized. However, gender differences in the inhaled pharmacotherapy profile are not well characterized.

Methods

We conducted a retrospective cohort study to investigate gender differences in new-users of inhaled corticosteroids (ICS), short-or long-acting beta₂-agonist (SABA or LABA), ICS/LABA, short-or long-acting muscarinic antagonist (SAMA or LAMA) among patients with asthma, COPD or asthma-COPD overlap (ACO). We used Clinical Practice Research Datalink to identify OAD patients, 18 years and older, who were new-users (1-year washout period) from 01-January-1998 to 31-July-2018. Multivariable logistic regression was used to examine gender differences in each of the inhaled pharmacotherapies after controlling for potential confounders.

Results

A total of 242,079 new-users (asthma: 84.93%; COPD: 10.19%; ACO: 4.88%) of inhaled pharmacotherapies were identified. The multivariable analyses showed that males with COPD were more likely to be a new user of a LABA (odds ratio [OR] 1.29; 95% confidence interval [CI], 1.12–1.49), LAMA (OR 1.21; 95% CI 1.10–1.33), SAMA (OR 1.11; 95% CI 1.01–1.21) and less likely to be a new user of a SABA (OR 0.84; 95% CI, 0.80–0.89) compared to females. Similar patterns were also observed for patients with ACO; males were more likely to be prescribed with LABA (OR 1.26; 95% CI 1.03–1.55), LAMA (OR 1.28; 95% CI 1.11–1.48), SAMA (OR 1.28; 95% CI 1.11–1.48), and less likely to be a new user of a SABA (OR 0.89; 95% CI, 0.82–0.96). Also, males with asthma were more likely to be a new-user of ICS/LABA (OR 1.15; 95% CI, 1.08–1.23) and less likely to start an ICS (OR 0.97; 95% CI, 0.95–0.99) in comparison with females.

Conclusion

Our study showed significant gender differences in new-users of inhaled pharmacotherapies among OAD patients. Adjusting for proxies of disease severity, calendar year, smoking and socioeconomic status did not change the association by gender.

Sex Differences in Cardiovascular Medication Prescription in Primary Care: A Systematic Review and Meta-Analysis

Background

Sex differences in the management of cardiovascular disease have been reported in secondary care. We conducted a systematic review with meta‐analysis of systematically investigated sex differences in cardiovascular medication prescription among patients at high risk or with established cardiovascular disease in primary care.

Methods and Results

PubMed and Embase were searched between 2000 and 2019 for observational studies reporting on the sex‐specific prevalence of aspirin, statins, and antihypertensive medication prescription, including beta blockers, calcium channel blockers, angiotensin‐converting enzyme inhibitors, and diuretics, in primary care. Random effects meta‐analysis was used to obtain pooled women‐to‐men prevalence ratios for each cardiovascular medication prescription. Metaregression models assessed the impact of age and year on the findings. A total of 43 studies were included, involving 2 264 600 participants (28% women) worldwide. Participants’ mean age ranged from 51 to 76 years. The pooled prevalence of cardiovascular medication prescription for women was 41% for aspirin, 60% for statins, and 68% for any antihypertensive medications. Corresponding rates for men were 56%, 63%, and 69% respectively. The pooled women‐to‐men prevalence ratios were 0.81 (95% CI, 0.72–0.92) for aspirin, 0.90 (95% CI, 0.85–0.95) for statins, and 1.01 (95% CI, 0.95–1.08) for any antihypertensive medications. Women were less likely to be prescribed angiotensin‐converting enzyme inhibitors (0.85; 95% CI, 0.81–0.89) but more likely with diuretics (1.27; 95% CI, 1.17–1.37). Mean age, mean age difference between the sexes, and year of study had no significant impact on findings.

Conclusions

Sex differences in the prescription of cardiovascular medication exist among patients at high risk or with established cardiovascular disease in primary care, with a lower prevalence of aspirin, statins, and angiotensin‐converting enzyme inhibitors prescription in women and a lower prevalence of diuretics prescription in men.

Sex Differences in the Assessment of Cardiovascular Risk in Primary Health Care: A Systematic Review

OBJECTIVE

To determine whether sex differences exist in the assessment of cardiovascular disease (CVD) risk scores/risk factors in primary health care.

DESIGN/METHODS

PubMed and EMBASE were systematically searched on 31 January 2017. Clinical trials and observational studies were included if they reported on the assessment of CVD risk score, blood pressure (BP), cholesterol or smoking status in primary health care, stratified by sex. Meta-analyses were performed, using random effects models, to determine differences between sexes, separately for adjusted and unadjusted data.

