Content uploaded by Thomas A Mackey
Author content
All content in this area was uploaded by Thomas A Mackey on Apr 27, 2021
Content may be subject to copyright.
Lessons Learned From a Survey of the Diagnosis and Treatment
Journeys of Postmenopausal Women With Hypertension
Lynne Doner Lotenberg, MA;
1
Lisa C. Clough, MS Ed, CHES;
2
Thomas A. Mackey, PhD, RN, FNP-BC;
3
Amy E. Rudolph, PhD;
4
Rita Samuel, MD;
4
JoAnne M. Foody, MD
5
Hager Sharp, Washington, DC;
1
WomenHeart: The National Coalition for Women with Heart Disease, Washington, DC;
2
University of Texas School of
Nursing at Houston, Houston, TX;
3
Novartis Pharmaceuticals Corporation, East Hanover, NJ;
4
and Brigham and Women’s Hospital, Boston, MA
5
In this qualitative, experiential study, 300 members of the
database of WomenHeart: The National Coalition for Women
With Heart Disease completed an online survey about
hypertension diagnosis and treatment, patient education,
and perceptions of this and related conditions. Based on the
findings from the survey, characteristics of the prototypical
journey were identified. To the extent to which the surveyed
WomenHeart members represent typical experiences, this
survey provides insights into common hurdles women
encounter in their journey throughout the hypertension
diagnosis and treatment process. Results of this study
suggest the need for a patient-centric approach to hyper-
tension management and to implement programs with the
intention of comprehensively assessing and meeting indi-
vidual needs. Further studies would be of value to expand on
patients’ journeys in the management of hypertension and
identify the types of products, services, and programming
that most effectively support treatment adherence and
achievement of optimal blood pressure control. J Clin
Hypertens (Greenwich). 2013;15:532–541. ª2013 Wiley Peri-
odicals, Inc.
While hypertension is more common in men than in
premenopausal women,
1,2
after the onset of meno-
pause, hypertension rates become higher in women than
in age-matched men. It is estimated that >40% of
postmenopausal women in the United States will
develop hypertension and >75% of women older than
70 years are hypertensive.
2–4
The high prevalence of
postmenopausal hypertension is concerning given the
associated increased risk of adverse cardiovascular,
cerebrovascular, and renal outcomes.
5
According to
the American Heart Association Heart Disease and
Stroke Statistics—2013 Update, high blood pressure
(BP) is associated with shorter overall life expectancy,
shorter life expectancy free of cardiovascular disease,
more years lived with cardiovascular disease, and
increased risks of ischemic stroke and intracranial
hemorrhage, compared with normal BP.
6
Hypertension
causes more than 61,000 deaths annually, including
more than 34,000 women.
6
For women, in particular,
age-adjusted mortality rates associated with BP-related
disease have increased in recent years.
7,8
More than 1 of
every 3 adult women in the United States currently has
some form of cardiovascular disease and, since 1984,
more women than men have died of cardiovascular
disease.
3
Data from National Health and Nutrition Examina-
tion Surveys (NHANES) indicate that although hyper-
tension awareness, treatment, and control rates have
increased significantly for both men and women in
recent years,
9
control rates are lower in women than in
men,
10
with less than half of postmenopausal women
having adequate BP control.
2,11
These findings have
been observed despite the fact that women are more
likely than men to have their BP checked and adhere to
their BP medications, which suggests that women may
not be treated as aggressively for hypertension com-
pared with their male counterparts and/or the mecha-
nisms contributing to postmenopausal hypertension
may differ from those in men and premenopausal
women.
1
For example, postmenopausal women are
more likely than premenopausal women to have BP
that does not decline by >10% during nighttime hours.
This type of hypertension is associated with more target-
organ damage in women than in men.
12
Physiologic factors that may play a role in the high
prevalence of hypertension in postmenopausal women
include changes in estrogen/androgen ratios, increased
endothelin and oxidative stress, activation of the renin-
angiotensin-aldosterone system (RAAS) and sympa-
thetic nervous system, and increased excretion of
vasoconstrictor eicosanoids.
13,14
Other factors associ-
ated with the increased prevalence of high BP in
postmenopausal women include increased rates of
obesity, diabetes, dyslipidemia, metabolic syndrome,
anxiety, and depression; increased consumption of
dietary sodium; more sedentary lifestyles; and subopti-
mal levels of health literacy.
15–19
According to the Hypertension 2008 online survey
conducted on behalf of the Preventive Cardiovascular
Nurses Association, which surveyed 1548 hypertensive
patients 44 years and older, age plays an important role in
attitudes and behaviors regarding health care education,
Address for correspondence: JoAnne M. Foody, MD, Director,
Cardiovascular Wellness Program, Brigham & Women’s Hospital,
75 Francis Street, PB-136, Boston, MA 02115
E-mail: JFOODY@partners.org
Manuscript received: January 11, 2013; revised: March 20, 2013;
accepted: March 20, 2013
DOI: 10.1111/jch.12114
532 The Journal of Clinical Hypertension Vol 15 | No 8 | August 2013 Official Journal of the American Society of Hypertension, Inc.
