A new study published in Hypertension, a peer-reviewed journal of the American Heart Association, reveals that the increase in pulse pressure—the difference between systolic and diastolic blood pressure—and aortic stiffness in women begins roughly two decades before menopause, challenging the long-held belief that menopause is the primary driver of these cardiovascular changes. The findings suggest that healthcare professionals should pay closer attention to pulse pressure in middle-aged and older women as an early indicator of heart disease risk.
The aorta, the body's largest blood vessel, stiffens with age, leading to a wider pulse pressure. This widening forces the heart to work harder and can damage small vessels in organs like the brain and kidneys. While pulse pressure typically falls in early adulthood as the aorta expands, it begins to rise after midlife. This transition occurs earlier in women—around their late 30s—compared to men, who experience it in their late 40s. The study, which analyzed data from 6,760 women and 3,248 men in the Framingham Heart Study over 14 years, found that the timing of menopause—whether early, average, or late—had no influence on when pulse pressure reached its lowest point. Even women who entered menopause early or late showed the same pattern, indicating that vascular aging may begin years before the final menstrual period.
“To our huge surprise, our results suggest that factors other than the timing of the final menstrual period were likely involved in the accelerated increase in pulse pressure in women after midlife,” said study senior author Gary F. Mitchell, M.D., a longstanding NIH-funded investigator with the Framingham Heart Study and president of Cardiovascular Engineering, Inc. “Healthcare professionals should definitely consider pulse pressure in middle-aged and older patients – especially women – with high blood pressure. Women and their doctors should sound the alarm if pulse pressure is higher than 60 mm Hg [such as 130/70 mm Hg] and track it over time to see if pulse pressure is rising.”
The implications for clinical practice are significant. Wide pulse pressure is an independent risk factor for cardiovascular disease, dementia, and kidney disease, and it may make high blood pressure less responsive to standard medications. Despite this, pulse pressure is not currently included in clinical guidelines for managing blood pressure. The study authors advocate for its inclusion, especially for women, who often have their heart disease risk underestimated. Samar R. El Khoudary, Ph.D., M.P.H., FAHA, who chaired the writing group for a 2020 American Heart Association scientific statement on the menopause transition and was not involved in the current study, emphasized that “we shouldn’t wait until menopause to start thinking about cardiovascular health. By the time a woman reaches her final menstrual period, vascular changes may already have been underway for years. Midlife is an opportunity to identify cardiovascular risk early and intervene before disease develops.”
The findings underscore the need for earlier monitoring of pulse pressure in women, potentially leading to tailored treatment approaches and improved prevention of heart disease, dementia, and kidney disease. As the population ages, recognizing pulse pressure as a key risk factor could transform how healthcare professionals assess and manage cardiovascular health in women.
