Hypertension and Its Treatment in Postmenopausal Women: Baseline Data from the

Women's Health Initiative

Sylvia Wassertheil-Smoller, Garnet Anderson, Bruce M. Psaty, Henry R. Black, JoAnn Manson,
Nathan Wong, Jon Francis, Richard Grimm, Theodore Kotchen, Robert Langer and Norman
Lasser

Hypertension. 2000;36:780-789
doi: 10.1161/01.HYP.36.5.780
Hypertension is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231
Copyright © 2000 American Heart Association, Inc. All rights reserved.
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 Hypertension and Its Treatment in Postmenopausal Women
Baseline Data from the Women’s Health Initiative
Sylvia Wassertheil-Smoller, Garnet Anderson, Bruce M. Psaty, Henry R. Black, JoAnn Manson,
Nathan Wong, Jon Francis, Richard Grimm, Theodore Kotchen, Robert Langer, Norman Lasser

Abstract—Little is known about the patterns of treatment and adequacy of blood pressure control in older women. The
Women’s Health Initiative, a 40-center national study of risk factors and prevention of heart disease, breast and
colorectal cancer, and osteoporosis in postmenopausal women, provides a unique opportunity to examine these issues
in the largest, multiethnic, best-characterized such cohort. Baseline data from the initial 98 705 women, aged 50 to 79
years, enrolled were analyzed to relate prevalence, treatment, and control of hypertension to demographic, clinical, and
risk-factor covariates, and logistic regression analyses were performed to estimate odds ratios after adjusting for multiple
potential confounders. Overall, 37.8% of the women had hypertension, which is defined as systolic blood pressure
ⱖ140 mm Hg and/or diastolic blood pressure ⱖ90 mm Hg or being on medication for high blood pressure; 64.3% were
treated with drugs, and blood pressure was controlled in only 36.1% of the hypertensive women, with lower rates of
control in the oldest group. After adjustment for multiple covariates, current hormone users had higher prevalence than
did nonusers (odds ratio 1.25). Hypertensive women had more comorbid conditions than did nonhypertensive women,
and women with comorbidities were more likely to be treated pharmacologically. Diuretics were used by 44.3% of
hypertensives either as monotherapy or in combination with other drug classes. As monotherapy, calcium channel
blockers were used in 16%, angiotensin-converting enzyme inhibitors in 14%, ␤-blockers in 9%, and diuretics in 14%
of the hypertensive women. Diuretics as monotherapy were associated with better blood pressure control than any of
the other drug classes as monotherapy. In conclusion, hypertension in older women is not being treated aggressively
enough because a large proportion, especially those most at risk for stroke and heart disease by virtue of age, does not
have sufficient blood pressure control. (Hypertension. 2000;36:780-789.)
Key Words: hypertension, essential 䡲 age 䡲 antihypertensive agents 䡲 blood pressure 䡲 women
䡲 Women’s Health Initiative (WHI)

H ypertension is a major risk factor for stroke and heart
disease among both men and women. Although com-
pared with men, women aged ⬍55 years tend to have lower
prevalence rates of hypertension, women aged 55 to 74 years
have similar rates, and those aged ⬎75 years have higher
rates. Blacks have higher rates of hypertension than do whites
for both genders1 Control of hypertension has been shown to
reduce the risk of stroke or death in older as well as in
younger persons and in those with stage I (or mild) hyper-
tension.2– 4 Nevertheless, as reported in the 6th Joint National
Committee (JNC) Report in 1997, data from the National
Health and Nutrition Examination Survey (NHANES), Phase
II, for 1991 to 1994 indicate that only 54% of hypertensives
were under treatment and that only 27% of hypertensives had
their hypertension under control among those aged 18 to 74
years.5 Treatment and control rates are worse for those ⬎75
years. However, little is known about the differences in
prevalence, treatment, and control rates among postmeno-
pausal women in various demographic and clinical sub-
groups. In both the 5th and the 6th JNC Reports,1,5 diuretics
and ␤-blockers are suggested as first-line drugs in uncompli-
cated hypertension; calcium channel blockers and angioten-
sin-converting enzyme (ACE) inhibitors are also listed as
first-line drugs for certain indications.1 Nevertheless, there
continues to be disagreement with regard to the type of drugs
to be used as initial therapy. Some data suggest that calcium
channel blockers may be associated with an excess of
morbidity and mortality,6,7 although a recent report indicated
benefit for those aged ⬎60 years with isolated systolic
hypertension.8 The pattern of use of antihypertensive drugs is

Received January 11, 2000; first decision February 17, 2000; revision accepted March 28, 2000.
From The Albert Einstein College of Medicine (S.W.-S.), Bronx, NY; the Fred Hutchinson Cancer Research Center (G.A., J.F.), Seattle, Wash; the
University of Washington (B.M.P.), Seattle; Rush Presbyterian St. Luke’s Medical Center (H.R.B.), Chicago, Ill; Brigham and Women’s Hospital (J.M.),
Harvard Medical School, Boston, Mass; the Heart Disease Prevention Program (N.W.), University of California, Irvine; the University of Minnesota
Medical School (R.G.), Minneapolis; the Medical College of Wisconsin (T.K.), Milwaukee; the University of California at San Diego (R.L.), La Jolla;
and the University of Medicine and Dentistry of New Jersey (N.L.), Newark.
Correspondence to Sylvia Wassertheil-Smoller, PhD, Department of Epidemiology and Social Medicine, The Albert Einstein College of Medicine,
1300 Morris Park Ave, Room 1312 Belfer, Bronx, NY 10461. E-mail smoller@aecom.yu.edu
© 2000 American Heart Association, Inc.
Hypertension is available at http://www.hypertensionaha.org

