Faster rates of BP elevation with aging in women vs. men

Sex Differences in Blood Pressure Trajectories Over the Life Course

Literature - Ji H, Kim A, Ebinger JE, et al. - JAMA Cardiol.2020, doi:10.1001/jamacardio.2019.5306

Introduction and methods

Differences between women and men in the manifestation of CVD are that in women onset of CVD is delayed and symptoms are atypical compared to men. Also, women are more likely to develop coronary microvascular dysfunction and HF with preserved ejection fraction (HFpEF), especially in the presence of hypertension [1-3]. Clinical experience and data now suggest that CV pathophysiology is different between women and men.

Sex differences in earlier-life CV physiology were examined to see whether they precede differences in later-life CV pathophysiology. Population-based multicohort data was used to analyze blood pressure (BP) trajectories during life time. Elevation in BP was chosen as this represent the single most accessible measure of vascular aging and largest contributor to ischemic heart disease and HF [4,5].

Longitudinally collected BP measurements from 4 community cohort were used: the Framingham Heart Study (FHS) offspring cohort, the Atherosclerosis Risk in Communities (ARIC) Study, the Coronary Artery Risk Development in Young Adults (CARDIA) Study, and the Multi-Ethnic Study of Atherosclerosis (MESA). A total of 32 833 unique participants were enrolled, 54% were women. 144,599 measurements were included over a time span of 43 years (1971-2014) with age of participants ranging from 5 to 98 years.

In the setting of antihypertensive therapy, 10 mmHg was added to SBP and 5 mmHg to DBP value s to account for treatment effects of antihypertensive therapy on BP. Incident hard CVD was defined as new-onset fatal or nonfatal myocardial infarction, HF or stroke.

Main results

  • BP values over life course show a trend suggesting that BP levels in women catch up with BP levels in men by the age of 60.
  • When expressed as BP elevation from baseline, women showed faster rates of BP elevation with aging than men, starting from 30 years of age (likelihood ratio test χ²= 531 for systolic BP; χ² = 123 for diastolic BP; χ² = 325 for mean arterial pressure (MAP); and χ² = 572 for pulse pressure (PP); P for all <.001).
  • Multivariable-adjusted BP trajectories remained higher in women than in men (likelihood ratio test χ²= 314 for systolic BP; χ² = 31 for diastolic BP; χ² = 129 for MAP; and χ² = 485 for PP; P for all <.001).
  • Incidence of new-onset hard CVD events was higher in men than in women (29.7% in men vs. 20.5% in women, HR:1.61, 95%CI: 1.54-1.69, P<0.001).


An analysis of BP data of >32,000 individuals in communities showed that BP elevations increased more rapidly in women than in men, suggesting that vascular changes develop earlier and progress faster in women. These vascular changes may precede differences in later-life CV pathophysiology and may explain why CVD tends to present differently between sexes.


1. Dean J, Cruz SD, Mehta PK, Merz CN. Coronary microvascular dysfunction: sex-specific risk,

diagnosis, and therapy. Nat Rev Cardiol. 2015;12(7):406-414.

2. Eaton CB, Pettinger M, Rossouw J, et al. Risk factors for incident hospitalized heart failure with preserved versus reduced ejection fraction in a multiracial cohort of postmenopausal women. Circ Heart Fail. 2016;9(10):e002883.

3. Beale AL,Meyer P, Marwick TH, Lam CSP, Kaye DM. Sex differences in cardiovascular pathophysiology: why women are overrepresented in heart failure with preserved ejection fraction.

Circulation. 2018;138(2):198-205.

4. Cheng S, Xanthakis V, Sullivan LM, Vasan RS. Blood pressure tracking over the adult life course: patterns and correlates in the Framingham heart study. Hypertension. 2012;60(6):1393-1399.

5. Mehta LS, Beckie TM, DeVon HA, et al; American Heart Association Cardiovascular Disease in Women and Special Populations Committee of the Council on Clinical Cardiology, Council on Epidemiology and Prevention, Council on Cardiovascular and Stroke Nursing, and Council on Quality of Care and Outcomes Research. Acute myocardial infarction in women: a scientific statement from the American Heart Association. Circulation. 2016;133(9):916-947.

Find this article online at JAMA Cardiol

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