ORIGINAL PAPER
burden of illness, and treatment.
18
When BP goals are not
met, older people may be more likely to express apathy
and discouragement and fail to adhere to treatment than
those who are younger. This survey
18
also found negative
differences between educational strategies for older vs
younger people, where better communication between
health care providers and older patients may improve
patient attitudes, knowledge, and adherence to lifestyle
and pharmacologic treatment regimens.
Based on the hypothesis that postmenopausal women
may have unique aspects to their journey or barriers to
care, the current study set out to map the journey taken
by women going through the processes of obtaining a
diagnosis of hypertension and managing high BP. By
mapping this journey, it may be possible to better
understand patient needs and identify areas where
improvements in care can result in faster diagnosis or
better disease management. Published studies mapping
other medical journeys (eg, cancer, rheumatoid arthritis,
and hearing loss) have provided valuable insight into
patient perspectives and key areas for improving clinical
management strategies.
20–23
Data on such journeys
through hypertension are limited
24
and this is the first
study to explore the processes of the US health care
system, specifically examining the experience of high-
risk postmenopausal women. Participants were mem-
bers of the database of WomenHeart: The National
Coalition for Women With Heart Disease, which is the
only national organization supporting women living
with or at risk for cardiovascular disease through
advocacy, education, and patient support.
METHODS
Online Survey
To build an original framework for the survey,
preliminary in-depth telephone interviews were con-
ducted with 6 women between the ages of 53 and
73 years. All were postmenopausal and had been
diagnosed with hypertension 6 years ago. The qual-
itative interviews ensured that the online survey
captured the key elements of the patient experience
and clearly phrased the questions of interest.
Invitations to participate in the online survey were e-
mailed to 9087 WomenHeart database members who
were self-identified as having at least one risk factor for
developing heart disease. Responses were collected from
January 19 to February 1, 2011. Questions covered the
following categories: initial diagnosis and treatment,
continuing treatment and management, health care
education, and perceptions of high BP and related
conditions. Survey responses were based on women’s
recall of events.
Analyses
The goal of this exploratory survey was to produce a
qualitative, experiential map of women’s hypertension
journey based on the concept that a woman’s overall
journey is made up of the sum of her experiences. Survey
results were used to construct a prototypical average
woman’s (“Jane’s”) journey based on the most common
responses to the survey questions. This vignette does not
present the case of a surveyed woman, but rather
presents an amalgam of survey results to provide
clinicians with examples of prototypical patient char-
acteristics and experiences.
To identify ways in which the journey differs for
various women, results were evaluated for subgroups
based on age (39–58 years, 59–65 years, and 66 years
and older), risk (higher risk was defined as history of
heart attack, stroke, congestive heart failure [CHF], or
kidney disease; lower risk was defined as no history of
these events), and time since diagnosis (within the past
5 years, 6–15 years ago, and 16 years ago). Reported
subgroup differences were statistically significant
(P<.05) unless stated otherwise.
RESULTS
Survey Response Characteristics
On average, the survey took 20 minutes to complete. A
total of 571 people responded to the survey. Of those,
201 did not qualify (ie, they were not hypertensive,
postmenopausal women living in the United States) and
70 were excluded because of missing survey data. The
number of database members who would have satisfied
the inclusion criteria for the survey (ie, hypertensive,
postmenopausal women living in the United States) is
unknown. A total of 300 qualified respondents had
survey data available and were included in the analysis.
Overall Themes Observed in Women’s Hypertension
Journeys
Figure 1 summarizes the results of the study, highlight-
ing many of the common themes observed in the
hypertension journey, including roadblocks women
frequently encounter during diagnosis and monitoring,
treatment, and long-term management. The following
sections present these results in detail, followed by a
vignette for Jane, a prototypical postmenopausal
woman with hypertension. The purpose of this vignette
is to create a portrait that brings to light some typical
patient experiences during the course of the hyperten-
sion journey.
Survey Respondent Characteristics
The demographic characteristics of the 300 female
respondents are summarized in the Table. The majority
of survey respondents were white, married, and had
some level of higher education, with nearly half being
college graduates. Participants were roughly equally
distributed across geographic regions of the United
States. Nearly all reported having health insurance,
predominantly Medicare and/or private insurance
through an employer or school. A majority of those
taking part had at least one comorbid condition.
About half of the respondents were categorized as
being at higher risk for future negative outcomes
Official Journal of the American Society of Hypertension, Inc. The Journal of Clinical Hypertension Vol 15 | No 8 | August 2013 533
Journeys of Postmenopausal Hypertensive Women | Doner Lotenberg et al.
FIGURE 1. Highlights of women’s journeys with hypertension.
534 The Journal of Clinical Hypertension Vol 15 | No 8 | August 2013 Official Journal of the American Society of Hypertension, Inc.
Journeys of Postmenopausal Hypertensive Women | Doner Lotenberg et al.
because of CHF, kidney disease, or a prior heart attack
or stroke. Compared with the lower-risk group, higher-
risk women were more likely to have diabetes and a
longer history of hypertension.
