Does the J-shaped curve for diastolic blood pressure exist? Review article
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Published:
Dec 31, 2018
Keywords:
diastolic blood pressure, J curve, hypertension, therapeutic goals
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Abstract
The J-shaped curve hypothesis related to the phenomenon of increased cardiovascular risk in patients with too low blood pressure, appeared in the end of 20th century. Reduced coronary blood flow related to low diastolic blood pressure constitutes pathophysiological background of the hypothesis. Currently recommended lower on-treatment blood pressure values may result in excessive diastolic blood pressure reduction and therefore J-shaped curve should be considered during hypotensive therapy. Available evidence, mostly based on post-hoc analyses of large randomized trials, reveal unfavorable clinical effects of excessive diastolic blood pressure reduction, especially in patients with prior cardiovascular disease. In the article data regarding low diastolic blood pressure in various population of hypertensive patients were shown.
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Sobieraj , P., Lewandowski , J., & Siński , M. (2018). Does the J-shaped curve for diastolic blood pressure exist?. Cardiology in Practice, 12(3-4), 37-46. Retrieved from https://journalsmededu.pl/index.php/kwp/article/view/1212
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Medical evidence in cardiology
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
Copyright: © Medical Education sp. z o.o. This is an Open Access article distributed under the terms of the Attribution-NonCommercial 4.0 International (CC BY-NC 4.0). License (https://creativecommons.org/licenses/by-nc/4.0/), allowing third parties to copy and redistribute the material in any medium or format and to remix, transform, and build upon the material, provided the original work is properly cited and states its license.
Address reprint requests to: Medical Education, Marcin Kuźma (marcin.kuzma@mededu.pl)
References
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24. Xiao WK, Ye P, Bai YY et al. Central pulse pressure but not brachial blood pressure is the predominant factor affecting aortic arterial stiffness. Nan Fang Yi Ke Da Xue Xue Bao. 2015; 35(1): 34-39.
25. Asayama K, Ohkubo T, Metoki H et al. Cardiovascular outcomes in the first trial of antihypertensive therapy guided by self-measured home blood pressure. Hypertens Res 2012; 35(11): 1102-1110.
26. Kjeldsen SE, Berge E, Bangalore S et al. No evidence for a J-shaped curve in treated hypertensive patients with increased cardiovascular risk: The VALUE trial. Blood Press 2016; 25(2): 83-92.
27. Messerli FH, Mancia G, Conti CR et al. Dogma disputed: can aggressively lowering blood pressure in hypertensive patients with coronary artery disease be dangerous? Ann Inter Med. 2006; 144(12): 884-893.
28. Sleight P, Redon J, Verdecchia P et al. Prognostic value of blood pressure in patients with high vascular risk in the Ongoing Telmisartan Alone and in combination with Ramipril Global Endpoint Trial study. J Hypertens 2009; 27(7): 1360-1369.29. Bohm M, Schumacher H, Teo KK et al. Achieved blood pressure and cardiovascular outcomes in high-risk patients: results from ONTARGET and TRANSCEND trials. Lancet 2017; 389(10085): 2226-2237.
30. Stensrud MJ, Strohmaier S. Diastolic hypotension due to intensive blood pressure therapy: Is it harmful? Atherosclerosis 2017; 265: 29-34.
31. Lee TC, Cavalcanti RB, McDonald EG et al. Diastolic hypotension may attenuate benefits from intensive systolic targets: secondary analysis of a randomized controlled trial. Am J Med 2018; 131(10): 1228-1233.
32. Vidal-Petiot E, Greenlaw N, Ford I et al. Relationships Between Components of Blood Pressure and Cardiovascular Events in Patients with Stable Coronary Artery Disease and Hypertension. Hypertens 2018; 71(1): 168-176.
33. Cooper-DeHoff RM, Gong Y, Handberg EM et al. Tight blood pressure control and cardiovascular outcomes among hypertensive patients with diabetes and coronary artery disease. JAMA 2010; 304(1): 61-68.
34. UKPDS Study Group. Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38. BMJ (Clin Res Ed) 1998; 317(7160): 703-713.
35. Estacio RO, Jeffers BW, Hiatt WR et al. The effect of nisoldipine as compared with enalapril on cardiovascular outcomes in patients with non-insulin-dependent diabetes and hypertension. N Engl J Med 1998; 338(10): 645-652.
36. Schrier RW, Estacio RO, Mehler PS, Hiatt WR. Appropriate blood pressure control in hypertensive and normotensive type 2 diabetes mellitus: a summary of the ABCD trial. Nat Clin Pract Nephrol 2007; 3(8): 428-438.