RESULTS

Of 14,928 studies found in the search, 22 studies (including 4,754,782 patients) were included in the systematic review with the meta-analysis for quantitative assessment. Overall, the assessment rates of CVD risk score and risk factors were similar in women and men (CVD risk score: 30.7% vs. 35.2% [difference (95% CI): -4.5 (-5.1, -3.9)]; BP: 91.3% vs. 88.5% [2.8 (2.5, 3.0)]; cholesterol: 69.9% vs. 71.0% [-1.1 (-1.5, -0.8)]; and smoking: 85.9% vs. 86.7% [-0.8 (-1.1, -0.5)]). The pooled, adjusted likelihood of having the risk score, BP and cholesterol assessments were comparable between women and men: OR (95% CI): 0.87 (0.70, 1.07); 1.41 (0.89, 2.25); and 1.15 (0.82, 1.60), respectively. However, women were 32% less likely to be assessed for smoking (0.68 [0.47, 1.00]). There was substantial heterogeneity between studies and the risk of publication bias was moderate.

CONCLUSION

Despite the guideline recommendations, assessment of CVD risk score in primary health care was low in both sexes. Further, women were less likely to be assessed for their smoking status than men, whereas no sex discrepancies were found for BP and cholesterol assessments.

Association of bariatric surgery with risk of acute care use for hypertension-related disease in obese adults: population-based self-controlled case series study

BACKGROUND

Hypertension carries a large societal burden. Obesity is known as a risk factor for hypertension. However, little is known as to whether weight loss interventions reduce the risk of hypertension-related adverse events, such as acute care use (emergency department [ED] visit and/or unplanned hospitalization). We used bariatric surgery as an instrument for investigating the effect of large weight reduction on the risk of acute care use for hypertension-related disease in obese adults with hypertension.

METHODS

We performed a self-controlled case series study of obese patients with hypertension who underwent bariatric surgery using population-based ED and inpatient databases that recorded every bariatric surgery, ED visit, and hospitalization in three states (California, Florida, and Nebraska) from 2005 to 2011. The primary outcome was acute care use for hypertension-related disease. We used conditional logistic regression to compare each patient's risk of the outcome event during sequential 12-month periods, using pre-surgery months 13-24 as the reference period.

RESULTS

We identified 980 obese patients with hypertension who underwent bariatric surgery. The median age was 48 years (interquartile range, 40-56 years), 74% were female, and 55% were non-Hispanic white. During the reference period, 17.8% (95% confidence interval [CI], 15.4-20.2%) had a primary outcome event. The risk remained unchanged in the subsequent 12-month pre-surgery period (18.2% [95% CI, 15.7-20.6%]; adjusted odds ratio [aOR] 1.02 [95% CI, 0.83-1.27]; P = 0.83). In the first 12-month period after bariatric surgery, the risk significantly decreased (10.5% [8.6-12.4%]; aOR 0.58 [95% CI, 0.45-0.74]; P < 0.0001). Similarly, the risk remained significantly reduced in the 13-24 months after bariatric surgery (12.9% [95% CI, 10.8-15.0%]; aOR 0.71 [95% CI, 0.57-0.90]; P = 0.005). By contrast, there was no significant reduction in the risk among obese patients who underwent non-bariatric surgery (i.e., cholecystectomy, hysterectomy, spinal fusion, or mastectomy).

CONCLUSIONS

In this population-based study of obese adults with hypertension, we found that the risk of acute care use for hypertension-related disease decreased by 40% after bariatric surgery. The data provide the best evidence on the effectiveness of substantial weight loss on hypertension-related morbidities, underscoring the importance of discussing options for weight reduction when treating obese patients with hypertension.

Trends of Prevalence of Uncontrolled Risk Factors for Cerebrocardiovascular Disease: Southern Italy from 1988/9 to 2008/9

The aim of this study was to determine the trends of cardiovascular risk factor prevalence between 1988/9 and 2008/9 in the 25–74-year-old population in an area of Southern Italy. We compared three cross-sectional studies conducted in random population samples, in 1988/9, 1998/9, and 2008/9 in Salerno, Italy. The methodology of data collection (lipid profile, systolic and diastolic blood pressure, glycaemia, and smoking) and conducting tests which the population underwent during the three phases was standardized and comparable. Prevalence of diabetes, hypertension, hypercholesterolemia, and smoking was calculated and standardized for age. A total of 3491 subjects were included. From 1988/9 to 2008/9, in males, the prevalence of all four risk factors was reduced. In women, there was a clear reduction of hypertension, a similar prevalence of hypercholesterolemia, and an increase of smoking and diabetes. In the area of Salerno, our data confirm that the global prevalence of the major risk factors is decreasing in men, but their absolute values are still far from optimization. In women, diabetes and smoking showed a negative trend, therefore requiring targeted interventions. These data are now used as a base for executive targeted programs to improve prevention of cardiovascular disease in our community.