780
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 Wassertheil-Smoller et al
not known among older women in different race/ethnic
groups, nor are the drug use patterns known in relation to
comorbid conditions, such as diabetes, hypercholesterolemia,
heart failure, and obesity.
The present study describes factors associated with the
prevalence, treatment, and control of hypertension as well as
the use of specific classes of antihypertensive drugs in older
women enrolled in the 40 centers of the Women’s Health
Initiative (WHI) across the United States. WHI is a multi-
center study of US women aged 50 to 79 years consisting of
overlapping clinical trials (CTs) and an observational study
(OS). The CT component tests 3 interventions (hormone
replacement therapy, a low fat diet, and calcium and vitamin
D supplements) on multiple end points, including cardiovas-
cular disease, cancer, and osteoporotic fractures. The OS,
conducted in parallel, is a long-term prospective cohort study
to identify and assess the impact of biological, lifestyle,
biochemical, and genetic factors on the risk of heart disease,
cancer, osteoporosis, and other major health events. The
present report uses baseline data obtained from the initial
98 705 women enrolled (43 427 in the CTs and 55 278 in the
OS) from September 1993 through the end of February 1997.
The questions addressed in this report are as follows: (1)
What is the prevalence of hypertension among different
subgroups of postmenopausal women? (2) How is hyperten-
sion treated in older women in the late 1990s, and how does
the treatment correspond to the national guidelines promul-
gated by the JNC on Prevention, Detection, Evaluation, and
Treatment of High Blood Pressure? (3) How adequately is
blood pressure controlled in postmenopausal women?
Methods
Women aged 50 to 79 years, who gave written informed consent,
were recruited into the WHI at 40 clinical centers in the United
States, mostly through mass mailings to age-eligible women from
large mailing lists, such as voter registration, driver’s license, and
Health Care Financing Administration (HCFA) or other insurance
lists. Recruitment of minorities and older women was a particular
study objective. Details of the WHI design are reported elsewhere.9
Women were either specifically recruited for the OS or entered it
because they were ineligible or unwilling to be randomized into the
CTs. Exclusions were participation in other randomized trials,
predicted survival of ⬍3 years, alcoholism, drug dependency, mental
illness, dementia, or other conditions making them unable to partic-
ipate in the study. Women with systolic blood pressure (SBP)
⬎200 mm Hg or diastolic blood pressure (DBP) ⬎105 mm Hg were
excluded from the CTs and were told to see their physician but were
eligible for the OS. The results reported in the present study combine
baseline data from women in all WHI components. Of the 98 705
women enrolled, 7411 were excluded from analyses because of early
changes in the data collection forms so that the definition of
hypertension could not be strictly applied. An additional 539 women
had missing data on hypertension status. Thus, 90 755 women
remained whose hypertension and treatment status could
be determined.
Blood pressure was measured at the first screening clinic visit by
certified staff with the use of standardized procedures and instru-
ments; it was measured in the right arm with a conventional mercury
sphygmomanometer after the participant was seated and had rested
for 5 minutes before the blood was drawn or a minimum of 30
minutes after the blood was drawn. The cuff, of appropriate size
based on arm measurement, was inflated to 30 mm Hg above
palpated SBP. SBP was defined as the pressure level at which the
first of ⱖ2 knocking sounds occurred in appropriate rhythm. DBP
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Hypertension in Postmenopausal Women 781
was phase V Korotkoff value (disappearance of sound). The average
of 2 readings, obtained at least 30 seconds apart, was used for
analysis.
Women were asked to bring all of their prescription medications,
currently used over-the-counter medications, and vitamins and min-
erals in their original bottles to the baseline visit. The product or
generic name, dosage, form, and strength of the medications were
transcribed from the label into the study computer database and
matched to the corresponding item in a pharmacy database: the
Master Drug Data Base (Medi-Span). This database includes drug
names (both brand and generic), national drug codes, and a thera-
peutic class code provided by the American Hospital Formulary
Service for both prescription and over-the-counter products. The
study-wide computer system was updated approximately every
quarter with a new pharmacy database to ensure completeness of the
list of available products.
Hypertensives were defined as those who reported that they were
told by a doctor that they had high blood pressure and that they were
currently taking medicine for their hypertension and/or they had a
clinic blood pressure of SBP ⱖ140 mm Hg and/or DBP
ⱖ90 mm Hg. Women who reported a diagnosis of hypertension but
did not report that they were currently on blood pressure medications
and did not have elevated pressures at the visit were classified as
unconfirmed hypertensives and were omitted from analyses of
hypertensives. Those having neither a physician diagnosis nor
elevated pressures constituted the remainder and were considered
normotensives. Treated hypertensives were those among the hyper-
tensives who responded yes to the following question: Do you now
take pills for high blood pressure? Controlled hypertensives were
those whose clinic blood pressures were SBP ⬍140 and DBP
⬍90 mm Hg. Over 85% of women who reported taking drugs for
hypertension provided medications at their baseline visit that fell into
one of the drug class categories. Past smokers were those who had
ever smoked at least 100 cigarettes but did not currently smoke. Past
drinkers were those who had ever had at least 12 alcoholic beverages
in their life but did not currently drink. Current drinkers were further
classified by current alcohol intake, based on the sum of beer, wine,
and liquor intake adjusted for portion size from a semiquantitative
food frequency questionnaire. Physical activity was assessed by
questions regarding the frequency and duration of walking at various
intensities and 3 other types of recreational activity classified by
intensity (strenuous, moderate, or light). These data were summa-
rized into episodes per week of moderate or strenuous activity (as
defined by a MET score of at least 4.0 as indicated by Ainsworth et
al10) of at least 20-minute duration. Women reporting some recre-
ational activity but of shorter duration and/or lesser intensity were
classified as those having “some activity.”
Other cardiovascular disease risk factors included history of
myocardial infarction (MI) in a first-degree relative, diabetes, obe-
sity, and hypercholesterolemia. Women were considered overweight
if their body mass index (BMI) exceeded 27.3 kg/m2. Pharmacother-
apy for hyperlipidemia was defined by self-report of current use of
medications for high cholesterol. Blood samples drawn at baseline
were frozen and sent to a central biological repository for future
nested case-control studies, and blood lipids were not analyzed at
baseline. Diabetes was defined as a physician diagnosis plus self-
reported use of insulin or oral medication. Other comorbid condi-
tions (MI, stroke, and heart failure) were defined on the basis of the
participant’s report of physician diagnosis.
The rates of prevalence, treatment, and control of hypertension are
presented for levels of the categorical variables of interest. For
bivariate analyses, women with missing values for other variables
were omitted only for the corresponding variable. Because these
results are primarily descriptive in nature and because the large
sample size would result in statistical significance for minor associ-
ations, statistical levels of significance are not generally shown.
Logistic regression analyses, with adjustment for covariates, were
conducted to describe factors related to prevalence, treatment, and
control of hypertension. Unconfirmed hypertensives were excluded
from these analyses. Independent variables were demographic fac-
tors, health behaviors, comorbid conditions, and other cardiovascular
782 Hypertension November 2000

