Big Missed Opportunities for BP Control in Premenopausal Women

A new report shows considerable gaps in the awareness, treatment, and control of hypertension in premenopausal women in the United States, with a key driver being regular access to healthcare.

In a nationally representative sample of women ages 35 to 54 with no prior cardiovascular disease, the prevalence of hypertension increased 8% from an estimated 15.2 million women between 2011 and 2014 to 16.4 million women between 2015 and 2018.

What’s more, the percentage of women with controlled hypertension dropped over the two time periods from 55% to 50%, which is well below the government’s Million Hearts target of 70%.

Missed opportunities for hypertension control in these premenopausal women were:

  • lack of awareness of their hypertension in 23%

  • ineffective treatment in 34%

  • lack of healthcare access in 43%; increasing to 51% in non-Hispanic Black and 56% in Hispanic patients

Notably, lack of healthcare access affected an estimated 3.1 million women (45%) in 2011 to 2014 and 3.5 million women (43%) in 2015 to 2018.

Equally stubborn over the two time periods was the lack of effective treatment, affecting 2.1 million (31%) vs 2.8 million (34%) women, and lack of awareness, affecting 1.6 million (24%) vs 1.9 million (23%) women.

“There’s been no improvement over the past decade and there is evidence of race/ethnic disparities,” study author Susan Hennessy, PhD, said at the recent Epidemiology, Prevention/Lifestyle & Cardiometabolic Health (EPI|Lifestyle) 2022 conference sponsored by the American Heart Association.



Dr Susan Hennessy

The prevalence of uncontrolled hypertension among non-Hispanic Whites was less than that of the US population, at 44%, and most of the missed opportunities were due to uncontrolled blood pressure (BP), noted Hennessy, a researcher with the University of California San Francisco School of Medicine.

However, the uncontrolled prevalence was 54% in non-Hispanic Black women and 66% in Hispanic women. “In both of these subgroups, over half of the missed opportunities occur because these women have no regular access to healthcare,” she said.

In women who identified as “other,” which includes non-Hispanic Asian and mixed-race populations, the uncontrolled prevalence reached 70%, and the biggest missed opportunity was in those who were untreated.

Raising awareness, empowering women, and delivery of guideline-concordant care will help premenopausal women gain control of their blood pressure, Hennessy said. “But underpinning all of this is ensuring equitable health care access because if we fail to get women into the system then we have no opportunity to help them lower their blood pressure.”

She reminded the audience that cardiovascular disease (CVD) is the number-one killer of women in the United States and that CVD risk, mediated through hypertension, increases after menopause. Thus managing hypertension prior to this life event is an important element of primary prevention of CVD and should be a priority.

Session moderator Sadiya S. Khan, MD, Northwestern University Feinberg School of Medicine, Chicago, Illinois, told theheart.org | Medscape Cardiology that the findings should raise “alarm and concern that hypertension is not just a disease of the old but very prevalent in younger women, particularly around the time of pregnancy. And this is a clear driver of maternal morbidity and mortality as well.”

“This idea that patients should ‘Know Your Numbers‘ is really important and we talk a lot about that for hypertension but if you don’t have a doctor, if you don’t have someone to go to, it’s very hard to know or understand what your numbers mean,” she said. “I think that’s really the main message.”

Speaking to theheart.org | Medscape Cardiology, Hennessy said there’s no simple solution to the problem, given that some women are not even in the system, whereas others are not being treated effectively, but that increasing opportunities to screen BP would be a start. That could be through community programs, similar to the Barbershop Hypertension trial, or by making BP devices available for home monitoring.

“Again, this is about empowering ourselves to take some level of control but, as a system, we have to be able to make it equitable for everyone and make sure they have the right equipment, the right cuff size,” she said. “The disparities arise because of the social determinants of health, so if these women are struggling to put food on the table, they aren’t going to be able to afford a blood pressure cuff.”

During a discussion of the findings, audience members noted that the National Health and Nutrition Examination Survey (NHANES) data used for the analysis were somewhat dated. Hennessy also pointed out that NHANES blood pressure is measured up to three times during a single visit, which differs from clinical practice, and that responses were based on self-report, and thus subject to recall bias.

The sample included 3343 women aged 35 to 54 years with no prior cardiovascular disease, representing an estimated 31.6 million American women. Hypertension was defined by a systolic BP of at least 140 mm Hg or a diastolic BP of at least 90 mm Hg or current BP medication use.

Epidemiology, Prevention/Lifestyle & Cardiometabolic Health (EPI|Lifestyle) 2022 conference: Abstract 069. Presented March 4, 2022.

The authors and Kahn report no relevant financial relationships.

Follow Patrice Wendling on Twitter: @pwendl For more from theheart.org | Medscape Cardiology, follow us on Twitter and Facebook.

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