Diagnosis and Monitoring
For most women, an initial diagnosis of hypertension
was made by a health care provider at a checkup or sick
visit. Only a small proportion (5%) of patients taking
part in the survey were found to have hypertension
using a home BP monitor, although this was more
common among those diagnosed within the past 5 years
than for those diagnosed 16 years ago. The diagnos-
ing health care provider was most commonly in family/
general practice, followed by internal medicine, cardi-
ology, obstetrics/gynecology, and other.
About half of the women reported discussing exer-
cise/physical activity, the causes of high BP, and
reducing salt intake at the first visit with a health care
provider. However, >1 in 10 women reported that they
had never discussed exercise/physical activity, heart
disease, or reducing salt intake, and >1 in 5 reported no
discussion around dietary changes other than salt
reduction, how often to check BP, consequences of
high BP, causes of high BP, losing weight, or using a
home BP monitor with their provider. Approximately
half of the group had not discussed controlling blood
sugar, the relationship between diabetes and high BP,
or smoking cessation. In some instances, however,
health care providers may not have felt the topics were
relevant for all patients based on medical history.
Respondents diagnosed with hypertension 16 years
TABLE. Characteristics of Respondents
Characteristic
Respondents,
%(N=300)
a
Age, y
3958 36
5965 33
66 32
Race/ethnicity
b
White 89
Black or African American 8
Hispanic or Latina 1
American Indian or Alaskan Native 1
Asian, Native Hawaiian, or Pacific Islander 1
Other 1
Declined to answer 1
Marital status
Married 68
Divorced/separated 18
Widowed 6
Never married 4
Member of unmarried couple 3
Education level
High school graduate or less 12
Some college/associate degree 41
4-Year college degree 26
Completed graduate school 20
Household income, $
14,999 3
15,000–24,999 4
25,000–34,999 9
35,000–49,999 11
50,000–74,999 15
75,000–99,999 12
100,000–124,999 9
125,000 8
Declined to answer 29
US region
Northeast 20
Midwest 31
South 29
West 19
Health insurance
b
Medicare 39
Through employer/school 37
Through family member’s employer/school 28
Private—paid for out-of-pocket 16
Medicaid/other public insurance 3
Veterans Affairs 3
Some other insurance 5
None 3
Medical diagnoses
b
High blood pressure 100
High cholesterol 81
Overweight 69
Heart attack 39
Diabetes 25
Osteoporosis 17
Congestive heart failure 16
Kidney disease 8
Stroke 5
TABLE. (Continued)
Characteristic
Respondents,
%(N=300)
a
Level of risk
Higher
c
52
Lower
d
48
Years since hypertension diagnosis
Within the past year 3
1–2 years ago 5
3–5 years ago 14
6–10 years ago 26
11–15 years ago 17
16–20 years ago 14
21–30 years ago 10
>30 years ago 10
a
Percentages may not total 100% as a result of rounding.
b
Respondents could select more than 1 response.
c
Defined as high blood pressure with myocardial infarction, conges-
tive heart failure, stroke, or kidney disease.
d
Defined as high blood pressure without myocardial infarction,
congestive heart failure, stroke, or kidney disease; when level of risk
was calculated using high blood pressure with only myocardial
infarction, congestive heart failure, or stroke, 51% of women were at
higher risk and 49% were at lower risk.
Official Journal of the American Society of Hypertension, Inc. The Journal of Clinical Hypertension Vol 15 | No 8 | August 2013 535
Journeys of Postmenopausal Hypertensive Women | Doner Lotenberg et al.
ago were less likely to have discussed heart disease,
exercise/physical activity, weight loss measures, con-
trolling blood sugar, using a BP monitor, or how
frequently to check BP than women diagnosed more
recently.
Figure 2 summarizes responses regarding frequency
of BP monitoring by health care providers and through
self-monitoring. Most women (89%) reported having
their BP checked by a health care provider at least once
every 6 months, and 77% reported checking their own
BP at least once every 2 to 3 months. When asked which
locations in a typical community would be convenient
and comfortable places to check BP, the most popular
answer among the choices provided in the survey was
the pharmacy (57%). Other common choices included
grocery stores (28%), health clubs (27%), and, among
the elderly (>65 years), senior/community centers
(27%).
Treatment
The majority of women (93%) reported taking medica-
tion to treat their hypertension. Most (55%) were
taking 2 antihypertensive medications, while 38%
reported taking a single medication (note: although the
survey asked about number of medications, it is not
known how women who take single-pill combination
medications counted them). Women diagnosed within
the past 5 years were more likely to take no medication
compared with the group who had hypertension for
16 years (15% vs 4%).
Treatment adherence was suboptimal, with 24% of
women reporting that they do not continuously take
their BP medication. Reasons for nonadherence
included forgetfulness (27%), medication expense
(10%), actual adverse effects (7%), and concerns about
side effects (7%). As shown in Figure 3, the most
common answers women gave when asked to identify
FIGURE 2. Frequency of blood pressure (BP) monitoring by (A) health care providers (HCPs) and (B) through self-monitoring; all respondents
(N=300).
