Gender inequality in hypertension

Cardiovascular Disease and Hypertension

Cardiovascular disease (CVD) is the leading cause of death globally, costing about 17.9 m lives worldwide.¹ More than 4 out of 5 CVD deaths are from myocardial infarction (MI) or stroke, and one-third of these occur prematurely in individuals under 70.¹ Although the incidence of most types of CVD in women is lower than in men, women have a higher mortality rate and poorer prognosis.^2,3

A 2024 longitudinal cohort study using data from the National Health and Nutrition Examination Survey (NHANES) (n = 38,924) found that the CVD mortality rates for men and women were equal (22.59 per 100,000 person-years for men, and 22.61 for women).⁴ However, given the disparity in the incidence of CVD between men and women (for example, men have a 2-fold higher incidence of coronary artery disease than women until older age), the equal death rate is cause for concern.³

Hypertension (htn) is a significant modifiable risk factor for CVD and CVD-related mortality, and its prevalence, management, and outcomes differ significantly between genders.⁵ Data collected by the Centers for Disease Control and Prevention (CDC) between 2021 and 2023 show that htn prevalence was 30.0% in men and 16.4% in women ages 18–39; and 55.9% among men versus 49.0% in women ages 40 to 59, but the prevalence equaled out at 71.6% at age 60 and older.⁶

However, although htn remains more common in males, the gradient by which women develop htn across the lifespan is steeper than in males, and the blood pressure thresholds for developing CVD are lower for women.⁵

Reasons for Gender-Based BP Differences

Gender-based differences in htn are certainly multifactorial, but pregnancy may be among the most influential factors in the accelerated trajectories of htn among women. Among women without baseline htn, gestational htn or pre-eclampsia during their first pregnancy doubles their risk of later developing chronic htn.⁷

The effects of estrogen on the renin–angiotensin–aldosterone system (RAAS) also appear to play a role in htn among women.⁵

There is evidence to suggest that women are partly at risk for htn and complications from htn due to inequalities in gender, domestic abuse, socioeconomic deprivation, poor health literacy, and environmental risk factors.⁸

Differences in Treatment

Addressing the gender mortality gap in such a prevalent but treatable disease is of utmost importance. The gender differences in htn suggest that differences in treatment approaches should be tailored to gender, particularly in light of our preference for precision medicine.^5,8 It is also of foremost importance to promote equitable access to the benefits of evidence-based healthcare. However, there is a paucity of data to determine and support gender-specific BP targets or treatment approaches.⁵

Similarly, there are no data that establish that gender affects different htn treatments.⁹ The question of gender-specific treatment for htn is understudied, despite a glaring need to clarify the issue.^9,10 There is likely a benefit to gender-specific guidelines for the diagnosis and management of htn, which currently do not exist in the United States (U.S.)⁵

Where Do We Go From Here?

In the absence of gender-specific htn guidelines, clinicians can recognize that women have a steeper gradient to develop htn as they age and are more likely than men to suffer adverse consequences from htn. Clinicians should ensure that they recognize that women can benefit from the same clinical vigilance as men.

Clinicians can improve the diagnosis and management of htn in any patient through home BP monitoring. Home BP is a predictor of CVD- and stroke-related morbidity and mortality and is a better prognosticator than office BP.¹¹

At-home patients using Omron home BP monitors can keep their healthcare provider “in the loop” through the OMRON connect app, which allows them to share their data.

Consider adding OMRON BP monitors to your practice, whether in-office or for patients’ at-home use.

By Andrew Proulx, MD