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J-shaped curve for cardiovascular mortality: systolic or diastolic blood pressure?

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Abstract

Aggressive reduction of blood pressure (BP) may increase cardiovascular events (the J-curve phenomenon) in certain populations. There is a high number of available studies of antihypertensive treatment that provide strong evidence for J-shaped relationships between both diastolic and systolic BP and main cardiovascular outcomes. Nonetheless, most available studies were observational, and randomized trials might not have or lost their statistical power in post-hoc analysis. Contrariwise, most of prospective trial to demonstrate the benefits of intensive blood pressure control were inconclusive. Therefore, further studies are still necessary in order to clarify this issue.

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References

  1. Kannel WB (1996) Blood pressure as a cardiovascular risk factor: prevention and treatment. JAMA 275:1571–1576

    Article  CAS  PubMed  Google Scholar 

  2. Zanchetti A, Thomopoulos C, Parati G (2015) Randomized controlled trials of blood pressure lowering in hypertension: a critical reappraisal. Circ Res 116:1058–1073

    Article  CAS  PubMed  Google Scholar 

  3. Mancia G, Laurent S, Agabiti-Rosei E, Ambrosioni E, Burnier M, Caulfield MJ et al (2009) Reappraisal of European guidelines on hypertension management: a European Society of Hypertension Task Force document. J Hypertens 27:2121–2158

    Article  CAS  PubMed  Google Scholar 

  4. Banach M, Kjeldsen SE, Narkiewicz K (2010) Editorial. Controversies in hypertension treatment. Curr Vasc Pharmacol 8:731–732

    Article  CAS  PubMed  Google Scholar 

  5. Messerli FH, Mancia G, Conti CR, Hewkin AC, Kupfer S, Champion A et al (2006) Dogma disputed: can aggressively lowering blood pressure in hypertensive patients with coronary artery disease be dangerous? Ann Intern Med 144:884–893

    Article  PubMed  Google Scholar 

  6. Boutitie F, Gueyffier F, Pocock S, Fagard R, Boissel JP, INDANA Project Steering Committee (2002) Individual data analysis of antihypertensive intervention. J-shaped relationship between blood pressure and mortality in hypertensive patients: new insights from a meta-analysis of individual-patient data. Ann Intern Med 19:136:438–448

    Article  Google Scholar 

  7. Cruickshank J (2003) The J-curve in hypertension. Curr Cardiol Rep 5:441–452

    Article  PubMed  Google Scholar 

  8. Stewart IM (1979) Relation of reduction in pressure to first myocardial infarction in patients receiving treatment for severe hypertension. Lancet 1:861–865

    Article  CAS  PubMed  Google Scholar 

  9. Cruickshank JM, Thorp JM, Zacharias FJ (1987) Benefits and potential harm of lowering high blood pressure. Lancet 1:581–584

    Article  CAS  PubMed  Google Scholar 

  10. Lindblad U, Rastam L, Ryden L, Ranstam J, Isacsson SO, Berglund G (1994) Control of blood pressure and risk of first acute myocardial infarction: Skaraborg hypertension project. BMJ 308:681–686

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  11. Somes GW, Pahor M, Shorr RI, Cushman WC, Applegate WB (1999) The role of diastolic blood pressure when treating isolated systolic hypertension. Arch Intern Med 159:2004–2009

    Article  CAS  PubMed  Google Scholar 

  12. Protogerou AD, Safar ME, Iaria P et al (2007) Diastolic blood pressure and mortality in the elderly with cardiovascular disease. Hypertension 50:172–180

    Article  CAS  PubMed  Google Scholar 

  13. Fagard RH, Staessen JA, Thijs L et al (2007) On-treatment diastolic blood pressure and prognosis in systolic hypertension. Arch Intern Med 167:1884–1891

    Article  PubMed  Google Scholar 

  14. Fletcher AE, Beevers DG, Bulpitt CJ et al (1988) The relationship between a low treated blood pressure and IHD mortality: a report from the DHSS Hypertension Care Computing Project (DHCCP). J Hum Hypertens 2:11–15

