High blood pressure is often dismissed as part of menopausal symptoms in older women, and that could raise a woman’s risk for heart trouble.

That warning, along with recommendations on how doctors can help middle-aged women avoid future heart problems, is included in a European Society of Cardiology (ESC) consensus document published in the European Heart Journal.

Up to half of women develop high blood pressure before age 60, but the symptoms — such as hot flashes and palpitations — are often blamed on menopause. High blood pressure puts women at risk for atrial fibrillation, heart failure, and stroke.

While hormone replacement therapy can ease menopause symptoms in women over 45, their heart disease risk factors need to be assessed before starting the therapy.

Prevention must begin early, and doctors must assess women differently from men — not just look at high cholesterol, according to study author Dr. Angela Maas, director of the Women’s Cardiac Health Program at Radboud University Medical Center in Nijmegen, Netherlands.