Abstract Body: Background:
Arterial stiffness is a subclinical cardiovascular risk factor and has been shown to predict the risk of stroke. The menopausal transition increases cardiovascular morbidity and mortality, but its association with arterial stiffness is understudied. Additionally, whether menopause modifies the association of arterial stiffness and stroke is largely unknown.

Objective:
To examine the association of menopause and arterial stiffness; and whether menopause modifies the relationship between arterial stiffness and incident stroke.

Methods:
We analyzed 9,036 women with hypertension and without a history of cardiovascular disease from the Hypertension and Stroke Prevention and Control Project (HSPCP), an observational study conducted since 2016 in rural China. Menopause status was acquired via questionnaires and was confirmed using multiple cross-checked questions. Carotid-femoral pulse wave velocity (cfPWV) was measured noninvasively using a Pulse Pen device. The primary outcome was incident stroke, and the secondary outcome was incident ischemic stroke.

Results:
At baseline, the mean age was 60.36 (SD,9.24) and 7,275 (81%) were postmenopausal. Over a mean follow-up time of 6.12 (SD, 1.08) years, 957 cases of stroke were reported, including 851 ischemic stroke. On average, postmenopausal women were approximately 12 years older than premenopausal women and had significantly higher levels of cfPWV, which remained higher after adjustment for covariates (b=1.11, 95% CI, 1.01-1.22; p<0.001). We found that the age-cfPWV slope was much steeper in postmenopausal women compared to premenopausal women. Additionally, we found that elevated cfPWV was only significantly associated with the risk of incident stroke among postmenopausal women, with an age-adjusted hazard ratio (HR) of 1.63 (95% CI, 1.21-2.19; per standard deviation of cfPWV). However, such an association was null in premenopausal women (HR 1.08 [95% CI, 0.41-2.86]). Similar findings were observed for incident ischemic stroke and after restricting the analysis to premenopausal women younger than 40 years.

Conclusions
Among hypertensive adults, postmenopausal transition is associated with higher cfPWV levels. Additionally, cfPWV was significantly associated with the risk of incident stroke among postmenopausal women, but not premenopausal women.