Women experience a steeper rise in blood pressure than men and this trend begins as early as the third decade of life, suggests a study published in JAMA Cardiology.

The results suggest that women may experience more rapid vascular aging, which may make them more vulnerable to cardiovascular risk factors at earlier stages in life, said senior author Susan Cheng, MD, Erika J. Glazer Chair in Women’s Cardiovascular Health at Cedars Sinai Medical Center in Los Angeles, and her colleagues earlier this year. Previously, Cheng and her colleagues had compared the effects of aging on cardiac remodeling in men and women using echocardiographic data over 16 years from more than 4000 participants in the Framingham Study and found that women had greater left ventricular wall thickening when compared with men. In the new study, the team decided to take a different approach by analyzing blood pressure trajectories in men and women separately. To do this, they analyzed data from more than 32 000 participants in 4 large cohort studies over 40 years. When the trajectories of men and women were tracked separately, it became apparent that women had a steeper rise in blood pressure.

“We didn’t appreciate that the [blood pressure] trajectories were actually different if you allow women to be analyzed separately from men and compared [women with women] as opposed to [women with men],” she explained.

The results are the latest in a growing body of evidence that suggests women’s heart disease is physiologically distinct from men’s heart disease. These differences likely have important implications for the disease presentation, trajectory, and treatment, and for the design of studies.

“We really should be thinking about males and females differently, not only with respect to anatomy and physiology, but also pathophysiology,” Cheng said.

Eva Gerdts, MD, PhD, Professor of Cardiology at the University of Bergen in Norway, who recently published a review in Nature Medicine of the sex differences in cardiometabolic disease, said many of the differences likely trace back to fundamental biologic differences between males and females. For example, she noted that the X chromosome is much larger than the Y chromosome and is home to about 1500 genes. Many of them that have nothing to do with sexual function but play important roles in immunity, the immune system, and the cardiovascular system.

Genetic differences between males and females extend far beyond the sex chromosomes, noted Cheng. She cited a study published by David Page, MD, Director of the Whitehead Institute, in Science last year that demonstrated profound sex differences in gene expression on multiple chromosomes in 12 different tissues in humans, macaques, mice, rats, and dogs.

“This basically tells us that males and females probably manifest fundamentally different biology, and potentially anatomy and physiology, starting from way before birth,” Cheng said. “It’s not just about having XY versus XX, at least in humans. It’s about something related to differences that are really there at the level of gene expression.”

Because of some of these biological differences, women may be more vulnerable to some cardiovascular risk factors. For example, Cheng noted that women have smaller caliber arteries even when you adjust for size differences between men and women. This may make women more sensitive to the effects of risk factors like smoking that affect the endothelial cells lining the arteries.

“If a woman smokes a pack a day of cigarettes and a man smokes a pack a day of cigarettes, the total dose of exposure to surface area is larger for that woman versus for that man,” she said.

Women are also more likely than men to have certain risk factors like obesity, and hypertension and obesity may have worse cardiovascular consequences for women, Gertz said. Estrogen has been shown to provide some cardiometabolic protection for women, but reduced levels after menopause make it a particularly vulnerable period.

“What you see in the female is that as long as she is premenopausal and has normal estrogen circulating levels in her blood, she will be more flexible in her cardiovascular system,” Gertz explained. “It is a big shift for the flexibility of the arteries, and also for the heart, when menopause comes into play, and so hormonal changes that are related to menopause can contribute to the exponential increase that we see in high blood pressure in women after middle age.”

These biological differences may also explain why women often present with different kinds of heart disease than men. For example, Gerdts noted that women are less likely to have a clotted artery during a heart attack.

“When you have the clotted artery, there is a targeted treatment that is well-documented, and that will prolong your life and save your heart muscle,” Gerdts said. “If there is no clotted artery, we don’t know the cause of your heart attack, we don’t know the best treatment, and this is then something that leads to heart failure and to increased mortality.”

Heart failure also often presents differently in women than men. Women are more likely to have heart failure with preserved ejection fraction, which is associated with hypertension and obesity, Gerdts noted. Although good treatments are available for types of heart failure more frequently seen in males, Gerdts noted that there are no medications available that prolong life in patients with preserved ejection fraction.

A recent study in the International Journal of Cardiology highlighted some of the sex differences in heart failure. Women are more likely to have preserved ejection fraction than men and less likely to dilate their heart, explained Noel Bairey Merz, MD, Medical Director of the Barbra Streisand Women’s Heart Center at Cedar-Sinai Medical Center’s Smidt Heart Institute.

“We used to think that the female pattern [of heart failure] was more benign or not as serious, but it turns out that’s not true,” Merz said. “The 50 years of heart failure research in men, for men, and by men have resulted in actually quite good therapies for the male pattern heart disease, but we really have nothing for the female pattern heart disease.”

But there is now intense interest and study in heart failure in women. Merz and her colleagues are currently exploring whether microvascular dysfunction leads to stiffening of the ventricle. If that proves to be true, it would highlight the importance of interventions to prevent ventricle stiffening, which already exist, Merz said.

Cheng emphasized that better understanding and treating women’s heart disease will take coordinated and interdisciplinary efforts.

“We are actively working on trying to better understand how these differences might translate into what we see in the clinic, in our day-to-day practice,” she said. n

A growing body of evidence detailing differences in women’s heart disease suggests a more tailored approach to their care.