536 The Journal of Clinical Hypertension Vol 15 | No 8 | August 2013 Official Journal of the American Society of Hypertension, Inc.
Journeys of Postmenopausal Hypertensive Women | Doner Lotenberg et al.
one aspect of BP medication deserving of improvement
were “nothing; everything is fine,” “take fewer medica-
tions,” “reduce cost,” and “eliminate side effects.”
Long-Term Disease Management
From the survey, several obstacles were identified as
affecting the ability to make the lifestyle changes
necessary to reduce hypertension. The most common
factors cited were events in life, family/work commit-
ments, amount of available time, and money. Women in
the youngest age group (39–58 years) were more likely
to identify these 4 factors compared with older women.
When presented with a list of possible resources or
services available to help achieve better BP control,
items of particular interest included dietary planning
and physical activity ideas (Figure 4). More than one
third of respondents expressed interest in receiving a list
of useful Web sites, information about local health and
wellness programs, or tracking sheets or online
resources to record BP readings and monitor progress
in achieving goals. However, these results should be
interpreted within the context that responders to an e-
mail survey may be more interested in online resources
than survey nonresponders and the general population
of postmenopausal women with hypertension.
The women responding to this survey reported that
they most often learned about high BP and other health
topics from health care providers (82%), the internet
(70%), and magazines, newspapers, or newsletters
(61%). Women were unlikely to use newer technologies
FIGURE 3. The one aspect of current high blood pressure (BP) medication women would most like to improve (n=278).
FIGURE 4. Resources or services identified by women as possibly helping to better control blood pressure (BP) (N=300).
Official Journal of the American Society of Hypertension, Inc. The Journal of Clinical Hypertension Vol 15 | No 8 | August 2013 537
Journeys of Postmenopausal Hypertensive Women | Doner Lotenberg et al.
as sources of information on high BP; only 7% of
respondents reported using social media (eg, Facebook),
and 0% reported using smartphone applications or text
messaging.
When asked about the perceived threat to health
associated with different medical conditions, the major-
ity of women reported high BP to be of greater concern
than any other condition (Figure 5). However, a
substantial proportion of the women surveyed viewed
the following commonly comorbid diseases as little or
no threat to health: stroke, CHF, diabetes, and kidney
disease (Figure 5). Subgroup analyses found older
women (66 years and older) perceived CHF, diabetes,
osteoporosis, kidney disease, and the need to lose weight
to be less of an issue compared with younger groups. In
the overall survey population, some of the reasons given
for high levels of concern about high BP included
learning more about the consequences of the disease,
finding it harder to lower BP than expected, and
experiencing a health consequence associated with high
BP (eg, heart attack, transient ischemic attack, stroke, or
kidney problems).
When asked for their opinions about the relationship
between BP control and other diseases, almost all
participants agreed that there was a link between high
BP and heart disease and that it was important to keep
BP values as close to goal as possible. However, many
women did not know what these goals were. When
asked to cite the values during the survey, only about
60% of respondents gave a feasible number for systolic
or diastolic BP. About 1 in 10 respondents did not know
their systolic or diastolic goals, and the remainder gave
unlikely responses.
There was a high level of agreement on questioning as
to whether there is a relationship between high BP and
diabetes, and 67% of women were aware of their blood
sugar goals. However, 53% of respondents had either a
neutral opinion or were not interested in learning more
about diabetes and how to control this disease.
Vignette of a Prototypical Journey
Consider Jane, a prototypical postmenopausal woman
with hypertension. Jane is 62 years old, white, married,
and has an annual household income between $50,000
and $75,000. Jane attended college but did not earn a 4-
year degree. Jane has health insurance through her
employer. She is a nonsmoker and exercises (at least
takes a walk) on 4 days a week. In addition to high
BP, Jane has high cholesterol and needs to lose weight.
She had a heart attack 2 years ago.
Jane first learned she had high BP about 10 years ago
when she saw her primary care doctor for a checkup. At
her initial visit, Jane and her provider discussed med-
ication, exercise, and reducing salt consumption. Jane
doesn’t recall for certain, but they may have discussed
losing weight and the risks or causes of high BP.
Jane left her provider’s office with a prescription and
returned for a follow-up visit within 3 months.
Jane prefers to get her BP checked by her provider,
usually every 2 to 3 months but sometimes every 4 to
6 months. However, occasionally Jane finds it easy and
comfortable to have her BP checked at the local phar-
macy. When Jane explored with her healthcare provider
the possibility of home BP monitoring, she decided the
above options were sufficient to meet her needs.
Jane takes 1 or 2 prescription BP medications; she
does not know whether she takes a combination
medication. She usually takes her medication as directed
but sometimes forgets. Jane is fairly satisfied with her
medications, although there are times when she wishes
she could take fewer medications and experience fewer
side effects.