disease risk factors. Prevalence models were run on the entire sample TABLE 1. Hypertension Status Among WHI Women
(excluding unconfirmed hypertensives). Regression models to deter-
mine factors associated with treatment were run on the sample of n %
hypertensive women, excluding those with missing data on treat- Prevalence of hypertension
ment. Models to explore the factors associated with control of
Normotensive 52 765 58.1
hypertension among the hypertensive women (excluding those with
missing data on control) also included drugs used from the medica- Unconfirmed Hypertensive 3 651 4.0
tion inventory. Hypertensive 34 339 37.8
Age, BMI, and waist-to-hip ratio were modeled as continuous
Self-report, confirmed with medication 12 406 36.1
variables. For BMI, a second-order term was included. Indicator
variables for clinical center were included to account for site-specific Elevated BP 12 243 35.7
variation (not shown). Missing values for categorical variables were Both 9 690 28.2
modeled as an additional level for each variable (not shown).
Total 90 755
Participants with missing values for the continuous values were
omitted from the multivariate analyses (n⫽962 for the prevalence Treated hypertensive
model). The results are presented as odds ratios (ORs), adjusted for No 11 930 34.8
covariates, with 95% CIs and 2-sided probability values based on
Yes 22 096 64.3
Wald statistics.11 All analyses were conducted by use of Statistical
Analysis Software (SAS Institute). Missing treatment information 313 0.9
Total 34 339
Results Controlled hypertensive
Baseline characteristics of the cohort (not shown) indicate No 21 933 63.9
that the cohort was 84% white, 9% black, 3% Hispanic Yes 12 383 36.1
(predominantly Mexican), and 4% other. Forty percent were Missing clinical BP information 23 0.1
aged 50 to 59 years, 40% were aged 60 to 69 years, and 20% Total 34 339
were aged 70 to 79 years. Seventy-seven percent had some
Prevalence of isolated systolic
education beyond high school, with 40% having a college
clinic BP elevations
degree or higher. Thirty-six percent had a family income of
ⱖ$50 000. Approximately 50% never smoked, and only 7% DBP ⬍90 and SBP ⱖ140 mm Hg
were current smokers. Forty-two percent were current hor- No 75 349 82.6
mone users; 46% were overweight (with a BMI ⬎27.3 Yes 15 821 17.4
kg/m2). DBP ⬍90 and 140ⱕSBP⬍160 mm Hg
The overall prevalence of hypertension was 37.8% (Table No 78 117 85.7
1). An additional 4.0% reported that they had hypertension Yes 13 053 14.3
but were not on medication and had normal clinic blood DBP ⬍90 and SBPⱖ160 mm Hg
pressures. This group of women was not included among
No 88 402 97.0
those defined as hypertensives. Among the 34 339 hyperten-
Yes 2 768 3.0
sives, 64.3% reported current use of antihypertensive drugs.
However, only 36.1% of the hypertensives had their blood BP indicates blood pressure.
pressures controlled to the level of SBP ⬍140 and DBP
⬍90 mm Hg. The mean⫾SD blood pressures by hypertensive lower socioeconomic status, as indicated by lower education
status, expressed as SBP/DBP, were as follows: 117⫾11.5/ and income levels.
72⫾7.7 mm Hg for normotensives; 125⫾9.7/76⫾7.5 for Overall, prevalence of hypertension was substantially
unconfirmed hypertensives; 141⫾16.9/81⫾10.3 for all hy- higher (48.0%) among the overweight (BMI ⬎27.3) than
pertensives; 137⫾17.8/78⫾9.7 for all treated hypertensives; among those not overweight (29.3%), and the same relation-
and 125⫾9.7/75⫾7.9 for controlled hypertensives. At the ship held within each category of smoking status. Among the
baseline clinic examination, 17.4% had elevations of SBP at nonoverweight, prevalence essentially did not vary by smok-
the clinic visit, with DBP ⬍90 and with SBP predominantly ing status, although among the overweight, there was a
between 140 and 160 mm Hg. Some of these women were on slightly lower prevalence in current smokers than in those
antihypertensive treatment; thus, they do not represent true who had never smoked (40.3% versus 49.6%). Alcohol
isolated systolic hypertension because some may have had consumption showed a U-shaped relationship with preva-
pretreatment elevations of DBP. They do, however, represent lence, with 46.2% of nondrinkers having hypertension com-
a group with inadequately controlled SBP in the presence of pared with 31.6% of those who reported drinking between 1
normal DBP. and 7 alcoholic beverages per week and 35.6% of those
drinking ⱖ7 alcoholic beverages per week. There was a
Factors Associated With Varying Prevalence Rates dose-response relationship between physical activity and
Prevalence rates varied by subgroups (Table 2). Older women prevalence, ranging from 45.3% among those with no mod-
(aged 70 to 79 years) had twice the prevalence rate (53.4%) erate or strenuous activity to 31% for those with ⱖ4 such
of women aged 50 to 59 years (26.7%). Prevalence was episodes per week. Persons with any one of the cardiovascu-
higher in blacks than in whites or in Hispanics (59.3% versus lar risk factors of family history of MI, high cholesterol, or
35.5% in whites and 33.4% in Hispanics) and in those with diabetes or a history of MI, heart failure, or stroke had