37. Berl T, Hunsicker LG, Lewis JB et al. Impact of achieved blood pressure on cardiovascular outcomes in the Irbesartan Diabetic Nephropathy Trial. J Am Soc Nephrol 2005; 16(7): 2170-2179.
38. Bergmark BA, Scirica BM, Steg PG et al. Blood pressure and cardiovascular outcomes in patients with diabetes and high cardiovascular risk. Eur Heart J 2018; 39(24): 2255-2262.
39. Redon J, Mancia G, Sleight P et al. Safety and efficacy of low blood pressures among patients with diabetes: subgroup analyses from the ONTARGET (ONgoing Telmisartan Alone and in combination with Ramipril Global Endpoint Trial). J Am Coll Cardiol 2012; 59(1): 74-83.
40. Chew EY, Ambrosius WT, Davis MD et al. Effects of medical therapies on retinopathy progression in type 2 diabetes. New Engl J Med 2010; 363(3): 233-244.
41. Somes GW, Pahor M, Shorr RI et al. The role of diastolic blood pressure when treating isolated systolic hypertension. Arch Intern Med 1999; 159(17): 2004-2009.
42. Williamson JD, Supiano MA, Applegate WB et al. Intensive vs. Standard Blood Pressure Control and Cardiovascular Disease Outcomes in Adults Aged ≥75 Years: A Randomized Clinical Trial. JAMA 2016; 315(24): 2673-2682.
43. Sandesara PB, O’Neal WT, Kelli HM et al. Diastolic Blood Pressure and Adverse Outcomes in the TOPCAT (Treatment of Preserved Cardiac Function Heart Failure With an Aldosterone Antagonist) Trial. J Am Heart Assoc 2018; 7(5).
44. Ferreira JP, Duarte K, Pfeffer MA et al. Association between mean systolic and diastolic blood pressure throughout the follow-up and cardiovascular events in acute myocardial infarction patients with systolic dysfunction and/or heart failure: an analysis from the High-Risk Myocardial Infarction Database Initiative. Eur J Heart Fail 2018; 20(2): 323-331.
45. Ambrosi P, Mace L, Habib G. Predictive value of achieved blood pressure for cardiac events in the long-term follow-up of heart transplant recipients. Blood Press Monit 2019; 24(1): 7-11.
46. Ahuja R, Ayala C, Tong X et al. Public Awareness of Health-Related Risks From Uncontrolled Hypertension. Prev Chronic Dis 2018; 15: E40.
47. Sobieraj P, Lewandowski J, Sinski M et al. Low Diastolic Blood Pressure is Not Related to Risk of First Episode of Stroke in a High-Risk Population: A Secondary Analysis of SPRINT. J Am Heart Assoc 2019; 8(4): e010811.
48. SHEP Study Group. Prevention of stroke by antihypertensive drug treatment in older persons with isolated systolic hypertension. Final results of the Systolic Hypertension in the Elderly Program (SHEP). JAMA 1991; 265(24): 3255-3264.
49. Voko Z, Bots ML, Hofman A et al. J-shaped relation between blood pressure and stroke in treated hypertensives. Hypertension 1999; 34(6): 1181-1185.
50. Kim JS. Stroke in Asia: a global disaster. Int J Stroke 2014; 9(7): 856-857.
51. Sundbøll J, Horváth-Puhó E, Schmidt M et al. Long-Term Risk of Stroke in Myocardial Infarction Survivors. Stroke 2016; 47(7): 1727-1733.
52. Benetos A, Thomas F, Bean K et al. Prognostic value of systolic and diastolic blood pressure in treated hypertensive men. Arch Intern Med 2002; 162(5): 577-581.
53. McEniery CM, Cockcroft JR, Roman MJ et al. Central blood pressure: current evidence and clinical importance. Eur Heart J 2014; 35(26): 1719-1725.
54. Baba BA, Johan PT, Mohan JC. Comparsion of central aortic pressure to brachial artery pressure in hypertensive patients on drug treatment: An observational study. Indian Heart J 2018; 70(3): S208-S12.
55. Beddhu S, Chertow GM, Cheung AK et al. Influence of Baseline Diastolic Blood Pressure on Effects of Intensive Compared With Standard Blood Pressure Control. Circulation 2018; 137(2): 134-143.
56. Basu S, Sussman JB, Rigdon J et al. Benefit and harm of intensive blood pressure treatment: Derivation and validation of risk models using data from the SPRINT and ACCORD trials. PLoS Med 2017; 14(10): e1002410.