Jane considers high BP to be a notable threat to her
health and is concerned about heart attacks, high
FIGURE 5. Perceived threats of different medical conditions to overall health (N=300).
a
538 The Journal of Clinical Hypertension Vol 15 | No 8 | August 2013 Official Journal of the American Society of Hypertension, Inc.
Journeys of Postmenopausal Hypertensive Women | Doner Lotenberg et al.
cholesterol, stroke, and CHF. She is less concerned
about losing weight, diabetes, or kidney disease, and
considers osteoporosis to be only a small threat. In an
attempt to control her high BP, Jane has tried to change
eating and exercise habits as well as reduce stress in her
life. Regardless of her intent, life sometimes makes these
changes difficult, as do family and work commitments;
however, Jane noted that these barriers have lessened
as she has aged. Over time, Jane has become more
concerned about high BP because she has learned more
about its health consequences from her health care
provider and from magazines and the internet. She also
acknowledges that it was harder to bring down her BP
than she thought it would be. Because she is a member
of WomenHeart, she knows that there is a relationship
between high BP and heart disease. She is less familiar
with diabetes and is uncertain whether there is a
relationship between diabetes and high BP.
Jane is somewhat interested in learning more about
high BP and how to control it. Topics of interest to Jane
include information on good food choices and the
benefits of exercise. Jane prefers to receive health
information from her health care provider, the internet,
magazines, newspapers, or newsletters. However, Jane
is unlikely to benefit from educational materials avail-
able through social media or smartphone applications.
DISCUSSION
This survey of 300 postmenopausal women with hyper-
tension provides unique insight into the journeys women
take on the path through diagnosis, treatment, and long-
term disease management. Examination of these jour-
neys revealed several important findings including the
fact that most women were diagnosed with hypertension
during a routine checkup or sick visit, and that many
were at high risk and on multiple medications. Despite
this, treatment adherence was suboptimal with approx-
imately 1 of 4 women reporting poor adherence.
Further, few women had discussed dietary interventions,
management strategies, or the relevance of high BP to
health with their health care provider. Important differ-
ences were identified in the journeys of women who were
older and who had been recently diagnosed. For exam-
ple, this survey identified educational gaps in conveying
the importance of weight loss and the consequences of
high BP to older women (66 years and older) and those
diagnosed more than 15 years ago.
In the current study, more than half of women (57%)
indicated that local pharmacies would be convenient
and comfortable places to check BP, and more than 1 in
4 women indicated that grocery stores, health clubs, or
senior/community centers would be convenient places.
These results imply that opportunities may exist to
establish regular BP monitoring at accessible community
locations outside of the health care provider’s office.
This point is supported by a cross-sectional mail survey
of 530 hypertensive patients in North Carolina, where
63% reported checking BP at locations other than a
doctor’s office or at home.
25
Most of these respondents
(66%) reported using a BP monitor stationed in a stand-
alone pharmacy or one located within a larger retail
store. This study also found that patients with comor-
bidities such as diabetes, heart disease, or stroke were
not more likely to monitor BP at community locations
than patients without such comorbidities. Further, older
people (older than 65 years) were significantly less likely
to use BP monitors than those between the ages of 45
and 65.
25
Identifying gaps such as these are important
because pharmacy and other community-based pro-
grams can have a positive impact on the early detection
of hypertension and can also monitor other easily
measured cardiovascular risk factors (eg, body mass
index and waist circumference).
26,27
Changes in the
early detection of hypertension could significantly
improve outcomes for postmenopausal women because
an estimated 39% of this population will have had
prehypertension (ie, systolic/diastolic BP of 120–139/
80–89 mm Hg),
16,28
and these early stages are indepen-
dently associated with increased risks for myocardial
infarction, stroke, hospitalization for heart failure, and
cardiovascular death.
16
Early detection can also be improved by encouraging
women to have regular physical examinations. In the
current survey, 40% of hypertension diagnoses occurred
during a routine physical examination.
Despite the fact that national and international guide-
lines recommend the use of home BP monitoring for the
diagnosis and management of hypertension,
28–32
results
of the current survey found that only 21% of patients
received a monitor or information on how to obtain one
and 28% never discussed this option with a health care
provider. Thus, increased emphasis on discussions of the
benefits of home BP monitoring between patients and
health care providers could positively impact the hyper-
tension journey. Regular home BP monitoring is a
practical, readily available, cost-effective method that is
increasingly used for diagnosing uncontrolled hyperten-
sion.
28–30
This approach is a better predictor of cardio-
vascular mortality and target-organ damage compared
with measurement in an office because it eliminates the
white-coat hypertension effect and allows patients to
regularly assess the ongoing efficacy of antihypertensive
medications. These features can improve both treatment
adherence/persistence and overall BP control.
33
Home
monitoring is also of benefit because readings can be
tracked over time and sent directly to health care
providers via telephone or wireless services.
33
These
options may be particularly beneficial for the elderly, who
are more likely to have challenges getting to a doctor’s
office and are more prone to white-coat hypertension.