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 Wassertheil-Smoller et al Hypertension in Postmenopausal Women 783

TABLE 2. Rates of Hypertension Prevalence, Treatment, and Control by Subgroups

% of Prevalent % of Prevalent
Group % of Group Total Hypertensives Hypertensives
Total, Who Are Who Are Who Are
n Hypertensives Treated Controlled
Total 90 755 37.8 64.3 36.1
Demographic
Age, y
50–59 35 927 26.7 64.2 41.3
60–69 36 591 41.0 65.1 37.1
70–79 18 237 53.4 63.2 29.3
Race/ethnicity
White/non-Hispanic 75 931 35.5 62.7 35.9
Black 7 991 59.3 75.6 40.5
Hispanic 2 974 33.4 59.4 30.2
Asian 2 309 43.8 61.6 27.4
Other 1 550 42.0 63.1 32.0
Insurance type
No insurance 3 429 33.4 54.9 30.0
Prepaid private only 27 009 32.7 65.2 39.1
Other private only 22 847 30.3 63.2 38.9
Medicare only 5 196 49.6 63.9 31.6
Medicaid only 374 52.9 80.8 43.9
All other combinations 26 093 46.3 65.6 34.3
Health behaviors and cardiovascular disease risk factors
Smoking/obesity
Never smoked
Nonoverweight 24 399 29.7 57.1 30.8
Overweight 20 349 49.6 68.7 37.8
Past smoker
Nonoverweight 20 332 28.9 58.5 32.2
Overweight 17 565 47.1 70.0 40.8
Current smoker
Nonoverweight 3 841 28.0 59.7 36.7
Overweight 2 557 40.3 65.2 42.9
Alcohol
Nondrinker 9 304 46.2 65.7 33.4
Past drinker 16 595 44.6 70.0 38.7
Drink ⬍1 beverage/mo 11 248 38.6 63.6 36.8
Drink ⬍1 beverage/wk 18 589 36.1 63.4 37.0
Drink 1–⬍7 beverages/wk 23 681 31.6 62.1 35.8
Drink ⱖ7 beverages/wk 10 764 35.6 58.9 32.3
Moderate or strenuous activity 90 181
No activity 17 643 45.3 68.2 38.2
Some activity 32 453 39.9 65.0 35.5
ⱕ2 episodes/wk 16 245 35.4 63.0 36.1
ⱖ4 episodes/wk 24 089 31.0 60.4 34.8

markedly higher rates of hypertension than did those without
such risk factors.
Current hormone users had lower prevalence (34.9%) than
did those who had never used hormones (40.5%) in bivariate
analyses. However, because current hormone users compared
with those who had never used hormones were younger (aged
60.8 versus 63.5 years) and thinner (BMI 26.9 versus 28.8),
confounding may have influenced the bivariate findings.
When age, BMI, and waist-to-hip ratio were included in a
logistic regression analysis, which also adjusted for educa-

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784 Hypertension November 2000

TABLE 2. Continued
% of Prevalent % of Prevalent
Group % of Group Total Hypertensives Hypertensives
Total, Who Are Who Are Who Are
n Hypertensives Treated Controlled
Hormone use
Never used hormones 29 446 40.5 63.2 34.3
Past hormone user 20 556 39.8 64.0 34.7
Current hormone user 39 405 34.9 65.6 38.4
Family history of MI
No 41 777 34.3 61.8 34.7
Yes 44 636 40.6 66.1 37.1
Pills for high cholesterol
No 78 795 35.6 61.8 34.6
Yes 10 958 53.6 77.3 43.9
Comorbid conditions
Diabetes
Nondiabetic 85 715 36.2 62.6 35.5
Diabetic (insulin dependent) 1 405 69.8 82.8 39.8
Diabetic (non–insulin 3 555 63.5 79.6 42.3
dependent)
MI ever
No 88 819 37.3 63.7 35.7
Yes 1 882 62.2 81.6 47.1
Heart failure
No 90 039 37.7 64.1 35.9
Yes 699 61.8 83.8 45.8
Stroke ever
No 89 623 37.5 64.0 35.9
Yes 1 091 66.4 81.9 41.7