Patient Stratification Using Electronic Health Records from a Chronic Disease Management Program

OBJECTIVE

The goal of this study is to devise a machine learning framework to assist care coordination programs in prognostic stratification to design and deliver personalized care plans and to allocate financial and medical resources effectively.

MATERIALS AND METHODS

This study is based on a de-identified cohort of 2,521 hypertension patients from a chronic care coordination program at the Vanderbilt University Medical Center. Patients were modeled as vectors of features derived from electronic health records (EHRs) over a six-year period. We applied a stepwise regression to identify risk factors associated with a decrease in mean arterial pressure of at least 2 mmHg after program enrollment. The resulting features were subsequently validated via a logistic regression classifier. Finally, risk factors were applied to group the patients through model-based clustering.

RESULTS

We identified a set of predictive features that consisted of a mix of demographic, medication, and diagnostic concepts. Logistic regression over these features yielded an area under the ROC curve (AUC) of 0.71 (95% CI: [0.67, 0.76]). Based on these features, four clinically meaningful groups are identified through clustering - two of which represented patients with more severe disease profiles, while the remaining represented patients with mild disease profiles.

DISCUSSION

Patients with hypertension can exhibit significant variation in their blood pressure control status and responsiveness to therapy. Yet this work shows that a clustering analysis can generate more homogeneous patient groups, which may aid clinicians in designing and implementing customized care programs.

CONCLUSION

The study shows that predictive modeling and clustering using EHR data can be beneficial for providing a systematic, generalized approach for care providers to tailor their management approach based upon patient-level factors.

Temporal trends in the population attributable risk for cardiovascular disease: the Atherosclerosis Risk in Communities Study

BACKGROUND

The extent to which the relative contributions of traditional cardiovascular risk factors to incident cardiovascular disease (CVD) may have changed over time remains unclear.

METHODS AND RESULTS

We studied 13 541 participants (56% women, 26% black) in the Atherosclerosis Risk in Communities Study, aged 52 to 66 years and free of CVD at exams in 1987 through 1989, 1990 through 1992, 1993 through 1995, or 1996 through 1998. At each examination, we estimated the population attributable risks (PAR) of traditional risk factors (hypertension, diabetes mellitus, obesity, hypercholesterolemia, and smoking) for the 10-year incidence of CVD. Overall, the PAR of all risk factors combined appeared to decrease from the late 1980s to the late 1990s (0.58 to 0.53). The combined PAR was higher in women than men in 1987 through 1989 (0.68 versus 0.51, P<0.001) but not by the late 1990s (0.58 versus 0.48, P=0.08). The combined PAR was higher in blacks than whites in the late 1980s (0.67 versus 0.57, P=0.049), and this difference was more pronounced by the late 1990s (0.67 versus 0.48, P=0.002). By the late 1990s, the PAR of hypertension had become higher in women than men (P=0.02) and also appeared higher in blacks than whites (P=0.08). By the late 1990s, the PAR of diabetes mellitus remained higher in women than men (P<0.0001) and in blacks than whites (P<0.0001).

CONCLUSIONS

The contribution to CVD of all traditional risk factors combined is greater in blacks than whites, and this difference may be increasing. The contributions of hypertension and diabetes mellitus remain especially high, in women as well as blacks. These findings underscore the continued need for individual as well as population approaches to CVD risk factor modification.

Role of physician gender in drug therapy

There is evidence that female patients receive less intensified drug therapy in many medical conditions than male patients. However, there are only limited data regarding the influence of physician gender on drug therapy. It has been shown, for example, that female physicians tend to adhere more closely to guideline-recommended pharmacotherapy compared to their male counterparts. In some medical conditions where drug therapy is only one among various components of a complex interplay of therapeutic regimes (e.g., diabetes, cardiovascular diseases, depression, pain management), female physicians seem to achieve better overall intermediate outcomes and some studies suggest that "better" drug therapy is provided by female compared to male physicians. The reasons for the overall better outcomes may be superior communication skills of female physicians, participatory decision making, and consequently improved drug adherence in addition to or in combination with more effective non-pharmacologic treatment results. It is impossible to distinguish between the individual contributions of drug- and nondrug-related influence on such improved outcomes and thus to determine whether they are due to unconfounded physician gender effects on drug therapy. There is until now in no area of medicine evidence to suggest that a patient will consistently receive higher quality of drug therapy by switching to a physician of a specific gender.