31
Home BP monitoring has also been shown to significantly
predict cardiovascular events, all-cause mortality, pro-
gression of chronic kidney disease, and functional decline
in elderly patients.
34
Results of the current survey found that treatment
strategies in hypertension often may not be aggressive
enough and the seriousness of the consequences of
uncontrolled high BP may be underestimated. Many
Official Journal of the American Society of Hypertension, Inc. The Journal of Clinical Hypertension Vol 15 | No 8 | August 2013 539
Journeys of Postmenopausal Hypertensive Women | Doner Lotenberg et al.
women (45%) reported not receiving any treatment or
only a single prescription for antihypertensive medica-
tion (despite the well-established finding that mono-
therapy does not effectively control BP in the majority
[>70%] of patients with hypertension, particularly
when this condition exists with comorbidities
35
). In
addition, many people have adherence challenges
driven, in part, by preferences for fewer medications,
reduced side effects, and lower costs.
It is important for all patients with hypertension to
implement lifestyle changes, even if medication is not
required. Guidelines recommend increasing physical
activity and making dietary changes (eg, reduced intake
of salt, saturated fat, and total fat; and increased intake
of fruits and vegetables) to lower BP and reduce
cardiovascular risk.
28,35
However, many factors make
it difficult to make lifestyle changes, and there is room
for improvement in the discussions taking place
throughout the patient journey. Approximately one
quarter of women recalled no mention of important
lifestyle changes or the causes and consequences of high
BP from a health care provider, and only 28% reported
receiving reading material on the effects of hyperten-
sion. Most of the individuals surveyed expressed interest
in information on meal planning/recipes and exercise
ideas. Discussions of these topics are examples of
opportunities for health care providers to engage both
patients and caregivers in conversations about healthy
household cooking and physical fitness and the benefits
of these approaches for the whole family.
Comorbidities are very common in postmenopausal
women with hypertension: data from the Women’s
Health Initiative indicate that >60% of this demo-
graphic also have diabetes, history of myocardial
infarction, heart failure, and/or history of stroke.
15
Consistent with these findings, >80% of the respondents
in the current study had at least one comorbidity. Issues
such as cardiovascular disease, kidney disease, and
diabetes present significant treatment challenges because
patients with these conditions frequently experience
increased resistance to antihypertensive therapy due to
several physiological factors, including increased
sodium retention and RAAS activation. Because indi-
viduals with comorbidities are at higher risk for
cardiovascular complications, more aggressive BP goals
are recommended (130–135/80 mm Hg) than for the
general population (<140/90 mm Hg).
28,35,36
The women surveyed often did not view comorbid-
ities as a serious health threat, however, and expressed a
lack of interest in learning more, especially for diabetes
(53% had a neutral opinion or were not interested in
learning more about diabetes, and 36% viewed diabetes
as no threat or only a small threat to health). Consistent
with this lack of motivation, approximately half the
group never discussed the relationship between BP and
diabetes or the importance of controlling blood sugar
with a health care provider. Patient awareness of the
risks and treatment challenges associated with hyper-
tension and diabetes, along with the potential benefits of
healthy eating habits, can be improved. Of the 25% of
women with self-reported diabetes mellitus, 78% would
not treat hypertension differently if diabetes were not
present and 18% did not know if treatment should
differ. Of further concern, many women with hyper-
tension may have undiagnosed diabetes or prediabetes.
3
Better awareness of these conditions is critical to
improving patient journeys because evidence from the
landmark UK Prospective Diabetes Study has shown
that early, tight, and continuous BP control can signif-
icantly improve outcomes when comorbid diabetes or
impaired fasting glucose are present.
37
Studies published to date on patient journeys have been
limited, providing data from small numbers of research
interviews or focus groups.
21–24,38
The current study,
while limited to 300 respondents, represents the largest
published examination of women’s journeys with hyper-
tension. Results of the current study reinforce themes
observed in other studies of patient journeys with
cardiovascular disease, including the need for patient-
centric communication
24
and the need for health care
providers to understand the social constructs that are
unique to women’s experiences with cardiac disease.
38
STUDY LIMITATIONS
This study had several limitations. First, the sample of
300 respondents from the WomenHeart database is a
highly selective group of women who are otherwise
engaged in heart health and because of this, health
behaviors may be overstated. Further, of 9087 Women-
Heart members surveyed, only 571 women responded
within the 2-week response period, suggesting that the
respondents may have been more at ease with computer
use and attentive to e-mail than the overall WomenHeart
population or hypertensive postmenopausal women in
the general population, which may have influenced the
study results (eg, preferences for receiving information
electronically). Hence, among less engaged or less
assertive women, the results may indicate even greater
barriers to care and BP control. Second, a large propor-
tion of respondents were white, which may limit the
generalizing of these results to other racial and ethnic
groups and to the general population of postmenopausal
women with hypertension. Third, surveys are subject to
multiple sources of error, many of which cannot be
quantified or estimated, such as those associated with
sampling, nonresponse, inaccurate recall, and misunder-
standings of the wording of the questions or response
options. Lastly, BP values were self-reported and relied
on respondent recall—the extent to which these data are
consistent with clinical BP measurements or respondents’
medical records is unknown.
