If we assume that women and men exhibit variations of the same fundamental vascular physiology, then conventional analyses of subclinical measures would suggest that women catch up to men by midlife ...in the extent of potentially important vascular disease. Alternatively, under the assumption that vascular physiology may fundamentally differ between women and men, a sex-specific analysis of existing data could offer new insights and augment our understanding of sex differences in cardiovascular diseases.
To evaluate whether longitudinal patterns of blood pressure (BP) elevation differ between women and men during the life course when considering baseline BP levels as the reference.
We conducted sex-specific analyses of longitudinal BP measures (144 599 observations) collected for a period of 43 years (1971 to 2014) in 4 community-based US cohort studies. The combined total included 32 833 participants (54% female) spanning ages 5 to 98 years. Data were analyzed between May 4, 2019, and August 5, 2019.
Age and serially assessed longitudinal BP measures: systolic BP, diastolic BP, mean arterial pressure (MAP), and pulse pressure (PP).
Sex-specific change in each primary BP measure compared with baseline BP levels, derived from multilevel longitudinal models fitted over the age span, and new-onset cardiovascular disease events.
Of the 32 833 participants, 17 733 were women (54%). Women compared with men exhibited a steeper increase in BP that began as early as in the third decade and continued through the life course (likelihood ratio test χ2 = 531 for systolic BP; χ2 = 123 for diastolic BP; χ2 = 325 for MAP; and χ2 = 572 for PP; P for all <.001). After adjustment for multiple cardiovascular disease risk factors, these between-sex differences in all BP trajectories persisted (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).
In contrast with the notion that important vascular disease processes in women lag behind men by 10 to 20 years, sex-specific analyses indicate that BP measures actually progress more rapidly in women than in men, beginning early in life. This early-onset sexual dimorphism may set the stage for later-life cardiovascular diseases that tend to present differently, not simply later, in women compared with men.
It is well known that cardiovascular disease manifests differently in women and men. The underlying causes of these differences during the aging lifespan are less well understood. Sex differences in ...cardiac and vascular phenotypes are seen in childhood and tend to track along distinct trajectories related to dimorphism in genetic factors as well as response to risk exposures and hormonal changes during the life course. These differences underlie sex-specific variation in cardiovascular events later in life, including myocardial infarction, heart failure, ischemic stroke, and peripheral vascular disease. With respect to cardiac phenotypes, females have intrinsically smaller body size-adjusted cardiac volumes and they tend to experience greater age-related wall thickening and myocardial stiffening with aging. With respect to vascular phenotypes, sexual dimorphism in both physiology and pathophysiology are also seen, including overt differences in blood pressure trajectories. The majority of sex differences in myocardial and vascular alterations that manifest with aging seem to follow relatively consistent trajectories from the very early to the very later stages of life. This review aims to synthesize recent cardiovascular aging-related research to highlight clinically relevant studies in diverse female and male populations that can inform approaches to improving the diagnosis, management, and prognosis of cardiovascular disease risks in the aging population at large.
Biologic prostheses are preferred for surgical aortic valve replacement (SAVR) in patients more than 70 years of age in clinical practice. This study investigated differences in long-term outcomes ...between SAVR-treated patients more than 70 years of age who received mechanical or biologic prosthetic valves.
All patients (excluding those with endocarditis) who were more than 70 years of age and who underwent isolated first-time SAVR (with or without coronary artery bypass grafting) in Finland between 2004 and 2014 were retrospectively studied (n = 4227). Propensity score matching (1:3) was used to account for baseline differences (n = 296 with mechanical prostheses and n = 888 with biologic prostheses). Outcomes were 10-year survival, major bleeding (all, gastrointestinal, intracranial), ischemic stroke, infective endocarditis, and aortic valve reoperation. Mean age was 75.8 years, and mean follow-up was 8.3 years.
Survival at 10 years was 46.1% with mechanical prostheses and 57.8% with biologic prostheses (hazard ratio HR, 1.48; 95% confidence interval CI, 1.21 to 1.80; P < .001; number needed to harm = 7.0). The 10-year major bleeding rates were 37.0% with mechanical valves and 18.8% with biologic valves (HR, 1.77; 95% CI, 1.25 to 2.49; P = .001; number needed to harm = 7.4). Both gastrointestinal bleeding (26.5% vs 8.9%; HR, 2.63; 95% CI, 1.63 to 4.23; P < .001) and intracranial bleeding (8.8% vs 6.0%; HR, 2.12; 95% CI, 1.09 to 4.15; P = .028) were significantly more frequent with mechanical valve prosthesis. Occurrence of ischemic stroke (18.9% with mechanical prosthesis vs 16.1% with biologic prosthesis; P = .341), infective endocarditis (3.7% vs 2.8%; P = .242), or aortic valve reoperation (0.8% vs 2.8%; P = .707) did not differ between study groups.
Mechanical aortic valve prosthesis is associated with worse long-term survival and increased bleeding after SAVR in patients more than 70 years old. The study results suggest caution when considering mechanical aortic valve prostheses in elderly patients.
Ambulatory blood pressure (BP) is considered as the gold standard of BP measurement although it has not been shown to be more strongly associated with cardiovascular risk than is home BP. Our ...objective was to compare the prognostic value of office, home, and ambulatory BP for cardiovascular risk in 502 participants examined in 1992 to 1996. The end point was a composite of cardiovascular mortality, myocardial infarction, stroke, heart failure hospitalization, and coronary intervention. We assessed the prognostic value of each BP in multivariable-adjusted Cox models. The likelihood χ2 ratio value was used to test whether the addition of a BP variable improved the model’s goodness of fit. After a follow-up of 16.1±3.9 years, 70 participants (13.9%) had experienced ≥1 cardiovascular event. Office (systolic/diastolic hazard ratio per 1/1 mm Hg increase in BP, 1.024/1.018; systolic/diastolic 95% confidence interval, 1.009–1.040/0.994–1.043), home (hazard ratio, 1.029/1.028; 95% confidence interval, 1.013–1.045/1.005–1.052), and 24-hour ambulatory BP (hazard ratio, 1.033/1.049; 95% confidence interval, 1.019–1.047/1.023–1.077) were predictive of cardiovascular events. When all 3 BP variables were included in the model simultaneously, only systolic/diastolic ambulatory BP was a significant predictor of cardiovascular events (P=0.002/<0.001). Home systolic/diastolic BP improved the fit of the model only marginally when added to a model including office BP (χ2=3.0/4.0, P=0.09/0.047). Ambulatory BP, however, improved the fit of model more clearly when added to office and home BP (χ2=9.0/12.3, P=0.001/<0.001). Our findings suggest that ambulatory BP is prognostically superior to office and home BP.
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