Considerations for initial therapy based on gender
Men and women appear to benefit equally with more intensive control of blood pressure in reducing the risk for cardiovascular end points. Men appear to have decreased resting heart rate, longer left ventricular ejection fraction time, and increased pulse pressure when stressed, compared with women. Women tend to have reduced total peripheral resistance and greater blood volume compared with men. Women have a lesser likelihood of coronary disease before menopause.
Table Consideration for Initial Therapy
| Pathophysiology | Desirable pharmacologic approach” |
| Men have J, resting HR, longer LVEF time, f stressed pulse, pressure compared to women | Use vasodilator (e.g., hydrochlorothiazide, angiotensin-converting enzyme inhibitor, ARB, calcium channel blocker). |
| Women have J, TPR and f blood volume compared to men. | Use vasodilator, heart rate reduction, less need for diuresis (hydrochlorothiazide, angiotensin-converting enzyme inhibitor, ARB, β-blocker, calcium channel blocker). |
| Postmenopausal women more frequently have coronary artery disease with atypical chest pain. | Use an antianginal; reduce heart rate (β-blocker, calcium channel blocker). |
| Osteoporosis. | Antagonize calciuria (hydrochlorothiazide). |
| Pregnancy. | Avoid teratogenic drugs (angiotensin-converting enzyme inhibitor, ARB). Avoid drugs that may delay labor (calcium channel blocker). Avoid drugs that may cause ureteroplacental insufficiency (loop diuretics). Optimal choices: alphamethyldopa, hydralazine, P-blocker. |
| Women report more pedal edema with calcium channel blocker and cough with ACEI than men. | Adjust medications if these symptoms are present. |
However, once menopause occurs, women rapidly develop coronary disease and more frequently present with atypical chest pain. Osteoporosis is also more frequent in women in the postmenopausal period.
The choice of an initial therapy should be based on the need for vasodilation as well as treatment of attendant comorbidities. Vasodilators such as hydrochlorothiazide, angiotensin-converting enzyme inhibitors, angiotensin type 1 receptor Mockers, and calcium channel blockers are reasonable choices. Many patients will require two or more of these drugs classes in order to facilitate more intensive blood pressure reduction. With concomitant coronary disease, an approach to lower antianginal heart rate with a β-blocker or nondihydropyridine calcium channel blocker could be used. In patients with diabetes and or renal disease, angiotensin-converting enzyme inhibitors, angiotensin type 1 receptor blockers, or nondihydropyridine calcium channel blockers could be used alone or in combination.
Women should avoid the use of drugs such as angiotensin-converting enzyme inhibitors and angiotensin type 1 receptor blockers in pregnancy because of their possible teratogenic effects. Similarly, calcium channel blockers may delay labor.
Table Considerations for Initial Therapy in African-American Patients
| Pathophysiology | Desirable pharmacologic approach |
| High peripheral vascular resistance with associated reduction in cardiac output | Use a vasodilator (e.g., hydrochlorothiazide, angiotensin-converting enzyme inhibitor, calcium channel blocker, ARB). |
| Salt sensitivity | Use natriuresis (hydrochlorothiazide, angiotensin-converting enzyme inhibitor, ARB, calcium channel blocker). |
| Variable blood volume (perhaps greater in some patients relative to f PVR) | Use natriuresis, diuresis (hydrochlorothiazide; if creatinine >2.0, loop diuretic). |
Optimal choices would remain alphamethyldopa, hydralazine, or a β-blocker under these circumstances. In women with osteoporosis, hydrochlorothiazide is the ideal agent because it antagonizes calciuria and facilitates bone mineralization. Women note more pedal edema with calcium channel blockers and a cough with angiotensin-converting enzyme inhibitors compared with men. These differences in side effects may be less apparent if lower doses of these medications are employed, particularly in concert with other medications. Despite underlying pathophysiologic differences between genders, there do not appear to be any specific differences in response rates to commonly used antihypertensive drugs.
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