CONCLUSIONS
To the extent to which the survey responses of Wom-
enHeart members can be considered to represent the
accurate recall of typical experiences, this survey
provides insights into common hurdles women may
encounter in their journey through hypertension diag-
540 The Journal of Clinical Hypertension Vol 15 | No 8 | August 2013 Official Journal of the American Society of Hypertension, Inc.
Journeys of Postmenopausal Hypertensive Women | Doner Lotenberg et al.
nosis and treatment. This study highlighted several areas
where health care and educational resources can be
tailored to fit individual needs and preferences. In the
context of the ongoing national and global economic
crisis, it is paramount to maintain a patient-centric
approach to hypertension management and to imple-
ment programs with the intention of comprehensively
assessing and meeting each individual’s needs. These
preliminary findings should foster further research in
this area and reaffirm the need for a careful consider-
ation of each patient’s journey through the hypertension
treatment paradigm and the US health care system.
Acknowledgments: The survey reported here was a research project
conducted by WomenHeart, and funding for the project was provided by
Novartis Pharmaceuticals Corporation. Detailed guidance on the contents of
the manuscript was provided by all authors during a teleconference in April
2012.
Disclosures: The authors would like to thank Cherie Koch, PhD, of Oxford
PharmaGenesis, Inc, for providing editorial assistance, the funding for which
was provided by Novartis Pharmaceuticals Corporation. All authors reviewed
and revised the manuscript critically for intellectual content. All authors
approved the final manuscript submitted for publication.
Author disclosures: L Doner Lotenberg: was a hired consultant of Women-
Heart for the duration of this project; LC Clough: nothing to disclose; TA
Mackey: nothing to disclose; AE Rudolph and R Samuel: employe es and
shareholders of Novartis Pharmaceuticals Corporation; JM Foody: consultant
for Pfizer, Aegerion, Merck, Bristol-Myers Squibb, Sanofi, and Gilead.
References
1. Lima R, Wofford M, Reckelhoff JF. Hypertension in postmenopausal
women. Curr Hypertens Rep. 2012;14:254–260.
2. Health, United States, 2010: with special feature on death and dying.
National Center for Health Statistics. Available at: http://www.cdc.
gov/nchs/data/hus/hus10.pdf. Accessed December 20, 2012.
3. Roger VL, Go AS, Lloyd-Jones DM, et al. Heart disease and stroke
statistics–2012 update: a report from the American Heart Association.
Circulation. 2012;125:e2–e220.
4. Cutler JA, Sorlie PD, Wolz M, et al. Trends in hypertension
prevalence, awareness, treatment, and control rates in United States
adults between 1988-1994 and 1999-2004. Hypertension.
2008;52:818–827.
5. Messerli FH, Williams B, Ritz E. Essential hypertension. Lancet.
2007;370:591–603.
6. Go AS, Mozaffarian D, Roger VL, et al. Heart disease and stroke
statistics—2013 update: a report from the American Heart Associa-
tion. Circulation. 2013;127:e6–e245.
7. Turnbull F, Woodward M, Anna V. Effectiveness of blood pressure
lowering: evidence-based comparisons between men and women.
Expert Rev Cardiovasc Ther. 2010;8:199–209.
8. Lawes CM, Vander Hoorn S, Law MR, et al. Blood pressure and the
global burden of disease 2000. Part II: estimates of attributable
burden. J Hypertens. 2006;24:423–430.
9. Egan BM, Zhao Y, Axon RN. US trends in prevalence, awareness,
treatment, and control of hypertension, 1988-2008. JAMA.
2010;303:2043–2050.
10. Kim JK, Alley D, Seeman T, et al. Recent changes in cardiovascular
risk factors among women and men. J Womens Health (Larchmt).
2006;15:734–746.
11. Centers for Disease Control and Prevention. Vital signs: prevalence
treatment, and control of hypertension–United States, 1999–2002 and
2005–2008. MMWR Morb Mortal Wkly Rep. 2011;60:103–108.
12. Routledge FS, McFetridge-Durdle JA, Dean CR. Stress, menopausal
status and nocturnal blood pressure dipping patterns among hyper-
tensive women. Can J Cardiol. 2009;25:e157–e163.
13. Reckelhoff JF, Fortepiani LA. Novel mechanisms responsible for
postmenopausal hypertension. Hypertension. 2004;43:918–923.
14. Yanes LL, Reckelhoff JF. Postmenopausal hypertension. Am J
Hypertens. 2011;24:740–749.
15. Wassertheil-Smoller S, Anderson G, Psaty BM, et al. Hypertension
and its treatment in postmenopausal women: baseline data from the
Women’s Health Initiative. Hypertension. 2000;36:780–789.
16. Hsia J, Margolis KL, Eaton CB, et al. Prehypertension and cardio-
vascular disease risk in the Women’s Health Initiative. Circulation.
2007;115:855–860.
