A growing body of research suggests that high blood pressure, or hypertension, affects men and women in different ways.
Emerging research suggests that women may have an increased risk of heart attack and stroke at a lower blood pressure than men, even when their blood pressure falls in the range that is currently considered healthy. Although the evidence is far from definitive, some scientists are calling for additional studies to learn whether guidelines on hypertension need to be updated to include different recommendations for men and women.
“There’s not enough evidence to say, ‘Yes, women should be treated for hypertension at a lower blood pressure level than men,’” says epidemiologist Tali Elfassy, an assistant professor of cardiometabolic research at the University of Miami Miller School of Medicine. “But there’s definitely enough information out there to suggest that maybe we really need to look into this further.”
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Nearly half of American adults have high blood pressure, and experts agree that hypertension is a serious public health problem. High blood pressure raises the risk of heart attack, stroke, pregnancy complications and other health problems.
Although a higher proportion of men overall have high blood pressure—which affects about 51 percent of men and 40 percent of women—hypertension rates are actually higher among women than men after age 60. Because women tend to live longer than men, the total number of women living with hypertension is greater than the number of men living with the condition.
The American Heart Association and the American College of Cardiology define hypertension as a blood pressure reading of 130/80 millimeters of mercury (mm Hg) or higher and normal blood pressure as a level below 120/80 mm Hg.
Those guidelines are the same for men and women. A study published in Circulation in 2021 called them into question. In an analysis of about 28,000 people, researchers focused on systolic blood pressure. Over an average of 28 years of follow-up, researchers found that women with a systolic blood pressure from 100 to 109 mm Hg—which is currently within the range that is considered healthy—had a cardiovascular disease risk equivalent to men with a systolic pressure of 130 to 139, which qualifies as hypertension, says C. Noel Bairey Merz, a coauthor of the paper and director of the Barbra Streisand Women's Heart Center at Cedars-Sinai’s Smidt Heart Institute.
“It seems relatively clear now that women have a slightly lower range of healthy blood pressure than men,” says Susan Cheng, senior author of the paper and director of public health research at the Smidt Heart Institute at Cedars-Sinai.
While Cheng says her research suggests the ideal systolic blood pressure for men is 120 mm Hg or lower, the healthiest level for women appears to be 110 or less.
It’s plausible that blood pressure—the force that blood exerts on artery walls—doesn’t need to be as high in women as in men to cause problems because women have smaller artery diameters even after accounting for body size, Elfassy says. Her research also found that women were at higher risk with a lower blood pressure than men. In a study published in Hypertension in 2023 that included health records of more than 53,000 people, Elfassy and her colleagues found that women were at an elevated risk of dying from cardiovascular disease with a systolic blood pressure 12 points lower than that of men. Compared with people with a systolic pressure of 105 mm Hg, a woman’s risk of cardiovascular death began to increase at 123 mm Hg, compared to 135 mm Hg for men.
These results support the possibility that blood pressure recommendations should be lower for women than for men, Elfassy says. Waiting until systolic blood pressure climbs to 130 mm Hg—the current level at which medication or lifestyle changes are recommended—to treat high blood pressure may put women at unnecessary risk, she says.
While blood pressure tends to rise in all people as they age, recent studies show that the increase follows different trajectories in men and women. Although women begin adulthood with lower blood pressure than men, women’s blood pressure climbs much more sharply than in men, Cheng says. In women, the increase in blood pressure can begin to accelerate as early as one’s 20s.
Responding to recent research, the European Society of Cardiology published a consensus document in 2022 that suggested that “sex-specific thresholds for diagnosis of hypertension may be reasonable.” But the authors noted that there’s not yet enough evidence to know whether hypertension should be managed differently in men and women.
That’s because clinical trials of cardiovascular disease have not always been designed to detect sex differences, Elfassy says.
A High Bar for Updating Guidelines
Although the American Heart Association and the American College of Cardiology are jointly in the process of updating their hypertension guidelines, they’re not looking into issuing sex-specific advice, says Joshua Beckman, a cardiologist and chair of the organizations’ Joint Committee on Clinical Practice Guidelines.
These organizations, which last updated their hypertension advice in 2017, only change their recommendations when medical evidence is “rock-solid,” says Beckman, who is also director of vascular medicine at the University of Texas Southwestern Medical Center.
The groups are unlikely to change their guidelines unless rigorous clinical trials—in which one group is randomly assigned to a treatment and the other is not—prove that doing so would save lives or prevent cardiovascular emergencies such as heart attacks and strokes, Beckman says.
Although researchers have amassed huge amounts of data on blood pressure from clinical trials in recent decades, those trials have usually enrolled fewer women than men, making it harder to draw conclusions about the ideal blood pressure in women, says Nanette Wenger, a cardiologist and a professor of medicine at the Emory University School of Medicine. Generating that evidence wouldn’t necessarily involve new clinical trials, however, Wenger says. Instead scientists could analyze data from the many previous hypertension studies performed over the past two decades, “mining old databases with the new luxury of artificial intelligence,” she says, noting that AI might help spot trends in data that researchers might miss.
Stephen Juraschek, a physician and epidemiologist at Beth Israel Deaconess Medical Center, says researchers would want to make sure that the benefits of treating women’s blood pressure more aggressively outweigh any potential harms. In previous trials, complications from more intensive use of hypertension medications included acute kidney injury, low blood pressure and fainting, although these problems affected men and women equally.
Although funding for large medical projects isn’t always easy to find, Wenger says researchers might be able to tap into the $100 million in funding from the White House Initiative on Women’s Health Research, which First Lady Jill Biden announced in February. Hypertension rates are particularly high among Black adults, who are 30 percent more likely to develop high blood pressure than white adults but less likely to have it controlled. Overall, only one in four Americans diagnosed with hypertension have lowered their blood pressure to a recommended level, according to the Centers for Disease Control and Prevention.
Some cardiologists say that doctors must do a better job of helping their patients reduce blood pressure to currently recommended levels rather than ponder new recommendations. “I don’t think we need more guidelines,” says Karol Watson, a professor of medicine and cardiology at the David Geffen School of Medicine at the University of California, Los Angeles. “We need to adhere to the guidelines we currently have.”
Targeting Those Most at Risk
Cheng says there’s already evidence suggesting that a specific group of women may benefit from more intensive blood pressure control.
Studies have long shown that, among people with type 2 diabetes, women have a relatively greater risk of developing cardiovascular disease than men, Cheng says. Although professional guidelines differ slightly on the exact treatment thresholds, most of them call for lowering systolic blood pressure in people with diabetes to less than 140 mm Hg, either by using higher doses of medication or adding additional antihypertensive drugs.
In a study published in April in Diabetes Care, Cheng and her colleagues at the Smidt Heart Institute found a benefit to using medication to reduce systolic pressure below 120 mm Hg—but only in women with diabetes who were diagnosed with hypertension before age 50. Over an average of 4.5 years, the risk of cardiovascular problems in these women fell by 35 percent. Researchers found no significant benefit to lowering blood pressure intensively in women with diabetes who were diagnosed with hypertension at age 50 or older or in men with diabetes of any age.
Although many heart-related recommendations are the same for everyone—including guidelines on blood sugar, smoking, exercise and diet—there are precedents for creating sex-specific guidelines in health, Cheng says.
Doctors use different reference standards for men and women, for example, when performing echocardiograms to measure the size of the heart simply because men typically have slightly larger hearts than women, Cheng says.
Conducting research on sex differences in hypertension could potentially help save lives, Juraschek says. “If we were to lower these normal-looking blood pressures in women,” he asks, “could we prevent cardiovascular events?”