Sex-specific blood pressure trajectories and cardiovascular disease in type 1 diabetes: 32-Year follow-up of the Pittsburgh Epidemiology of Diabetes Complications cohort

ABSTRACT Objective: We examined sex differences in longitudinal blood pressure (BP) and 32-year cardiovascular disease (CVD) incidence in the Pittsburgh Epidemiology of Diabetes Complications (EDC) type 1 diabetes cohort. Research Design and Methods: BP was measured up to nine (median six) times between 1986-88 baseline and 2016-18. N=300 women and 304 men without CVD at baseline were followed until December 2020 for incidence of total CVD, major adverse cardiovascular events (MACE: CVD death, myocardial infarction (MI), or stroke), and hard coronary artery disease (hCAD: CAD death, MI, or coronary revascularization/blockage≥50%). We estimated associations between time to event and longitudinal systolic (SBP) and diastolic (DBP) BP by sex using joint models adjusted for time-varying longitudinal antihypertensive (AH) medication use, HbA1c, and overt nephropathy, baseline age, and other CVD risk factors. Results: Longitudinal SBP was 5.8 mmHg lower (p<0.0001) and DBP 6.2 mmHg lower (p<0.0001) in women versus men. Women had -0.3 mmHg/year faster DBP decline (p<0.0001) despite similar AH rates by sex. Incidence of CVD was similar by sex. Each 5-mmHg increment in longitudinal SBP (HR=1.23, 95% confidence interval (CI) 1.04, 1.45) and DBP (HR=1.56, 95% CI 1.20, 2.04) were associated with MACE in men only; DBP (HR=1.28, 95% CI 1.05, 1.56) was associated with hCAD in women only. Conclusions: BP was lower in women than men and the strength of its association with the initial manifestation of CVD differed by sex. Further research into sex-specific BP mechanisms is needed to improve CVD risk reduction in people living with type 1 diabetes.