Risk-factor control in treated hypertensive patients : epidemiological, gender-related, and quality-control aspects

The overall aim was to investigate the risk-factor profile in patients with hypertension, and patients on combined lipid-lowering (LLD) and antihypertensive treatment (AHT) in primary health care, in order to evaluate cardiovascular risk factors in relation to age, gender, lifestyle (smoking), and gender of the physician.

Objectives: To compare cardiovascular risk factors in smokers with non-smokers in a national sample of treated hypertensives (tHT) (Study I); to evaluate any gender differences in the control of blood pressure (BP) and lipid levels as well as other cardiovascular (CV) risk factors for cardiovascular disease in tHT patients in primary health care (PHC) (Study II); to investigate the relationship of physician's gender to control of blood pressure and lipid levels and CV risk factors in tHT men and women (Study III); to investigate any gender differences in CV risk factors, lipid- and BP control in patients on combined lipid-lowering (LLD) and antihypertensive treatment (AHT), stratified for gender of their physician (Study IV).

Methods and materials: These cross-sectional clinical studies, of tHTs (Studies I-III) and patients on both AHT and LLD (Study IV) were carried out in 2002-2003 (Study I), 2002-2005 (Studies II and III), and 2002-2006 (Study IV). They were run by 182 (Study I), 264 (Studies II, III) and 356 (Study IV) primary care physicians (PCPs) at primary health care centres (PHCs) in Sweden. The number of patients included were, in Study I, 4,424 tHTs (48% men); in Studies II and III: 6,537 tHTs (48% men) and in Study IV 4,319 patients on both AHT and LLD (53% men). The mean age was 66 years in all four studies. Patients were included retrospectively and consecutively and their data were registered on a web-form. BP and lipid control were defined as SBP/DBP <140/90 mmHg and total cholesterol (TC) <5.0 mmol/l in patients without diabetes mellitus (DM), and SBP/DBP <130/80 mmHg and TC <4.5 mmol/l in patients with DM.

Results: Study I: tHTs who reported daily smoking had a poorer CV risk factor profile than non-smokers, with higher DBP levels and a higher prevalence of microalbuminuria. Male smokers had left ventricular hypertrophy (LVH) and microalbuminuria more often than non-smokers did. Females smokers had higher mean levels of DBP and TC than non-smokers.

Study II: only 28% of the tHTs achieved the BP treatment goal. The main clinical problem was the persistence of high SBP despite treatment. In addition, men had higher DBP and higher prevalence of DM and target organ damage (LVH and microalbuminuria) than women did. In contrast, women had higher SBP, pulse pressure (PP), and TC and higher prevalence rates of uncontrolled BP and TC than in men. Study III: female tHTs reached the BP treatment goal more often when treated by female PCPs than when treated by male PCPs. However, the majority of the patients did not reach the BP treatment goal, regardless of gender of physician. Both male and female tHTs more often achieved the TC and LDL-C treatment goals when treated by female PCPs than when treated by male PCPs. Study IV: male diabetic patients on both AHT and LLD more often had well-controlled SBP and TC when treated by female PCPs than when treatment was given by male PCPs.

When the female diabetic patients were treated by female PCPs they more often achieved the BP treatment goals than when they were treated by male PCPs. In those patients with well- and intermediate-controlled SBP and TC, both men and women were more often treated by PCPs of their own gender. A low proportion of patients on both AHT and LLD achieved both BP and TC goals (16 % of the men and 10 % of the women).

Conclusion: There is still a need for intensifying treatment of elevated blood pressure and other risk factors for cardiovascular disease in patients on antihypertensive treatment, especially women. Female patients appeared to achieve the target blood pressure more often when treated by a female physician than when treated by a male physician. Both male and female hypertensives achieved cholesterol treatment goals more often when treated by female physicians than when treated by male physicians. Hypertensive men and women at the same cardiovascular risk level should be treated equally well and regardless of the gender of their physician.

List of scientific papers

I. Journath G, Nilsson P M, Petersson U, Paradis B-A, Theobald H, and Erhardt L for the Hyper-Q study group, Sweden. (2005). "Hypertensive smokers have a worse cardiovascular risk profiles than non-smokers in spite of treatment – a national Study In Sweden." Blood Pressure 14: 144-150
https://pubmed.ncbi.nlm.nih.gov/16036494

II. Journath G, Hellénius M-L, Petersson U, Theobald H and Nilsson P M for the Hyper-Q Study Group Sweden. (2008). "Sex differences in risk factor control of treated hypertensives: a national primary health care-based Study In Sweden." Eur J Cardiovasc Prev Rehabil 15: 258-262
https://pubmed.ncbi.nlm.nih.gov/18525379

III. Journath G, Hellénius M-L, Manhem K, Kjellgren K I and Nilsson P M, for the Hyper-Q Study Group, Sweden. (2008). "Association of physicians’ gender and risk factor control in treated hypertensive patients from Swedish primary health care." Journal of Hypertension 26: 2050-2056
https://pubmed.ncbi.nlm.nih.gov/18806630

IV. Journath G, Hellénius M-L, Carlsson A C, Wändel P, and Nilsson P M for the HyperQ and EKO Study Groups, Sweden. (1970). "Physicians´ gender is associated with risk factor control in patients on combined antihypertensive and lipid-lowering treatment." (Submitted)