《美国医学会杂志》（JAMA Cardiology）发表的一项研究表明，女性的血压上升幅度要比男性高，而且这种趋势最早出现在生命的第三个十年。

研究结果表明，女性可能经历更快的血管衰老，这可能使她们在生命的早期阶段更容易受到心血管危险因素的影响，塞达斯西奈医学中心女性心血管健康部门主席Erika J. Glazer的医学博士Susan Cheng说在洛杉矶和她的同事今年初。此前，Cheng和她的同事使用Framingham研究的4000多名参与者的16年超声心动图数据，比较了衰老对男女心脏重构的影响，发现与男性相比，女性左心室壁增厚更大。在这项新研究中，研究小组决定采用不同的方法，分别分析男女的血压轨迹。去做这个，他们分析了40年来4项大型队列研究的32,000多名参与者的数据。当分别追踪男女的轨迹时，很明显，女性的血压上升更为陡峭。

她解释说：“如果让女性与男性分开进行分析并比较女性与女性而不是男性与女性，那么我们的[血压]轨迹实际上是不同的，”她解释道。

该结果是越来越多的最新证据，表明女性心脏病在生理上不同于男性心脏病。这些差异可能对疾病的表现，轨迹和治疗以及研究设计具有重要意义。

程说：“我们确实应该对男性和女性进行不同的思考，不仅在解剖学和生理学方面，而且在病理生理学方面。”

挪威卑尔根大学心脏病学教授Eva Gerdts博士最近在《自然医学》杂志上发表了一篇有关心血管代谢疾病性别差异的评论，他说，许多差异可能都源于男性和女性之间的基本生物学差异。 。例如，她指出X染色体比Y染色体大得多，并且拥有约1500个基因。其中许多与性功能无关，但在免疫，免疫系统和心血管系统中起重要作用。

程说，男性和女性之间的遗传差异远远超出了性染色体。她引用了怀特海德研究所（Whitehead Institute）主任戴维·佩奇（David Page，MD）去年在科学杂志上发表的一项研究，该研究证明了人类，猕猴，小鼠，大鼠和狗的12种不同组织在多条染色体上基因表达的深刻性别差异。

程说：“这基本上告诉我们，男性和女性可能从出生前就开始表现出根本不同的生物学，以及潜在的解剖学和生理学。” “至少在人类中，这不仅仅是XY与XX。这是与基因表达水平上确实存在的差异相关的东西。”

由于某些生物学差异，妇女可能更容易受到某些心血管危险因素的影响。例如，Cheng指出，即使根据男性和女性的体型差异进行调整，女性的动脉口径也较小。这可能会使女性对诸如吸烟之类的危险因素的影响更加敏感，而吸烟会影响动脉内壁的内皮细胞。

她说：“如果一个女人每天吸一包烟，而一个男人每天吸一包烟，那么与那个男人相比，该女人暴露在表面积上的总剂量会更大。”

盖茨说，女性也比男性更有可能患肥胖等某些危险因素，而高血压和肥胖对女性的心血管后果可能更严重。雌激素已被证明可以为女性提供一些心脏代谢保护，但是绝经后血脂水平的降低使其成为特别脆弱的时期。

Gertz解释说：“您在女性中看到的是，只要她处于绝经前并且血液中的雌激素循环水平正常，她的心血管系统就会更加灵活。” “绝经开始时，这对于动脉以及心脏的柔韧性都是一个很大的转变，因此，与绝经有关的荷尔蒙变化可能会导致女性高血压后的指数增加。中年。”

这些生物学上的差异也可以解释为什么女性经常表现出与男性不同的心脏病。例如，盖尔兹（Gerdts）指出，女性在心脏病发作期间不太可能患有动脉凝块。

Gerdts说：“当您的动脉被凝结时，有针对性的治疗方法将有据可查，这将延长您的寿命并节省您的心脏肌肉。” “如果没有凝结的动脉，我们不知道您心脏病发作的原因，我们也不知道最好的治疗方法，那么这会导致心力衰竭并增加死亡率。”

女性的心力衰竭也常常与男性不同。Gerdts指出，女性更容易患有射血分数受损的心力衰竭，这与高血压和肥胖症有关。尽管对于男性中较常见的心力衰竭类型，可以使用良好的治疗方法，但Gerdts指出，尚无可延长射血分数保留的患者延长寿命的药物。

《国际心脏病学杂志》最近的一项研究强调了心力衰竭的一些性别差异。Cedar-Sinai医学中心Smidt心脏研究所的Barbra Streisand妇女心脏中心医学主任Noel Bairey Merz医师解释说，女性比男性更可能保留射血分数，并且不太可能扩张心脏。

“我们以前认为[心力衰竭]的女性模式更为温和或不那么严重，但事实并非如此，”默兹说。“对男性，男性和男性进行的50年心力衰竭研究实际上已经为男性型心脏病提供了很好的疗法，但是对于女性型心脏病我们却一无所获。”

但是，现在人们对女性心力衰竭的兴趣和研究都非常强烈。Merz和她的同事目前正在研究微血管功能障碍是否导致心室僵硬。默兹说，如果事实证明这是真的，那将凸显干预措施对防止心室僵直的重要性。

程强调，要更好地了解和治疗妇女心脏病，将采取协调和跨学科的努力。

她说：“我们正在积极努力，以更好地理解这些差异如何在我们的日常实践中转化为我们在诊所看到的东西。” ñ

越来越多的证据详细说明了女性心脏病的差异，这提示了一种针对性更强的护理方法。