Sex Differences in Cardiovascular Risk After Emergency Department Discharge for Hypertensive Urgencies

Objective: To evaluate sex-related differences in all-cause mortality, cardiovascular mortality, and major adverse cardiovascular events (MACE) after emergency department (ED) discharge for hypertensive urgencies (HU). Design and method: We conducted a retrospective observational cohort study including 2,398 adults evaluated in the ED for hypertensive urgencies, with at least one year of follow-up. Survival analyses for all-cause mortality, cardiovascular mortality, and incident MACE were performed using Kaplan–Meier methods and adjusted Cox proportional hazards models. MACE were defined as TIA, IS, HS, ACS, AF, AHF, AAD, RA, sPAD. Results: Overall mortality was 7.9%, with no significant sex differences in crude mortality rates. Kaplan–Meier survival curves showed similar trajectories between men and women. However, in adjusted Cox analyses, female sex was independently associated with lower all-cause mortality (hazard ratio HR 0.62; p = 0.004). Increasing age, diabetes mellitus, chronic kidney disease, and active smoking were strong independent predictors of mortality. For incident MACE, Kaplan–Meier analysis showed no significant differences in time to first event between men and women (median 143 days in men vs. 176 days in women; log-rank p = 0.41). In contrast, adjusted Cox models demonstrated that female sex was independently associated with a lower risk of developing a Mduring follow-up (HR 0.70; 95% confidence interval 0.53–0.93), mirroring the protective association observed for all-cause mortality. Age and smoking exposure emerged as the strongest predictors of MACE, whereas most traditional cardiovascular risk factors did not retain independent associations after adjustment. For cardiovascular mortality, age, diabetes mellitus, and chronic kidney disease remained independently associated with higher risk, whereas female sex was not independently associated after multivariable adjustment. Conclusions: Despite similar unadjusted mortality and event rates, female sex is independently associated with lower all-cause mortality and a reduced risk of major cardiovascular events after ED discharge for hypertensive urgencies. The absence of sex differences in unadjusted Kaplan–Meier analyses, together with the protective associations observed after multivariable adjustment, suggests that sex-related biological and clinical factors modulate cardiovascular risk beyond baseline differences. Incorporating sex-specific considerations into post-discharge risk stratification may improve long-term cardiovascular assessment and follow-up strategies after hypertensive urgencies.