High blood pressure: an invisible danger (especially for women)

Hypertension, the "silent killer": According to the global hypertension report by the World Health Organisation (WHO) from September 2023, one in three adults suffers from high blood pressure - and of those affected, four out of five are not treated adequately. They may not even be aware of their condition. This is because hypertension comes without symptoms, at least initially.

However, permanently high pressure damages the blood vessels: hypertension is considered the biggest risk factor for cardiovascular disease, which is the leading cause of death in Switzerland. Just like in Germany and Austria. However, according to projections, half of all heart attacks and strokes could be avoided if high blood pressure was recognised and treated in good time.

Statistically, men are affected by high blood pressure slightly more often than women. However, mainly at a younger age. In women, hypertension usually only occurs after the menopause. And then the ratio reverses: From around the age of 65, women are statistically more likely to be affected than men.

Hypertension should be considered from a gender-sensitive perspective, says Prof Dr Burkhard Sievers. He is Chief Physician at the Clinic for Cardiology, Angiology, Pneumology, Nephrology and Intensive Care Medicine at the Sana Clinic in Remscheid and owner of the private practice Cardiomed24 in Meerbusch near Düsseldorf. In this interview, he tells me what is important to know about high blood pressure - for both men and women.

**The WHO warns that high blood pressure is a "silent killer". At what levels does it become critical? **

**Prof Dr Sievers: **There is an upper and a lower value and both values describe the elasticity of the blood vessels and also define the limits of high blood pressure. Normal blood pressure is usually well below 140 to 90 mmHg (millimetres of mercury, a unit of measurement for pressure, the ed.). On average, however, if a 24-hour blood pressure measurement is carried out, for example, it should be below 135 to 85 during the day and below 120 to 75 at night. Mind you, these are the limit values. If you visit your GP and measure a blood pressure that is around 140 over 90, it will be measured two or three more times at different times. If the values remain the same, a long-term measurement over 24 hours is recommended. The average values can then be used to assess whether or not you have high blood pressure.

Assuming there is a disease. What should you do first?

The first thing we advise is a lifestyle change, which means integrating nutrition and endurance sports into everyday life and giving up smoking and drinking. If this is not enough, drug therapy is recommended. Personally, however, I take a slightly different approach because I know from experience: Changing your lifestyle is often not that easy. If the values are in favour of treatment, I therefore recommend mild blood pressure medication in parallel with the lifestyle change. In this way, you have not done nothing at all for several months or even years, which a lifestyle change like this can sometimes take, and left the patient untreated. With this parallel approach, the medication is constantly scrutinised, so the dose is reduced, increased or even discontinued if there are signs of improvement. It really depends on the discipline of each individual.

**You mentioned standard and limit values for high blood pressure. Are these values the same for men and women? **

That's a good question. Let me answer it first with the results of the Deutsche Hochdruckliga e.V. and the European Society of Hypertension and all the committees that deal with it: In the current guidelines, there is no gender-specific distinction in the definition of blood pressure limits. There is therefore no distinction between men and women or between different people, but - regardless of how tall or short someone is, or how much muscle mass he or she has - the same limits always apply. However, some studies have now shown that Women would benefit from having lower blood pressure than men. For women, the threshold value is more likely to be set at 120 over 80 instead of 140 over 90. And we also know from these studies that the complication rate, i.e. permanent damage such as strokes, heart attacks and heart failure, can be significantly reduced in women if their blood pressure is lower than 120 to 80.

So women with hypertension need to be medicated sooner and differently?

Yes exactly, in women you would start earlier with lifestyle changes, endurance sports, dietary changes and also drug therapy, already at values of over 120 to 80. In current guidelines and in general medical understanding, these are still completely normal blood pressure values at which it would not previously have occurred to take action or even prescribe medication. However, studies suggest that even at lower systolic blood pressure values (above 120 mmHg), women have a comparable risk of permanent damage to their health as men at higher systolic blood pressure values.as men with higher systolic blood pressure values (greater than 160 mmHg for the risk of heart attack and greater than 140 mmHg for the risk of stroke).