tion, smoking, alcohol intake, physical activity, high choles-
terol, diabetes, family history of MI, and comorbid condi-
tions, current hormone use in this cross-sectional study was
associated with a 25% greater likelihood of hypertension than
past use or no previous use (OR for current users versus
nonusers was 1.25, 95% CI 1.21 to 1.30).
The multivariate analyses generally confirmed the findings
on prevalence shown in Table 2, except for hormone use, as
noted above. The likelihood of hypertension, after control for
the multiple covariates, increased with increasing BMI (OR
per unit BMI increase was 1.17, 95% CI 1.16 to 1.19).
Waist-to-hip ratio was a significantly associated with preva-
lence even after controlling for BMI (OR per 1 SD, which is
an ⬇10% increase in the ratio, was 1.20; 95% CI 1.18 to
1.22). Logistic regression models were also run for the cohort
excluding those who had a history of MI, stroke, or heart
failure and separately for the group who did have such a
history, with similar results.
Factors Associated With Varying Rates of
Treatment of Hypertension
Treatment rates did not vary by age group but did vary by
race/ethnicity, with black women having the highest treat-
ment rates (75.6%) and Hispanic women having the lowest
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(59.4%). There was a weak inverse relationship between
treatment rates and family income, ranging from 70.8% of
those with income ⬍$10 000 to 61.0% of those with income
of ⱖ$75 000. Women whose only insurance was Medicaid
had substantially and significantly higher rates of treatment
(80.8%, 95% CI 75.3 to 80.3) than did those with other types
of insurance, such as prepaid private insurance (65.2%, 95%
CI 64.2 to 66.2), other private insurance (63.2, 95% CI 62.1
to 64.3), or Medicare only (63.9%, 95% CI 62.1 to 65.8).
Logistic regression analyses, controlling for multiple po-
tential confounders (not shown), indicated that among the
34 339 hypertensives, the likelihood of being on drug treat-
ment was significantly higher for blacks than for whites (OR
1.63, 95% CI 1.49 to 1.79) and for Asians than for whites (OR
1.21, 95% CI 1.10 to 1.45). Current hormone users compared
with those who had never used hormones were 26% more
likely to be on drug treatment (OR 71.26, 95% CI 1.18 to
1.34), supporting the inference that current hormone users are
generally more health conscious as well as being younger and
thinner. Those who had seen a health care provider in the past
year were 3.62 times as likely to be on drug treatment (95%
CI 3.36 to 3.89) as those who had not seen a provider.
Most hypertensives were treated with only 1 class of drugs
(57.6%). Two drug classes were used in 31.8% of those
 Wassertheil-Smoller et al Hypertension in Postmenopausal Women 785

TABLE 3. Selected Types of Antihypertensive Drugs Used in Different Subgroups of Treated Hypertensives
% of Treated Using Specified Drug Class as
Monotherapy*

Calcium Multidrug Use

No. Reporting ACE Channel (ⱖ2 Drug
Drug Treatment Diuretic ␤-Blocker Inhibitor Blocker Classes)†
Total use of drug (in combination or as 22 096 44.3‡ 23.4‡ 30.0‡ 33.5‡
monotherapy)
Total use of drug as monotherapy 22 096 14.4 9.2 14.3 16.4 38.1
Demographic
Age, y
50–59 6 171 14.0 9.9 16.3 16.1 36.0
60–69 9 770 14.2 9.3 14.3 16.3 38.2
70–79 6 155 15.1 8.2 12.2 16.7 40.3
Race/ethnicity
White/non-Hispanic 16 888 14.2 10.4 15.5 14.9 37.8
Black 3 585 17.3 3.6 7.5 19.9 43.1
Hispanic 589 7.8 7.5 19.4 23.3 29.7
Asian 623 8.5 10.8 14.3 29.9 27.9
Other 411 15.1 8.3 14.6 16.1 36.3
Insurance type
No insurance 629 11.0 6.4 12.4 17.3 35.9
Prepaid private only 5 751 15.8 10.3 15.3 16.1 36.5
Other private only 4 379 13.2 9.9 17.3 15.3 37.0
Medicare only 1 648 14.0 7.4 12.3 17.4 39.4
Medicaid only 160 11.3 5.6 10.6 21.3 43.8
Other combinations 8 383 14.4 8.7 12.8 16.6 39.8
Comorbid condition
Diabetes
Nondiabetic 19 453 14.9 9.6 14.0 16.7 36.9
Diabetic (insulin dependent) 812 8.5 2.8 15.4 14.0 52.7
Type II diabetic (non–insulin dependent) 1 798 10.8 6.8 16.5 14.3 44.8
MI ever
No 21 130 14.7 9.1 14.6 16.4 37.4
Yes 955 7.1 11.1 7.0 14.9 55.3
Heart failure
No 21 732 14.5 9.2 14.4 16.5 37.6
Yes 362 8.3 3.9 6.1 9.9 68.2
Stroke
No 21 493 14.6 9.2 14.3 16.3 37.8
Yes 593 7.8 5.4 12.5 17.7 49.9
*Drug classes are mutually exclusive.
†Sum of percentages of drug class use do not add to 100% because ⬇9% of respondents who reported treatment of hypertension
did not have their medications entered into the medications inventory database.
‡Drug classes are not mutually exclusive.

treated, and ⱖ3 classes were used in 6.4%. As monotherapy, multiple drug classes in different subgroups of participants.
the most commonly used drug class was calcium channel ACE inhibitors as monotherapy were more likely to be used
blockers, with 16.4% of treated hypertensives taking calcium in the younger age group of treated hypertensives than in the
channel blockers either as monotherapy and 33.5% when oldest group (16.3% versus 12.2%, respectively); mono-
including combinations with another drug class, compared therapy use of the other drug classes was similar across the 3
with 14.4% using a diuretic as monotherapy and 44.3% on age groups. Calcium channel blockers were more likely to be
diruetics overall, including combination therapy. Table 3 used by Asians (29.9%), blacks (19.9%), and Hispanics
shows use of these drug classes as monotherapy and use of (23.3%) than by whites (14.9%). The type of insurance did
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786 Hypertension November 2000