57. Patel KK, Arnold SV, Chan PS et al. Personalizing the Intensity of Blood Pressure Control: Modeling the Heterogeneity of Risks and Benefits From SPRINT. Circ Cardiovasc Qual Outcomes 2017; 10(4).
58. Ferreira JP, Gregson J, Duarte K et al. Individualizing treatment choices in the systolic blood pressure intervention trial. J Hypertens 2018; 36(2): 428-435.
59. Muntner P, Carey RM, Gidding S et al. Potential US Population Impact of the 2017 ACC/AHA High Blood Pressure Guideline. Circulation 2018; 137(2): 109-118.
60. Thomopoulos C, Parati G, Zanchetti A. Effects of blood pressure lowering treatment in hypertension: 8. Outcome reductions vs. discontinuations because of adverse drug events – meta-analyses of randomized trials. J Hypertens 2016; 34(8): 1451-1463.
2. Chow CK, Teo KK, Rangarajan S et al. Prevalence, awareness, treatment, and control of hypertension in rural and urban communities in high-, middle-, and low-income countries. JAMA 2013; 310(9): 959-968.
3. Falaschetti E, Mindell J, Knott C, Poulter N. Hypertension management in England: a serial cross-sectional study from 1994 to 2011. Lancet 2014; 383(9932): 1912-1919.
4. Tocci G, Rosei EA, Ambrosioni E et al. Blood pressure control in Italy: analysis of clinical data from 2005-2011 surveys on hypertension. J Hypertens 2012; 30(6): 1065-1074.
5. Whelton PK, Carey RM, Aronow WS et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation 2018; 138(17): e426-e483.
6. Zanchetti A, Dominiczak A, Coca A et al. 2018 ESC/ESH Guidelines for the management of arterial hypertension. Eur Heart J 2018; 39(33): 3021-3104.
7. SPRINT Research Group, Wright JT Jr, Williamson JD et al. A Randomized Trial of Intensive versus Standard Blood-Pressure Control. N Engl J Med 2015; 373(22): 2103-2116.
8. Cushman WC, Evans GW, Byington RP et al. Effects of intensive blood-pressure control in type 2 diabetes mellitus. N Engl J Med 2010; 362(17): 1575-1585.
9. Bohm M, Schumacher H, Teo KK et al. Achieved diastolic blood pressure and pulse pressure at target systolic blood pressure (120-140 mmHg) and cardiovascular outcomes in high-risk patients: results from ONTARGET and TRANSCEND trials. Eur Heart J 2018; 39(33): 3105-3114.
10. Dawber TR, Moore FE, Mann GV. Coronary heart disease in the Framingham study. Am J Public Health Nations Health 1957; 47(4 Pt 2): 4-24.
11. Veterans Administration Cooperative Study Group. Effects of treatment on morbidity in hypertension. Results in patients with diastolic blood pressures averaging 115 through 129 mm Hg. JAMA 1967; 202(11): 1028-1034.
12. Veterans Administration Cooperative Study Group. Effects of treatment on morbidity in hypertension. II. Results in patients with diastolic blood pressure averaging 90 through 114 mm Hg. JAMA 1970; 213(7): 1143-1152.
13. Medical Research Council Working Party. MRC Trial Of Treatment Of Mild Hypertension: Principal Results. Br Med J (Clin Res Ed) 1985; 291(6488): 97-104.
14. The Management Comitee. The Australian therapeutic trial in mild hypertension. Lancet 1980; 1: 1261-1267.
15. Hypertension Detection and Follow-up Program Cooperative Group. Five-year findings of the hypertension detection and follow-up program. Reduction in stroke incidence among persons with high blood pressure. JAMA 1982; 247(5): 633-638.
16. Hansson L, Zanchetti A, Carruthers SG et al. Effects of intensive blood-pressure lowering and low-dose aspirin in patients with hypertension: principal results of the Hypertension Optimal Treatment (HOT) randomised trial. Lancet 1998; 351(9118):1755-1762.
17. Mancia G, Fagard R, Narkiewicz K et al. 2013 ESH/ESC Guidelines for the management of arterial hypertension: the Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). J Hypertens 2013; 31(7): 1281-1357.
18. Malyszko J, Muntner P, Rysz J, Banach M. Blood Pressure Levels and Stroke: J-curve Phenomenon? Curr Hypertens Rep 2013; 15(6): 575-581.
19. Messerli FH, Panjrath GS. The J-curve between blood pressure and coronary artery disease or essential hypertension: exactly how essential? J Am Coll Cardiol 2009; 54(20): 1827-1834.
