Aortic structure may affect midlife rise in pulse pressure, aortic stiffness in women
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Contradicting conventional wisdom, menopause may not be the driving force behind an increase in aortic stiffness in women after midlife, according to new, independent research published today in Hypertension.
The aorta, the largest blood vessel in the body, receives oxygen-rich blood from the heart and delivers it to other organs throughout the body. In many people, particularly after midlife, the walls of the aorta stiffen. Pulse pressure is influenced by the stiffness and width of the aorta and is measured by the difference between the upper (systolic) and lower (diastolic) numbers in a blood pressure reading. A wider pulse pressure (higher number) means the heart is working harder, and it can also damage the small vessels of other organs, such as the brain or kidneys.
Between early adulthood and midlife, pulse pressure usually falls because the internal diameter of the aorta increases, easing blood flow. After midlife, pulse pressure widens or rises as aortic diameter stops increasing and the aortic walls stiffen. This midlife transition is particularly marked in women, who start life with a smaller volume of elastic fibers in the aorta. Because women have fewer elastic fibers in the aorta, the transition from having a lower pulse pressure than men before midlife results in a much higher pulse pressure after midlife.
"Many people believe that the change in pulse pressure is linked to the hormonal shifts caused by menopause. Here, we are evaluating whether the timing of this change, from falling to rising pulse pressure, is connected to menopause timing in a long-term study," said study senior author Gary F. Mitchell, MD, an investigator with the Framingham Heart Study and president of Cardiovascular Engineering Inc. in Needham, Massachusetts.
Researchers analyzed data from the Framingham Heart Study, which has conducted health exams and collected information for up to three generations of families living in Massachusetts, to investigate heart disease risk factors.
Study findings include:
- Pulse pressure reached its lowest point and changed from a falling to a rising profile about a decade earlier in women than in men: in their late 30s among women rather than their late 40s among men.
- Whether menopause (date of last menstrual period) occurred early, late or at a typical time had no influence on the age at which women had the lowest pulse pressure, which occurred up to two decades before the onset of menopause.
- Pulse pressure increased with age in both men and women after midlife, although the increase was faster in women, resulting in an average pulse pressure that was higher in women than in men after age 60.
"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," Mitchell said.
While high blood pressure is the most modifiable risk factor for cardiovascular disease, strong evidence indicates that wide pulse pressure is an independent risk factor for various cardiovascular conditions, as well as dementia and kidney disease. However, pulse pressure is currently not included in clinical guidelines for managing blood pressure.
"Health care professionals should definitely consider pulse pressure in middle-aged and older patients—especially women—with high blood pressure," Mitchell said. "Because women's overall heart disease risk is lower, they are often told that a blood pressure that is 'borderline'—for example, an upper number of 130 mm Hg—can just be watched. However, 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."
Greater attention to pulse pressure may also help guide individual treatment approaches. High blood pressure with a wide pulse pressure is less likely to respond to the usual treatments, so tailored treatment is important, Mitchell added.
"Vascular aging may begin years before menopause, but that doesn't mean menopause is irrelevant. The trajectory may accelerate as women enter perimenopause," said Samar R. El Khoudary, Ph.D., MPH, FAHA, who chaired the writing group for a 2020 American Heart Association scientific statement on the menopause transition.
El Khoudary was not involved in the current study and is chair and professor of epidemiology at the School of Public Health and director of Women's Public Health Research Initiatives at the Institute of Women's Health at Virginia Commonwealth University in Richmond, Virginia. She added that women and health care professionals should be thinking about heart health long before menopause.
"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."
Publication details
Relations of Menopause Timing With Pressure Pulsatility in the Framingham Study, Hypertension (2026). DOI: 10.1161/HYPERTENSIONAHA.126.27015
Journal information: Hypertension
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CardiologyWomen's healthHealthy agingCommon illnesses & Prevention Provided by American Heart Association Who's behind this story?
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