not appear to be strongly related to the type of drug class used TABLE 4. Adjusted ORs for Control of Hypertension
as monotherapy, except that those on Medicaid had slightly Control (Total n⫽22 096)
higher rates of use of calcium channel blockers both as
monotherapy and in combination with other drugs, but this OR 95% CI
may be confounded by race. Those with comorbid conditions Age, per year 0.96 0.96–0.96
(diabetes, history of stroke, MI, or heart failure) were sub- Race/ethnicity
stantially more likely to be treated with multiple drug classes White/non-Hispanic* 1
than those without such conditions. Diabetic status was not
Black 0.82 0.74–0.90
related to the use of calcium channel blockers as mono-
Hispanic 0.74 0.61–0.90
therapy, but use of calcium channel blockers in combination
with other drugs (not shown) was higher in diabetics than in Asian 0.78 0.63–0.97
nondiabetics (45.4% of insulin-dependent treated diabetics Other 0.77 0.63–0.95
and 37.8% of non–insulin-dependent diabetics versus 32.5% Smoking
of nondiabetics). ␤-Blocker use as monotherapy was fairly Never smoked* 1
similar among those with a history of MI (11.1%) and those Past smoker 1.05 0.99–1.12
without such history (9.1%); however, ␤-blockers in combi- Current smoker 1.37 1.21–1.56
nation with other drugs were more likely to be used by those
Diabetes
with a history of MI (37.5%) than by those with no prior MI
Nondiabetic* 1
(22.8%).
Diabetic (insulin dependent) 0.75 0.64–0.87
Factors Associated With Varying Rates of Control Type II diabetes (non–insulin dependent) 0.93 0.83–1.03
of Hypertension BMI, per unit BMI increase 1.01 1.00–1.01
As shown in Table 2, although older hypertensive women Drug use
(aged 70 to 79 years) were as likely to be on treatment Diuretics only* 1
(63.2%) as the younger women (64.2%), a substantially
␤-Blocker only 0.71 0.63–0.80
smaller percentage of them had their blood pressures under
ACE inhibitor only 0.68 0.61–0.80
control (29.3% versus 41.3% for the older versus younger
women, respectively). These older women are most at risk for Calcium channel blocker only 0.57 0.52–0.63
stroke and other complications of hypertension, but even Multidrug use (ⱖ2 classes) 0.76 0.69–0.83
among those who were on pharmacological treatment, less ORs are adjusted for all variables shown in table and, in addition, for
than half (46.4%) had their blood pressures under control education, alcohol intake, activity level, having seen a healthcare provider in
compared with 64.2% of women aged 50 to 59 years on past year, hormone use, family history of MI, stroke, or heart failure, and high
cholesterol requiring pills; they are also adjusted for clinical center.
treatment (not shown), suggesting that older women may be
*Reference category.
more difficult to control and/or may not be treated as
aggressively as younger postmenopausal women. In bivariate
analyses, black hypertensive women had the highest rates of obese. Educational level, alcohol intake, activity level, having
control. Control rates among hypertensives on Medicaid only seen a heathcare provider in the past year, hyperlipidemia
were similar to those with prepaid or private insurance, requiring drug treatment, hormone use, and comorbid condi-
although they were significantly higher (43.9%, 95% CI 37.0 tions (except for diabetes) were not related to the control of
to 50.8) than for those on Medicare only (31.6%, 95% CI 29.8 hypertension among those being treated after adjustment for
to 33.4) or for those with no insurance (30.0%, 95% CI 27.4 covariates. Of particular interest is that those who were on a
to 32.7). The higher rate of control among Medicaid-covered ␤-blocker, ACE inhibitor, or calcium channel blocker as
women than among Medicare-covered women may reflect monotherapy were less likely to have their blood pressures
age differences between these 2 groups but may also be due controlled than were those on a diuretic alone, after adjust-
to the fact that Medicaid covers drugs but Medicare does not. ment for multiple covariates that might be related to choice of
Eighty-one percent of the Medicaid-insured hypertensive therapy. (Unadjusted control rates, not shown, were 63% of
women were being pharmacologically treated compared with those on monotherapy with diuretics, 57% of those on
64% of the Medicare-insured women (Table 2). monotherapy with ␤-blockers, 56% on ACE inhibitors, and
Among those 22 096 hypertensives who were treated 50% of those on calcium channel blockers.) Hypertension
pharmacologically, after adjustment for multiple covariates, control was not related to the number of drug classes. Of
those less likely to have their hypertension under control were those treated with 1 drug class, 56% had their hypertension
older women and all nonwhite groups (Table 4). Current under control; of those treated with 2 drug classes, 58% had
smokers were more likely than those who had never smoked their hypertension under control, and of those treated with ⱖ3
to have their blood pressures under control (OR 1.37, 95% CI drug classes, 52% had their hypertension under control.
1.21 to 1.56). Women who were heavier were more likely to
be treated (not shown, OR 1.06 per unit increase in BMI), and Discussion
of those treated, they were slightly more likely to be con- WHI provided an opportunity to examine factors associated
trolled (OR 1.01 per unit increase in BMI). Possibly, this with prevalence, treatment, and control of hypertension in
implies more aggressive treatment of hypertension among the different subgroups of a multiethnic cohort of nearly 100 000
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 Wassertheil-Smoller et al
postmenopausal women across the United States. The overall
prevalence rate of hypertension was 38%, with a prevalence
of 59% for black women and 36% for white women. Despite
the fact that the WHI cohort is composed of volunteers who
are in relatively good health, the prevalence rates are fairly
close to the prevalence for this age group in NHANES III.12,13
NHANES is a national probability sample and so may be
more representative of American women, but the NHANES
data are based on only ⬇1740 women in this age group. This
WHI report is based on nearly 100 000 women ages 50 to 79
years and is the largest and best-characterized cohort of
postmenopausal women, with data on the current patterns of
hypertension treatment and control.
Women who were current hormone users had a higher
prevalence of hypertension when controlling for age, BMI,
and waist-to-hip ratio. The univariate protective effect of
