Bakgrund
Högt blodtryck är vanligt förekommande, cirka 27% av den vuxna befolkningen i Sverige har högt blodtryck, ungefär lika många kvinnor som män. Hos kvinnor stiger det systoliska blodtrycket efter klimakteriet så att äldre kvinnor har ett högre systolisk blodtryck jämfört med män i samma ålder. Högt blodtryck är en av de starkaste risk-faktorerna för hjärt-kärlsjukdom hos både kvinnor och män. Kvinnor och män verkar ha lika stor nytta av blodtryckssänkande behandling och enligt rådande riktlinjer ska behandlingen ske utan att hänsyn tas till kön. Trots detta behandlas kvinnor och män med olika blodtryckssänkande läkemedel enligt observationella studier. Orsaken till detta är inte klarlagd, men samsjuklighet med hjärt-kärlsjukdom som män oftare har skulle kunna vara en förklaring. Kvinnor får oftare läkemedelsbiverkningar jämfört med män och detta skulle också kunna vara en bidragande orsak. Andra faktorer som skulle kunna påverka förskrivning är psykosociala faktorer som utbildning, födelse-land eller psykisk sjukdom men detta är inte studerat. I olika studier har kvinnor med behandling för högt blodtryck antingen högre eller lika högt blodtryck som män. Hur det ser ut i Sverige idag med uppnådda blodtrycknivåer och målblodtryck i relation till kön är inte helt klarlagt och inte heller vet vi hur det ser ut hos patienter med hjärt-kärlsjukdom eller om psykosociala faktorer påverkar detta.
Syfte
Syftet med avhandlingen var att undersöka det vetenskapliga underlaget för dagens svenska riktlinjer för behandling av måttligt förhöjt blodtryck hos kvinnor och män.
Vidare var syftet att studera uppnådda blodtrycksnivåer och skillnader i läkemedels-behandling mellan kvinnor och män både med nyinsatt och pågående läkemedels-behandling.
Slutligen var syftet att studera vilket infl ytande samsjuklighet med hjärt-kärlsjukdom och psykosociala faktorer (utbildning, födelseland och psykisk sjukdom) har på blod-trycksbehandling hos kvinnor och män.
Resultat
Kvinnors deltagande i studier som gäller högt blodtryck har ökat med åren. I delarbete I fann vi två stora studier där blodtryckssänkande behandling med kalciumfl ödes-hämmare sänker blodtrycket bättre än med ACE-ödes-hämmare och angiotensinreceptor-blockerare. Detta var tydligast hos kvinnor. Likaså verkar kalciumfl ödeshämmare minska risken för stroke och större hjärt-kärlhändelse mer än ACE-hämmare och angiotensinreceptor-blockerare och detta var tydligast hos kvinnor. I delarbete II stu-derades 332 män och 334 kvinnor i en studie i primärvården på patienter med nyinsatt behandling för högt blodtryck. Det fanns inga skillnader mellan kvinnor och män i systoliskt blodtryck före och efter behandling, däremot hade kvinnor ett lägre dias-tolisk blodtryck innan och efter behandling. Det skiljde inte heller i tid till uppnått målblodtryck mellan kvinnor och män. I delarbete III och IV inkluderades 40 825 patienter i primärvården med pågående blodtrycksbehandling. Hos patienter över 69 år hade kvinnorna ett högre systolisk blodtryck överhuvudtaget och i samtliga grupper
med samsjuklighet i hjärt-kärlsjukdom. Kvinnor uppnådde målblodtryck (<140/90 mm Hg) mer sällan än männen. Kvinnor behandlades oftare med vätskedrivande lä-kemedel och betablockerare medan männen oftare behandlades med ACE-hämmare och kalciumfl ödeshämmare. Även hos patienter med diabetes, ischemisk hjärtsjuk-dom och tidigare stroke behandlades männen oftare med ACE-hämmare. Män hade oftare provat ACE-hämmare eller angiotensinreceptor-blockerare men slutat, jämfört med kvinnorna. Utbildningsnivå, födelseland eller psykisk sjukdom påverkade inte förskrivningen av ACE-hämmare och kalciumfl ödeshämmare till männen. I gruppen med högst utbildningsnivå förskrevs inte vätskedrivande läkemedel och betablock-erare oftare till kvinnorna vilket talar för att förskrivningsmönstret till viss del påver-kas av utbildningsnivån hos patienten. Faktorer som påverkar uppnått målblodtryck skiljer till viss del mellan kvinnor och män. Hos kvinnor var högre utbildningsnivå och psykisk sjukdom associerat med uppnått målblodtryck.
Slutsats
Kvinnor och män behandlas med olika blodtryckssänkande läkemedel och detta för-klaras inte helt av skillnader i samsjuklighet med hjärt-kärlssjukdom. Kvinnor med högt blodtryck och diabetes behandlas inte lika ofta med ACE-hämmare eller angio-tensinreceptor-blockerare som män med högt blodtryck och diabetes. Kvinnor når målblodtryck mer sällan än männen och har ett högre systoliskt blodtryck i samtliga grupper med hjärt-kärlsjukdom jämfört med männen. Högre utbildningsnivå och psy-kisk sjukdom är associerat med uppnått målblodtryck hos kvinnor. Riskbedömning och behandling av kvinnor med högt blodtryck och hjärt-kärlsjukdom behöver för-bättras.
ACKNOWLEDGEMENT
Karin Manhem my supervisor and good friend. Thank you for your support, knowl-edge and inspiration in science. Thank you for believing in me, my ideas and giving my both freedom and structure in the complicated fi eld of research.
Thomas Kahan my co-supervisor. Thank you for your great scientifi c knowledge and for sharing your expertise in writing scientifi c articles.
Professor Annika Rosengren, assistant head of Institute of Medicine, Department of Molecular and Clinical Medicine/Östra, thank you for resources and good advice in epidemiological studies.
Björn Wettermark, Kristina Bengtsson Boström, Per Hjerpe, Jan Hasselström, mem-bers of the steering committee in the SPCCD. Thank you all for cooperating in the sometimes rather complicated work building a database. I am thankful for your scien-tifi c comments and expertise.
Per Albertsson, head of Cardiology Sahlgrenska university hospital for time off clini-cal work and Bert Andersson and Bengt Rundqvist for introducing me to the world of renal denervation.
Linus Schiöler, statistician and coauthor, thank you for your expertise in SAS and teaching me everything essential about statistical models.
Eva Thydén for great secretarial skills and with the process and layout of this book.
My good friends and colleagues Anna-Clara Collén, Lina Holmqvist and Lena Mortensen who made this so much more fun.
Former colleagues at Sahlgrenska university hospital/Östra and colleagues at the de-partment of Cardiology at Sahlgrenska university hospital, thank you for making time at work stimulating.
To all friends outside the hospital and especially Pia Eckerstein and Lisa Rosenblad for your friendship.
Monica and Lars-Gunnar, my mother and father for your love and for letting me know that everything is possible.
My sister and good friend Camilla Ljungman with family for always being there.
Anders my husband for your love and support. Albert and Axel, our sons for all your love. ♥
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