20. McEvoy JW, Chen Y, Rawlings A et al. Diastolic Blood Pressure, Subclinical Myocardial Damage, and Cardiac Events: Implications for Blood Pressure Control. J Am Coll Cardiol 2016; 68(16): 1713-1722.
21. Rabkin SW, Waheed A, Poulter RS, Wood D. Myocardial perfusion pressure in patients with hypertension and coronary artery disease: implications for DBP targets in hypertension management. J Hypertens 2013; 31(5): 975-982.
22. Senthong V, Kukongviriyapan U, Settasatian N et al. Low diastolic blood pressure is associated with a high atherosclerotic burden in patients with obstructive coronary artery disease. Cardiol J 2018; 25(3): 345-352.
23. Topel ML, Sandesara PB, Stahl EP et al. Mechanisms underlying the J-curve for diastolic blood pressure: Subclinical myocardial injury and immune activation. Int J Cardiol 2019; 276: 255-260.
24. Xiao WK, Ye P, Bai YY et al. Central pulse pressure but not brachial blood pressure is the predominant factor affecting aortic arterial stiffness. Nan Fang Yi Ke Da Xue Xue Bao. 2015; 35(1): 34-39.
25. Asayama K, Ohkubo T, Metoki H et al. Cardiovascular outcomes in the first trial of antihypertensive therapy guided by self-measured home blood pressure. Hypertens Res 2012; 35(11): 1102-1110.
26. Kjeldsen SE, Berge E, Bangalore S et al. No evidence for a J-shaped curve in treated hypertensive patients with increased cardiovascular risk: The VALUE trial. Blood Press 2016; 25(2): 83-92.
27. Messerli FH, Mancia G, Conti CR et al. Dogma disputed: can aggressively lowering blood pressure in hypertensive patients with coronary artery disease be dangerous? Ann Inter Med. 2006; 144(12): 884-893.
28. Sleight P, Redon J, Verdecchia P et al. Prognostic value of blood pressure in patients with high vascular risk in the Ongoing Telmisartan Alone and in combination with Ramipril Global Endpoint Trial study. J Hypertens 2009; 27(7): 1360-1369.29. Bohm M, Schumacher H, Teo KK et al. Achieved blood pressure and cardiovascular outcomes in high-risk patients: results from ONTARGET and TRANSCEND trials. Lancet 2017; 389(10085): 2226-2237.
30. Stensrud MJ, Strohmaier S. Diastolic hypotension due to intensive blood pressure therapy: Is it harmful? Atherosclerosis 2017; 265: 29-34.
31. Lee TC, Cavalcanti RB, McDonald EG et al. Diastolic hypotension may attenuate benefits from intensive systolic targets: secondary analysis of a randomized controlled trial. Am J Med 2018; 131(10): 1228-1233.
32. Vidal-Petiot E, Greenlaw N, Ford I et al. Relationships Between Components of Blood Pressure and Cardiovascular Events in Patients with Stable Coronary Artery Disease and Hypertension. Hypertens 2018; 71(1): 168-176.
33. Cooper-DeHoff RM, Gong Y, Handberg EM et al. Tight blood pressure control and cardiovascular outcomes among hypertensive patients with diabetes and coronary artery disease. JAMA 2010; 304(1): 61-68.
34. UKPDS Study Group. Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38. BMJ (Clin Res Ed) 1998; 317(7160): 703-713.
35. Estacio RO, Jeffers BW, Hiatt WR et al. The effect of nisoldipine as compared with enalapril on cardiovascular outcomes in patients with non-insulin-dependent diabetes and hypertension. N Engl J Med 1998; 338(10): 645-652.
36. Schrier RW, Estacio RO, Mehler PS, Hiatt WR. Appropriate blood pressure control in hypertensive and normotensive type 2 diabetes mellitus: a summary of the ABCD trial. Nat Clin Pract Nephrol 2007; 3(8): 428-438.
37. Berl T, Hunsicker LG, Lewis JB et al. Impact of achieved blood pressure on cardiovascular outcomes in the Irbesartan Diabetic Nephropathy Trial. J Am Soc Nephrol 2005; 16(7): 2170-2179.
38. Bergmark BA, Scirica BM, Steg PG et al. Blood pressure and cardiovascular outcomes in patients with diabetes and high cardiovascular risk. Eur Heart J 2018; 39(24): 2255-2262.
39. Redon J, Mancia G, Sleight P et al. Safety and efficacy of low blood pressures among patients with diabetes: subgroup analyses from the ONTARGET (ONgoing Telmisartan Alone and in combination with Ramipril Global Endpoint Trial). J Am Coll Cardiol 2012; 59(1): 74-83.