Multimorbidity and blood pressure control in 37 651 hypertensive patients from Danish general practice

Background

Patients with hypertension are primarily treated in general practice. However, major studies of patients with hypertension are rarely based on populations from primary care. Knowledge of blood pressure (BP) control rates in patients with diabetes and/or cardiovascular diseases (CVDs), who have additional comorbidities, is lacking. We aimed to investigate the association of comorbidities with BP control using a large cohort of hypertensive patients from primary care practices.

Methods and Results

Using the Danish General Practice Database, we included 37 651 patients with hypertension from 231 general practices in Denmark. Recommended BP control was defined as BP <140/90 mm Hg in general and <130/80 mm Hg in patients with diabetes. The overall control rate was 33.2% (95% CI: 32.7 to 33.7). Only 16.5% (95% CI: 15.8 to 17.3) of patients with diabetes achieved BP control, whereas control rates ranged from 42.9% to 51.4% for patients with ischemic heart diseases or cerebrovascular or peripheral vascular diseases. A diagnosis of cardiac heart failure in addition to diabetes and/or CVD was associated with higher BP control rates, compared with men and women having only diabetes and/or CVD. A diagnosis of asthma in addition to diabetes and CVD was associated with higher BP control rates in men.

Conclusion

In Danish general practice, only 1 of 3 patients diagnosed with hypertension had a BP below target. BP control rates differ substantially within comorbidities. Other serious comorbidities in addition to diabetes and/or CVD were not associated with lower BP control rates; on the contrary, in some cases the BP control rates were higher when the patient was diagnosed with other serious comorbidities in addition to diabetes and/or CVD.

Trends in blood pressure control in patients with type 2 diabetes: data from the Swedish National Diabetes Register (NDR)

We assessed blood pressure (BP) trends in patients with type 2 diabetes from a national diabetes register using three cross-sectional samples (aged 30?85 years) in 2005, 2007 and 2009, and in patients from 2005 followed individually until 2009. The prevalence of hypertension was 87% among all 180 369 patients in 2009, although lower in subgroups with ages 30?39, 40?49 and 50?59 years: 40%, 60% and 77%. In the three cross-sectional surveys, mean BP decreased (141/77?136/76 mmHg), uncontrolled BP? 140/90 mmHg decreased (58?46%), and antihypertensive drug treatment (AHT) increased (73?81%). Comparatively in 79 185 patients followed individually for 5 years, mean BP decreased (141/77?137/75 mmHg), uncontrolled BP ?140/90 mmHg decreased (58?47%) and AHT increased (73?82%). Independent predictors of BP decrease were BMI decrease (stronger) and increase in AHT. AHT occurred among 81% of all patients in 2009. In 57 645 patients on AHT followed individually, mean BP decreased (143/77?138/75 mmHg) and uncontrolled BP ?140/90 mmHg decreased (63?50%). Among 5164 patients with nephropathy on AHT followed individually, BP <130/80 mmHg increased (12?21%). In conclusion, BP control improved from 2005 to 2009, relative to BMI decrease and AHT increase, although still about half had BP ?140/90 mmHg.

Physicians' gender is associated with risk factor control in patients on antihypertensive and lipid lowering treatment

The objective was to study gender differences in cardiovascular risk factors, lipid and blood pressure control in patients on combined lipid-lowering and antihypertensive treatment, in relation to gender of their physician. This was a cross-sectional study of 4319 patients (53% men) on lipid-lowering and antihypertensive treatment from two national surveys. Male physicians included 1643 men and 1311 women, and female physicians 605 men and 648 women. All data were collected consecutively from medical records. Women were older, had a higher systolic blood pressure (SBP), pulse pressure (PP), total cholesterol (TC), low-density lipoprotein-cholesterol (LDL-C), SBP>or=140 mmHg, and more often isolated systolic hypertension (ISH) compared with men. Men compared with women had more often diabetes, higher cardiovascular risk (SCORE) and achieved treatment goals more often for blood pressure in non-diabetics and TC in both non-diabetics and diabetics. Both men and women in well controlled and intermediate controlled groups were more often treated by physicians of their own gender. The female diabetes patients treated by female primary healthcare physicians more often achieved treatment goals for blood pressure [SBP/diastolic blood pressure (DBP)<130/80 mmHg]. Female physicians' male patients with diabetes more often belonged to the well controlled group. Physicians' gender may influence the control of risk factors for cardiovascular disease in both men and women on combined antihypertensive and lipid-lowering therapy.