hormone use is confounded by these 3 variables because
hypertensive hormone users were “healthier” in the sense that
they were thinner and younger. After accounting for age and
weight-related variables, current hormone use was associated
with a greater odds of being hypertensive. This cross-
sectional result differs from the effect of hormone use on
hypertension found in the Postmenopausal Estrogen/Proges-
tin Interventions (PEPI) trial,14 which reported no significant
differences from placebo in SBP or DBP change in women
treated with hormones over a 3-year period. The PEPI cohort,
however, was considerably younger, with ages ranging from
45 to 64 years (average age 56 years) than the WHI cohort,
with ages ranging from 50 to 79 years (average age 62 years).
The Hormone Therapy Replacement Clinical Trial compo-
nent of WHI, to be completed in the year 2005, will address
the question of the effect of hormones on the development of
hypertension prospectively in these older women.
The second issue addressed in the present report concerned
the patterns of treatment common in the mid and late 1990s
and their correspondence to national guidelines for the
treatment of hypertension. In the WHI, 64% of hypertensives
were treated pharmacologically; that rate was similar to the
treatment rates found in NHANES,13 with little difference by
age group. Black women and those on Medicaid had higher
rates of treatment. Although the numbers of women on
Medicaid were small in this cohort, it should be noted that the
treatment rate in this subgroup was the highest of all
insurance categories (81% compared with ⬇63% to 65% for
those with private insurance or Medicare), suggesting that
insurance coverage of drugs has a substantial impact on the
percent being treated.
It is noteworthy that actual treatment patterns differ from
the JNC guidelines for the treatment of uncomplicated hy-
pertension. The JNC V1 and JNC VI5 guidelines recommend
the use of diuretics and ␤-blockers in uncomplicated hyper-
tensive patients. The data from WHI suggest that these
guidelines are not uniformly followed for postmenopausal
women, in view of the fact that the most common drug class
used as monotherapy was calcium channel blockers, in 16%
of treated hypertensives and the least common drug class was
␤-blockers in 9%. Diuretics and ACE inhibitors were used in
⬇14.5% of treated hypertensives. Others have also reported
the lack of effect of JNC V recommendations with regard to
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Hypertension in Postmenopausal Women 787
the drug used.15 There are several possible explanations for
this discrepancy. Because only 2% of this group had a history
of MI, 1% had a history of stroke, and 5% had a history of
diabetes, the possibility that a large number of women in this
cohort who are on monotherapy may actually have compli-
cated hypertension seems unlikely. Another possibility is that
physicians are not appropriately following guidelines, possi-
bly because of insufficient or ineffective dissemination of
these guidelines or because of countervailing influences, such
as the marketing efforts of pharmaceutical companies. Fi-
nally, physicians may not be strictly adhering to guidelines
for appropriate reasons, which are based on their clinical
judgment about individual patients. The answer to the ques-
tion of which monotherapy has most beneficial effects on
heart disease outcomes awaits the results of the Antihyper-
tensive and Lipid Lowering Treatment to Prevent Heart
Attack Trial (ALLHAT),16 a randomized double-blind trial
comparing 3 different antihypertensive drug classes with
diuretic therapy that is being conducted among 40 000
high-risk hypertensive patients and is to be completed in the
year 2002.
In hypertensive patients with diabetes, the JNC VI guide-
lines recommend the use of diuretics for type 2 diabetics and
ACE inhibitors for type 1 diabetics.5 Diuretics were used in
hypertensive patients with diabetes in 11% as monotherapy
and in a total of 43% when including combination therapy.
Although ACE inhibitors were commonly used in these WHI
participants (16% as monotherapy and 48% and 38% includ-
ing combination therapy in type 1 and 2 diabetics, respec-
tively), so were calcium channel blockers (14% as mono-
therapy and 45% and 38% including combination therapy in
type 1 and 2 diabetics, respectively). Several recent CTs have
directly compared diuretics or ACE inhibitors with calcium
channel blockers in hypertensive patients with diabetes.17–20
The Appropriate Blood Pressure Control in Diabetes (ABCD)
trial,17 for instance, was stopped early because of an increased
risk of cardiovascular events in hypertensive diabetic patients
randomized to calcium channel blockers compared with those
randomized to the ACE inhibitors (risk ratio 5.5, 95% CI 2.1
to 14.6). Another trial of the ACE inhibitor ramipril versus
placebo was also stopped early with data released before the
publication date because of significant and marked reductions
of cardiovascular events in a broad range of high-risk patients
with the use of ramipril.21 Given the results of these recent
comparative trials, it is likely that ACE inhibitor use will
increase.
The final issue examined was the adequacy of control of
hypertension in older women. Although overall, 64% of the
WHI hypertensive women were treated, only about a third
were controlled. In NHANES III (1988 to 1991), data
indicate that 81% of hypertensive women aged 18 to 74 years
are aware of their condition, 65% are under treatment, and
38% have their hypertension under control.13 This is more
than double the percentage under control in NHANES II,
when only 15% of hypertensive women had blood pressures
⬍140/90 mm Hg. Concomitantly, with the increase in control
of hypertension over the last several decades, there has been
a marked decrease of deaths from heart disease by ⬇50% and
of deaths from strokes by ⬇57%. A recent report from the
788 Hypertension November 2000
Framingham Heart Study22 indicated that use of antihyper-
tensive medication increased substantially between 1950 and
1989 as well as from the 1970s to the 1980s, with a
concomitant decline in left ventricular hypertrophy. Thus,
there has been an improvement in the public health related to
hypertension treatment and control in general, but this may
not apply to older people. Although treatment and control
rates among WHI women are similar to those found in
NHANES III, nevertheless, two thirds of all the WHI hyper-
tensive women had blood pressures ⬎140/90 mm Hg, and in
