Hypertension and Organ Damage in Women

An adequate cardiovascular (CV) prevention strategy in women should consider the acknowledgement of sex-specific risk factors, such as hypertension in pregnancy, the concomitant presence of autoimmune diseases and the benefit of evaluating subclinical organ damage and treating hypertension. In accordance to current guidelines, the diagnostic approach does not differ between men and women, although the cardiac response to pressure overload may suggest greater sensitivity in women, and may vary according to age, ethnic background and obesity, that potentiates the effect of hypertension on left ventricular (LV) hypertrophy. Several studies have observed peculiar abnormalities in LV systolic and diastolic function according to gender. The possible mechanisms that influence a different cardiac adaptation to chronic pressure overload in men and women are not fully understood, although hormonal status, and in particular the lack of estrogen effects after menopause may contribute to the cardiovascular adaptation response to increased afterload. The increase in LV mass in response to chronic pressure overload is associated with higher LV ejection fraction in women than in men and LV torsion is maintained with aging in women but not in men. Interstitial fibrosis may reduce circumferential shortening and early diastolic strain rate, in the presence of a preserved ejection fraction in women, favoring the development of heart failure with preserved ejection fraction. Changes in aortic stiffness with aging may influence cardiac structural and functional changes. Isolated systolic hypertension reflects an increase in aortic stiffness, is frequent in women and may be associated to a greater development of concentric LVH. The regression of hypertensive LVH is more difficult in women, and residual hypertrophy is more common in women than in men despite effective antihypertensive treatment and blood pressure control. Carotid atherosclerosis has been extensively investigated in men and women, showing that women usually develop carotid plaques after menopause, with smaller and less unstable plaques; however large and/or a hypoechogenic plaques are more strictly related to cerebrovascular events in women than in men. More advanced abnormalities in the subcutaneous microcirculation have been recently observed, and well translate in the evidence of more prevalent coronary microcirculation involvement in women ischemic heart disease. The prevalence of albuminuria and of reduced estimated glomerular filtration rate (eGFR < 60 ml/min/1.73) are respectively lower and higher in postmenopausal women than in men. Experimental data suggest the possible involvement of renin-angiotensin-aldosterone system and of T regulatory lymphocytes to this regard.