Present narative review article by Vriend et al. has given an overview of the current studies on the topic of sex differences in blood pressure (BP), hypertension and hypertension - mediated cardiovascular complications which have become an increasingly important focus of attention (1).

The aim of the article was to provide a deeper understanding of the sex-based disparities in hypertension with essential insights for improving prevention and management strategies for both men and women. Beside search for studies in current databases, authors additionally included baseline data of the HEalthy Life in an Urban Setting (HELIUS) study, a multi-ethnic, population-based cohort study including more than 20,000 participants living in Amsterdam, The Netherlands (2). The substantial sex-disparities in BP-trajectories throughout life have been revealed in the past decade in various population-based studies. Importantly,  although women have a lower arterial blood pressure than men, they also have a larger increase in hypertension prevalence after 30 years of age. Systolic blood pressure (SBP) increases much steeper in men between 15 and 20 years, while from 20 years of age onwards SBP increases more rapidly in women (3). Interestingly, there was a higher prevalence of white coat HT in women than in men (1).  

Women also had a stronger association between BP and cardiovascular disease (CVD). Hypertensive women had higher pulse-wave velocity (PWV), greater brain white matter damage and exhibited a concentric cardiac remodeling more than men (1). A study by Regitz-Zagrosek showed a more marked small-artery remodeling in women than in men which supported the notion of a higher prevalence of microvascular pathogenesis in women with ischemic heart disease (4). Blood pressure and glucose induce small-artery remodeling in women in study by Bruno et al 5. Interestingly, in study by Stupin at al, in 203 young healthy individuals (67 men/136 women), young healthy women exhibit higher microvascular reactivity compared to age-matched men. Systolic blood pressure or waist-to-hip ratio were negatively associated with vascular reactivity only in women, suggesting that blood pressure and central obesity may pose greater risk to young healthy women than men by adversely affecting peripheral microvascular function (6).

On the other hand, women had lower risk of end-stage kidney disease than men. However, there are marked disparities in the studies on the interaction between sex, hypertension, and white matter damage and also paradoxical results in prevalence of chronic kidney disease, suggesting overdiagnosing in one or other sex, coincident with the life duration expectancy (1).

In general, the effects of antihypertensive treatment appear to be consistent across sexes in different populations, although there remains uncertainty about differences in the efficacy of BP lowering drugs below 55 years of age (1). Older men reported better control of HT than women, while women reported more side effects of antihypertensive drugs than men (1). Nevertheless, a recent meta-analysis assessing the effectiveness of antihypertensive medication, based on data from 51 randomized controlled trials involving 358,636 participants (42% women), indicates that the reduction in blood pressure and the relative benefits for cardiovascular disease treatment are comparable between men and women. Moreover, these effects are consistent across different age groups and types of antihypertensive drugs (7), as authors also referred (1).

Authors concluded that the current uniform approach to the diagnosis and management of hypertension in both sexes neglects the distinctions in hypertension, while the differences underscore the need for sex-specific recommendations, particularly for younger individuals. A major limitation affecting insights into sex differences in BP-related outcomes is the lack of sex-stratified analyses or an adequate representation of women, particularly young women. Since the most pronounced difference in BP tra¬jectories is present in the young individuals, additional large-scale, longitudinal studies are essential (1). Particularly, endothelium - dependent mechanisms and their involvement in vascular reactivity and remodeling in relation to blood pressure levels should be more thoroughly explored, due to potential significant impact on sex-determined blood pressure trajectories.