particular, 71% of those aged 70 to 79 years had clinic blood
pressures above those levels. Even among those women who
were on drug treatment, only 56% had controlled hyperten-
sion, indicating that the goal of an SBP ⬍140 mm Hg and a
DBP ⬍90 mm Hg is not being met in half of the hypertensive
older women being treated with drugs. In fact, hypertensive
women who had seen a healthcare provider in the past year
were 3.6 times more likely to be on drug treatment, but those
treated were not significantly more likely to be controlled
than those who had not seen a provider, after adjusting for
multiple covariates. Inadequate control of blood pressure has
also been recently reported in a population of older men who
were receiving regular medical care at Veterans Affairs sites
and who made frequent visits for health care.23 Fewer than
25% of these patients had blood pressures ⬍140/90 mm Hg.
The authors conclude that poor blood pressure control could
not be explained by lack of access to medical care but that
physicians were not treating high blood pressure sufficiently
aggressively. In the JNC recommendations, target blood
pressure levels are the same regardless of age, although there
is some inconsistent evidence on the optimum blood pressure
levels for older people.
In the WHI, monotherapy with diuretics was more strongly
associated with good control of blood pressure than was
monotherapy with ␤-blockers, calcium channel blockers,
ACE inhibitors, or the use of multiple drugs. In the absence
of information on pretreatment levels of blood pressure, it is
possible that part of the association of diuretics with good
control may represent confounding by the severity of hyper-
tension and that those who were put on other classes of drugs
were initially resistant to diuretics. Nonetheless, diuretics are
known from CTs to be effective in lowering blood pressure
and in preventing complications such as MI, stroke, and
congestive heart failure in men and women.3,4,24,25
In conclusion, it is important to note that two thirds of older
hypertensive women, who are most at risk for stroke and
cardiovascular events, do not have their hypertension ade-
quately controlled, either because they are not on drug
treatment or because in spite of taking antihypertensive drugs,
their blood pressure is still above recommended levels.
Additionally, the guidelines for drug treatment of hyperten-
sion as recommended by the JNC on the Detection, Evalua-
tion and Treatment of High Blood Pressure are not being
widely implemented in this group with regard to goal blood
pressure levels. The drug class most commonly used by WHI
women as monotherapy was calcium channel blockers, al-
though these drugs were associated with a lower likelihood of
control when used as monotherapy than was monotherapy
with diuretics. The question of which drug classes offer the
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most benefit for older hypertensive women is as yet
unanswered.
Appendix: Short List of WHI Investigators
Program Office
National Heart, Lung, and Blood Institute, Bethesda, Md: Carolyn K.
Clifford, Suzanne S. Hurd, Joan A. McGowan, Linda Pottern, and
Jacques E. Rossouw.
Clinical Coordinating Centers
Fred Hutchinson Cancer Research Center, Seattle, Wash: Ross
Prentice, Maureen Henderson, Garnet Anderson, Andrea LaCroix,
and Anne McTiernan; Bowman Gray School of Medicine, Winston-
Salem, NC: Curt Furberg and Pentti Rautaharju; Medical Research
Labs, Highland Heights, Ky: Evan Stein; University of California at
San Francisco: Steven Cummings; University of Minnesota, Minne-
apolis: John Himes; and University of Washington, Seattle: Bruce
Psaty.
Clinical Centers
Albert Einstein College of Medicine, Bronx, NY: Sylvia
Wassertheil-Smoller; Baylor College of Medicine, Houston, Tex:
Jennifer Hays; Brigham and Women’s Hospital, Harvard Medical
School, Boston, Mass: JoAnn Manson; Brown University, Provi-
dence, RI: AnnLouise R. Assaf; Emory University, Atlanta, Ga:
Nelson Watts; Fred Hutchinson Cancer Research Center, Seattle,
Wash: Shirley Beresford; George Washington University Medical
Center, Washington, DC: Judith Hsia; Harbor-UCLA Research and
Education Institute, Torrance, Calif: Rowan Chlebowski; Kaiser
Permanente Center for Health Research, Portland, Ore: Barbara
Valanis; Kaiser Permanente Division of Research, Oakland, Calif:
Bette Caan; Medical College of Wisconsin, Milwaukee: Jane Morley
Kotchen; Medlantic Research Institute, Washington, DC: Barbara V.
Howard; Northwestern University, Chicago/Evanston, Ill: Philip
Greenland; Cook County Hospital, Rush-Presbyterian St. Luke’s
Medical Center, Chicago, Ill: Henry Black; Stanford Center for
Research in Disease Prevention, Stanford University, Stanford,
Calif: Marcia L. Stefanick; State University of New York at Stony
Brook: Dorothy Lane; The Ohio State University, Columbus: Re-
becca Jackson; University of Alabama at Birmingham: Albert
Oberman; University of Arizona, Tucson/Phoenix: Tamsen Bass-
ford; University at Buffalo, Buffalo, NY: Maurizio Trevisan; Uni-
versity of California at Davis, Sacramento: John Robbins; University
of California at Irvine, Orange: Frank Meyskens; University of
California at Los Angeles: Howard Judd; University of California at
San Diego, La Jolla/Chula Vista: Robert D. Langer; University of
Cincinnati, Cincinnati, Ohio: James Liu; University of Florida,
Gainesville/Jacksonville: Marian Limacher; University of Hawaii,
Honolulu: David Curb; University of Iowa, Iowa City/Davenport:
Robert Wallace; University of Massachusetts, Worcester: Judith
Ockene; University of Medicine and Dentistry of New Jersey,
Newark: Norman Lasser; University of Miami, Miami, Fla: Mary Jo
O’Sullivan; University of Minnesota, Minneapolis: Richard Grimm;
University of Nevada, Reno: Sandra Daugherty; University of North
Carolina, Chapel Hill: Gerardo Heiss; University of Pittsburgh,
Pittsburgh, Pa: Lewis Kuller; University of Tennessee, Memphis:
Karen C. Johnson; University of Texas Health Science Center, San
Antonio: Robert Schenken; University of Wisconsin, Madison:
Catherine Allen; Wake Forest University School of Medicine,
Winston-Salem, NC: Electra Paskett; and Wayne State University
School of Medicine/Hutzel Hospital, Detroit, Mich: Susan Hendrix.
Acknowledgments
This study was supported by grant NO1-WH-4-2119 from the
National Institutes of Health, Department of Health and Human
Services. We wish to acknowledge all WHI Centers and their
Principal Investigators for their participation in this research.
 Wassertheil-Smoller et al
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