Sex Differences in Blood Pressure Associations With Cardiovascular Outcomes
Key result
SBP from 100-109 mm Hg is linked to ~25% higher CVD risk in women vs. men.
- HR 1.25
- n=27,542
Why the study?
Data on potential sex differences in outcomes associations defining normal systolic blood pressure are limited, leaving unclear whether a lower systolic blood pressure range should be considered normal for women versus men.
Does systolic blood pressure elevation increase incident cardiovascular disease risk at lower thresholds in women compared to men?
Key Points
- To determine whether sex-specific thresholds exist for the association between systolic blood pressure ranges and incident cardiovascular disease outcomes.
- Evaluated 27 542 participants (54% women) without baseline cardiovascular disease from 4 community-based cohort studies followed over 28±12 years.
- Categorized systolic blood pressure in 10 mm Hg increments (from <100 mm Hg to ≥160 mm Hg) to evaluate incident myocardial infarction, heart failure, and stroke using multivariable-adjusted Cox proportional hazards models.
- Relative to systolic blood pressure <100 mm Hg, cardiovascular disease risk began at 100 to 109 mm Hg in women (hazard ratio 1.25) but at 130 to 139 mm Hg in men (hazard ratio 1.26).
- Myocardial infarction risk for women with systolic blood pressure 110 to 119 mm Hg was comparable to men with systolic blood pressure ≥160 mm Hg, with significant sex interaction observed for myocardial infarction (P=0.006) and heart failure (P=0.058).
- The association of systolic blood pressure with cardiovascular disease risk was more pronounced in younger versus older women (median age <52 versus ≥52 years; P<0.001), whereas no age interaction was observed for men (P=0.098).
Study Design
Type
Cohort (n=27,542)
Multicenter
Yes
Structured PICO
Does systolic blood pressure elevation increase incident cardiovascular disease risk at lower thresholds in women compared to men?
P
Population
27,542 participants without baseline cardiovascular disease from 4 community-based cohorts, 54% women, followed for 28±12 years.
E
Exposure
Systolic blood pressure categories (10 mm Hg increments from <100 mm Hg to ≥160 mm Hg)
C
Comparator
Systolic blood pressure <100 mm Hg
O
Outcome
Incident nonfatal or fatal cardiovascular disease (myocardial infarction, heart failure, and stroke) over 28±12 yearshard clinical
Main Result
Hazard Ratio: 1.25
Cardiovascular disease risk increases at lower systolic blood pressure thresholds in women compared to men, suggesting a need for sex-specific definitions of optimal blood pressure.
Key expert perspectives
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“We've been assuming up to this time that 120 is the number to worry about, and anything under 120 is totally fine and safe for both women and men. It turns out it's probably fine and safe for men, but not necessarily for women.”
“Our latest findings suggest that this one-size-fits-all approach to considering blood pressure may be detrimental to a woman's health. Based on our research results, we recommend that the medical community reassess blood pressure guidelines that do not account for sex differences.”
“It seems relatively clear now that women have a slightly lower range of healthy blood pressure than men. The ideal systolic blood pressure for men is 120 mm Hg or lower, but the healthiest level for women appears to be 110 or less.”
Implication
Sex-specific SBP thresholds may merit evaluation in women; leaves open whether guidelines should adopt lower targets pending randomized confirmation.
Abstract
blood pressure cardiovascular diseases sex F or decades, 120 mm Hg has been considered the normal upper limit for adult systolic blood pressure (SBP). Practice guidelines have long referred to this threshold for classifying ranges of blood pressure (BP) elevation and treatment targets, given the consistent epidemiologic finding that cardiovascular disease (CVD) risk is continuously increased from the SBP level of 120 mm Hg and upwards. 1 Amid previous studies using outcomes associations to determine a normal SBP range, there remain limited data on potential sex differences. It is well known that BP levels in adulthood are on average lower in women than men in the healthy state 2 ; however, whether or not a lower range of SBP might be considered normal for women versus men is unclear.
Discussion
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Cite This Study
Ji et al. (2021) conducted a cohort in Without baseline cardiovascular disease (n=27,542). Systolic blood pressure 100 to 109 mm Hg vs. Systolic blood pressure <100 mm Hg was evaluated on Incident nonfatal or fatal cardiovascular disease (myocardial infarction, heart failure, and stroke) (HR 1.25). Elevations in systolic blood pressure from lower ranges (100-109 mm Hg) were associated with increased incident cardiovascular disease risk in women, whereas comparable risk in men was observed at higher thresholds (130-139 mm Hg).