BP elevations occur earlier in life for women vs. men
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BP elevations occurred more rapidly in women compared with men and as early as the third decade of life, which may explain why CVD presents at different times between both sexes, according to a study published in JAMA Cardiology.
“Many of us in medicine have long believed that women simply ‘catch up’ to men in terms of their cardiovascular risk,” Cardiology Today Editorial Board Member Susan Cheng, MD, MPH, MMSc, director of public health research at the Smidt Heart Institute, director of cardiovascular population sciences at the Barbra Streisand Women’s Heart Center and the Erika J. Glazer Chair in Women’s Cardiovascular Health at Cedars-Sinai, said in a press release. “Our research not only confirms that women have different biology and physiology than their male counterparts, but also illustrates why it is that women may be more susceptible to developing certain types of cardiovascular disease and at different points in life.”
Data from community cohorts
Hongwei Ji, MD, of the division of cardiology at Brigham and Women’s Hospital and Harvard Medical School, and colleagues analyzed from 32,833 participants (54% female) aged 5 to 98 years from four community cohorts: Framingham Heart Study offspring cohort, the CARDIA study, the ARIC study and MESA.
Data including BP measures were collected from 144,599 observations from 1971 to 2014. BP trajectories were estimated with mixed-effects regression models for women and men with age as a common timescale.
New-onset hard CVD events occurred in 24.8% of participants over 4 decades.
Compared with men, women exhibited a faster rate of BP elevation with aging, which was present as early as the third decade of life (likelihood ratio chi-square test = 531 for systolic BP; chi-square test = 123 for diastolic BP; chi-square test = 325 for mean arterial pressure; chi-square test = 572 for pulse pressure; P for all < .001).
Differences between both sexes persisted after adjusting for clinical covariates including total cholesterol, BMI, current smoking and diabetes life (likelihood ratio chi-square test = 314 for systolic BP; chi-square test = 31 for diastolic BP; chi-square test = 129 for mean arterial pressure; chi-square test = 485 for pulse pressure; P for all < .001).
“In effect, sex differences in physiology, starting in early life, may well set the stage for later-life cardiac as well as vascular diseases that often present differently in women compared with men,” Ji and colleagues wrote. “Additional work is needed to further understand sexual dimorphism in cardiovascular risk to optimize prevention and management efforts in both women and men.”
Women in research
In a related editorial, Cardiology Today Editorial Board Member Nanette K. Wenger, MD, MACC, MACP, professor of medicine (cardiology) at Emory University School of Medicine, consultant at Emory Heart and Vascular Center, wrote: “We must remember that the cardiovascular health of women involves more than sex-specific medical research. The emerging science will be useful only when women have equal access to high-quality, affordable health care. Women’s equity thus involves equity in research and prevention and equal access to care and treatments.” – by Darlene Dobkowski
Disclosures: Cheng reports she received grants from the NIH and personal fees from Zogenix. Ji and Wenger report no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.
Perspective
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Martha Gulati, MD, MS, FACC, FAHA, FASPC
With women, we all thought that there was a delay in when BP rises. The point where we say hypertension increases in terms of occurrence and diagnosis was at menopause, but that just meant the BP met our threshold for diagnosis of hypertension.
Looking at these four cohorts and comparing across sex, you can clearly see BP rises at a greater incline than men (ie, higher trajectory). Women start out with lower BP, but the degree of change is faster, meaning potentially the vascular effects are different at this rate of incline.
This is all new knowledge. It makes me personally question if there is a different diagnostic threshold for hypertension in women vs. men. Is this the difference in women that explains some of the other vascular sex differences we see in women, in addition to spontaneous coronary artery dissection and microvascular disease? Is this why women have more nonobstructive ischemia (ischemia with nonobstructive CAD [INOCA]/MI in the absence of obstructive CAD [MINOCA])? Can this explain also why stress can induce Takotsubo’s more often in women than in men? All of this is important but raises a lot of questions.
These data make us again consider that women may be different than men, and assumptions we made from male data may not apply in women. Plotting BP repeatedly over time really tells us the temporal changes, and this demonstrates the trajectory of change over time with clear sex differences with implications for atherosclerosis/CVD, HF and many cardiac conditions as well as stroke. HF with preserved ejection fraction may result from this too. Additionally, this may relate to peripheral artery disease and stroke and why women have been noted to have more vascular effects with age, such as stiffer aortas/greater vascular effects, quite possibly due to this trajectory of increase in BP over time.
Further research is needed to determine if there is a different BP threshold for treating women and what is “normal BP” in pregnant women. We also need more information on what BP drop is expected, what actually is abnormal in pregnancy and if there is an impact in those with any gestational hypertension to change this trajectory for the worse. Lots of questions arise for the impact on the CV system overall.
BP is so clinically important. It is poorly treated in general, yet can be lifesaving and is relatively easy to treat with both medications and lifestyle changes. We don’t measure it accurately (despite guidelines and tools to help us). Especially in young women, we attribute hypertension to stress and anxiety, and they remain often undertreated. Its impact is huge; hypertension accounts for over half of the strokes and half of the ischemic heart disease globally. We need to know more about this in women so we can be adequately treating and preventing heart disease.
Missing younger women with hypertension and undertreating hypertension in women may impact younger women more than men. Prolonged vascular effects to chronic hypertension are bound to affect the CV system adversely. As a result of a misconception about elevations in BP and when they occur in women have made us think of this a disease that occurs in women later and usually at menopause. The trajectory seems continuous, not necessarily hormonal, or at least not completely hormonal.
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Ji H, et al. JAMA Cardiol. 2020;doi:10.1001/jamacardio.2019.5306.
Wenger NK. JAMA Cardiol. 2020;doi:10.1001/jamacardio.2019.5576.
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