40. Chew EY, Ambrosius WT, Davis MD et al. Effects of medical therapies on retinopathy progression in type 2 diabetes. New Engl J Med 2010; 363(3): 233-244.
41. Somes GW, Pahor M, Shorr RI et al. The role of diastolic blood pressure when treating isolated systolic hypertension. Arch Intern Med 1999; 159(17): 2004-2009.
42. Williamson JD, Supiano MA, Applegate WB et al. Intensive vs. Standard Blood Pressure Control and Cardiovascular Disease Outcomes in Adults Aged ≥75 Years: A Randomized Clinical Trial. JAMA 2016; 315(24): 2673-2682.
43. Sandesara PB, O’Neal WT, Kelli HM et al. Diastolic Blood Pressure and Adverse Outcomes in the TOPCAT (Treatment of Preserved Cardiac Function Heart Failure With an Aldosterone Antagonist) Trial. J Am Heart Assoc 2018; 7(5).
44. Ferreira JP, Duarte K, Pfeffer MA et al. Association between mean systolic and diastolic blood pressure throughout the follow-up and cardiovascular events in acute myocardial infarction patients with systolic dysfunction and/or heart failure: an analysis from the High-Risk Myocardial Infarction Database Initiative. Eur J Heart Fail 2018; 20(2): 323-331.
45. Ambrosi P, Mace L, Habib G. Predictive value of achieved blood pressure for cardiac events in the long-term follow-up of heart transplant recipients. Blood Press Monit 2019; 24(1): 7-11.
46. Ahuja R, Ayala C, Tong X et al. Public Awareness of Health-Related Risks From Uncontrolled Hypertension. Prev Chronic Dis 2018; 15: E40.
47. Sobieraj P, Lewandowski J, Sinski M et al. Low Diastolic Blood Pressure is Not Related to Risk of First Episode of Stroke in a High-Risk Population: A Secondary Analysis of SPRINT. J Am Heart Assoc 2019; 8(4): e010811.
48. SHEP Study Group. Prevention of stroke by antihypertensive drug treatment in older persons with isolated systolic hypertension. Final results of the Systolic Hypertension in the Elderly Program (SHEP). JAMA 1991; 265(24): 3255-3264.
49. Voko Z, Bots ML, Hofman A et al. J-shaped relation between blood pressure and stroke in treated hypertensives. Hypertension 1999; 34(6): 1181-1185.
50. Kim JS. Stroke in Asia: a global disaster. Int J Stroke 2014; 9(7): 856-857.
51. Sundbøll J, Horváth-Puhó E, Schmidt M et al. Long-Term Risk of Stroke in Myocardial Infarction Survivors. Stroke 2016; 47(7): 1727-1733.
52. Benetos A, Thomas F, Bean K et al. Prognostic value of systolic and diastolic blood pressure in treated hypertensive men. Arch Intern Med 2002; 162(5): 577-581.
53. McEniery CM, Cockcroft JR, Roman MJ et al. Central blood pressure: current evidence and clinical importance. Eur Heart J 2014; 35(26): 1719-1725.
54. Baba BA, Johan PT, Mohan JC. Comparsion of central aortic pressure to brachial artery pressure in hypertensive patients on drug treatment: An observational study. Indian Heart J 2018; 70(3): S208-S12.
55. Beddhu S, Chertow GM, Cheung AK et al. Influence of Baseline Diastolic Blood Pressure on Effects of Intensive Compared With Standard Blood Pressure Control. Circulation 2018; 137(2): 134-143.
56. Basu S, Sussman JB, Rigdon J et al. Benefit and harm of intensive blood pressure treatment: Derivation and validation of risk models using data from the SPRINT and ACCORD trials. PLoS Med 2017; 14(10): e1002410.
57. Patel KK, Arnold SV, Chan PS et al. Personalizing the Intensity of Blood Pressure Control: Modeling the Heterogeneity of Risks and Benefits From SPRINT. Circ Cardiovasc Qual Outcomes 2017; 10(4).
58. Ferreira JP, Gregson J, Duarte K et al. Individualizing treatment choices in the systolic blood pressure intervention trial. J Hypertens 2018; 36(2): 428-435.
59. Muntner P, Carey RM, Gidding S et al. Potential US Population Impact of the 2017 ACC/AHA High Blood Pressure Guideline. Circulation 2018; 137(2): 109-118.
60. Thomopoulos C, Parati G, Zanchetti A. Effects of blood pressure lowering treatment in hypertension: 8. Outcome reductions vs. discontinuations because of adverse drug events – meta-analyses of randomized trials. J Hypertens 2016; 34(8): 1451-1463.