So you shouldn't lump men and women together and define the same threshold values. German, European and American guidelines are still lagging behind in this respect. Nevertheless, there are advantages in the USA: the American health authorities do not differentiate between men and women, either in terms of treatment or the definition of threshold values. However, they recommend starting treatment from a value of 130 to 80, so women are theoretically better off in the USA because treatment is started earlier there.

**Does research know where these differences come from? **

Hormones play an important role in gender medicine in particular. There is a lot of focus on female sex hormones, but also on the changes in male sex hormones over the course of a lifetime. The fact is that women are protected against cardiovascular disease for a long time by oestrogen. This works well until the menopause. Because oestrogen levels, i.e. the female sex hormones, then "plummet" and are only present to a small extent, the protective effect is then lost and women rapidly catch up with men in terms of their vulnerability to cardiovascular disease. And then, of course, there are risk factors such as stress, predisposition, diabetes, etc. For women, there is often the additional burden of children and family.

Hypertension often goes undetected because it is asymptomatic at the beginning. Later on, it can lead to symptoms such as dizziness, headaches or sleep disorders. Are there also gender-specific differences in the symptoms?

You have mentioned some of the main symptoms, but here too it is important to emphasise the difference between the sexes. This is because women often do not categorise these often uncharacteristic, chameleon-like symptoms correctly - and ignore them or play them down.

Other symptoms include, for example, general nervousness, agitation and reduced resilience. These are all symptoms that do not necessarily indicate high blood pressure. The basic rule is therefore: if you suddenly have symptoms that you did not have before, you should not take them lightly. The aim is to recognise and treat high blood pressure at an early stage in order to prevent or delay more complex damage.

By the way: cardiovascular and vascular diseases can also trigger vascular dementia. There are forms of dementia that are caused by calcified, constricted or rigid blood vessels, which is often due to high blood pressure that has been inadequately treated over many years.

What medication is used to treat high blood pressure?

A total of seven or eight medications are available, which can also be combined with each other in cases of severe high blood pressure. Initially, drug therapy starts with one, usually two medications. The approach should always be individualised.

What must medicine pay particular attention to when treating women and men?

Women obviously need around 30 to 40 per cent less of at least many medications to achieve their full effect. This would also have the advantage of a lower rate of side effects. This is around 30 per cent higher in women than in men. This means that women are probably currently very often given too high a dose. And this in turn can lead to them stopping the medication due to the side effects and saying: "I won't take it any more". With the result that the disease remains untreated and the prognosis worsens.

**Are these the results of the so-called gender data gap, i.e. the fact that a lot of research has been done on men and not on women? Is there already a general rethink towards gender-equitable medicine? **

It's true: In medicine, the individual should always be considered alongside gender. Considering gender alone does not do justice to the complexity. So you always look at the person in front of you first. Is the person tall or short, does he or she have a lot or little body fat, a high muscle mass or not? The dose of medication is then based on this. To come back to the topic, when doctors prescribe high blood pressure for women, they usually prescribe the dose recommended in the package leaflet. And there is a certain range. However, it is important to know that even if the lower initial dose is used as a guide, this can often be too high for women.

With what consequences?

Many patients then come back complaining of fatigue, coldness, poor performance and dizziness; in some cases, this can even lead to collapse. The common conclusion: the medication is not tolerated, although it was actually due to the dose. For this reason, the dosage for women with hypertension must be approached slowly and the person, i.e. the patient, must be considered holistically. And even if, according to the official guidelines, there are no gender-specific differences in high blood pressure, neither for the normal blood pressure values nor for the blood pressure limits above which treatment is recommended: It obviously makes sense to treat women a little earlier in order to achieve a target blood pressure of less than 120 to 80 mmHg.