17. Polotsky HN, Polotsky AJ. Metabolic implications of menopause.
Semin Reprod Med. 2010;28:426–434.
18. Miller NH, Berra K, Long J. Hypertension 2008–awareness, under-
standing, and treatment of previously diagnosed hypertension in baby
boomers and seniors: a survey conducted by Harris interactive on
behalf of the Preventive Cardiovascular Nurses Association. J Clin
Hypertens (Greenwich). 2010;12:328–334.
19. Mozumdar A, Liguori G. Persistent increase of prevalence of
metabolic syndrome among U.S. adults: NHANES III to NHANES
1999–2006. Diabetes Care. 2011;34:216–219.
20. Trebble TM, Hansi N, Hydes T, et al. Process mapping the patient
journey: an introduction. BMJ. 2010;341:c4078.
21. Sloan JA, Scott-Findlay S, Nemecek A, et al. Mapping the journey of
cancer patients through the health care system. Part 2: Methodological
approaches and basic findings. Can Oncol Nurs J. 2004;14:224–232.
22. Oliver S, Bosworth A, Airoldi M, et al. Exploring the healthcare
journey of patients with rheumatoid arthritis: a mapping project –
implications for practice. Musculoskeletal Care. 2008;6:247–266.
23. Manchaiah VK, Stephens D, Meredith R. The patient journey of
adults with hearing impairment: the patients’ views. Clin Otolaryngol.
2011;36:227–234.
24. Bane C, Hughes CM, Cupples ME, McElnay JC. The journey to
concordance for patients with hypertension: a qualitative study in
primary care. Pharm World Sci. 2007;29:534–540.
25. Viera AJ, Cohen LW, Mitchell CM, Sloane PD. Hypertensive patients’
use of blood pressure monitors stationed in pharmacies and other
locations: a cross-sectional mail survey. BMC Health Serv Res.
2008;8:216.
26. Mooney LA, Franks AM. Impact of health screening and education on
knowledge of coronary heart disease risk factors. J Am Pharm Assoc
(2003). 2011;51:713–718.
27. Ahrens RA, Hower M, Best AM. Effects of weight reduction
interventions by community pharmacists. J Am Pharm Assoc
(2003). 2003;43:583–589.
28. Chobanian AV, Bakris GL, Black HR, et al. Seventh report of the
Joint National Committee on prevention, detection, evaluation, and
treatment of high blood pressure. Hypertension. 2003;42:1206–1252.
29. Williams B, Poulter NR, Brown MJ, et al. British Hypertension
Society guidelines for hypertension management 2004 (BHS-IV):
summary. BMJ. 2004;328:634–640.
30. Parati G, Stergiou GS, Asmar R, et al. European Society of Hyper-
tension guidelines for blood pressure monitoring at home: a summary
report of the Second International Consensus Conference on Home
Blood Pressure Monitoring. J Hypertens. 2008;26:1505–1526.
31. Pickering TG, Miller NH, Ogedegbe G, et al. Call to action on use
and reimbursement for home blood pressure monitoring: a joint
scientific statement from the American Heart Association, American
Society of Hypertension, and Preventive Cardiovascular Nurses
Association. Hypertension. 2008;52:10–29.
32. Hypertension. Clinical management of primary hypertension in adults.
NICE clinical guideline 127. National Institute of Health and Clinical
Excellence (NICE). Available at: http://www.nice.org.uk/nicemedia/
live/13561/56008/56008.pdf. Accessed December 20, 2012.
33. Stergiou GS, Bliziotis IA. Home blood pressure monitoring in the
diagnosis and treatment of hypertension: a systematic review. Am J
Hypertens. 2011;24:123–134.
34. Sheikh S, Sinha AD, Agarwal R. Home blood pressure monitoring:
how good a predictor of long-term risk? Curr Hypertens Rep.
2011;13:192–199.
35. Mancia G, De Backer G, Dominiczak A, et al. Guidelines for the
management of arterial hypertension: The Task Force for the
Management of Arterial Hypertension of the European Society of
Hypertension (ESH) and of the European Society of Cardiology (ESC).
Eur Heart J. 2007;28:1462–1536.
36. Bangalore S, Kumar S, Lobach I, Messerli FH. Blood pressure targets
in subjects with type 2 diabetes mellitus/impaired fasting glucose:
observations from traditional and Bayesian random-effects meta-
analyses of randomized trials. Circulation. 2011;123:2799–2810.
37. Parati G, Bilo G, Ochoa JE. Benefits of tight blood pressure control in
diabetic patients with hypertension: importance of early and sustained
implementation of effective treatment strategies. Diabetes Care.
2011;34(suppl 2):S297–S303.
38. Doiron-Maillet N, Meagher-Stewart D. The uncertain journey:
women’s experiences following a myocardial infarction. Can J
Cardiovasc Nurs. 2003;13:14–23.
Official Journal of the American Society of Hypertension, Inc. The Journal of Clinical Hypertension Vol 15 | No 8 | August 2013 541
Journeys of Postmenopausal Hypertensive Women | Doner Lotenberg et al.