    CAS  PubMed  Google Scholar 

  15. Cooper SP, Hardy RJ, Labarthe DR et al (1988) The relation between degree of blood pressure reduction and mortality among hypertensives in the hypertension detection and follow-up program. Am J Epidemiol 127:387–403

    Article  CAS  PubMed  Google Scholar 

  16. Waller PC, Isles CG, Lever AF, Murray GD, McInnes GT (1988) Does therapeutic reduction of diastolic blood pressure cause death from coronary heart disease? J Hum Hypertens 2:7–10

    CAS  PubMed  Google Scholar 

  17. Coope J, Warrender TS (1986) Randomised trial of treatment of hypertension in elderly patients in primary care. Br Med J (Clin Res Ed) 293:1145–1151

    Article  CAS  Google Scholar 

  18. Alderman MH, Ooi WL, Madhavan S, Cohen H (1989) Treatmentinduced blood pressure reduction and the risk of myocardial infarction. JAMA 262:920–924

    Article  CAS  PubMed  Google Scholar 

  19. Staessen J, Bulpitt C, Clement D et al (1989) Relation between mortality and treated blood pressure in elderly patients with hypertension: report of the European Working Party on high blood pressure in the elderly. BMJ 298:1552–1556

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  20. The IPPPSH Collaborative Group (1985) Myocardial infarctions and cerebrovascular accidents in relation to blood pressure control. J Hypertens Suppl 3:S513–S518

    Google Scholar 

  21. Management Committee (1981) Treatment of mild hypertension in the elderly. A study initiated and administered by the National Heart Foundation of Australia. Med J Aust 2:398–402

    Google Scholar 

  22. Samuelsson OG, Wilhelmsen LW, Pennert KM, Wedel H, Berglund GL (1990) The J-shaped relationship between coronary heart disease and achieved blood pressure level in treated hypertension: further analyses of 12 years of follow-up of treated hypertensives in the Primary Prevention Trial in Gothenburg, Sweden. J Hypertens 8:547–555

    Article  CAS  PubMed  Google Scholar 

  23. McCloskey LW, Psaty BM, Koepsell TD, Aagaard GN (1992) Level of blood pressure and risk of myocardial infarction among treated hypertensive patients. Arch Intern Med 152:513–520

    Article  CAS  PubMed  Google Scholar 

  24. Hasebe N, Kido S, Ido A, Kenjiro K (2002) Reverse J-curve relation between diastolic blood pressure and severity of coronary artery lesion in hypertensive patients with angina pectoris. Hypertens Res 25:381–387

    Article  PubMed  Google Scholar 

  25. Pastor-Barriuso R, Banegas JR, Damian J, Appel LJ, Guallar E (2003) Systolic blood pressure, diastolic blood pressure, and pulse pressure: an evaluation of their joint effect on mortality. Ann Intern Med 139:731–739

    Article  PubMed  Google Scholar 

  26. Zanchetti A, Hansson L, Clement D et al (2003) Benefits and risks of more intensive blood pressure lowering in hypertensive patients of the HOT study with different risk profiles: does a J-shaped curve exist in smokers? J Hypertens 21:797–804

    Article  CAS  PubMed  Google Scholar 

  27. Bavry AA, Anderson RD, Gong Y, Denardo SJ, Cooper-Dehoff RM, Handberg EM, Pepine CJ (2010) Outcomes Among hypertensive patients with concomitant peripheral and coronary artery disease: findings from the International VErapamil-SR/Trandolapril STudy. Hypertension 55:48–53

    Article  CAS  PubMed  Google Scholar 

  28. Bulpitt CJ, Palmer AJ, Fletcher AE, Beevers DG, Coles EC, Ledingham JG, O’riordan PW, Petrie JC, Rajagopalan BE, Webster J (1992) Relation between treated blood pressure and death from ischaemic heart disease at different ages: a report from the Department of Health Hypertension Care Computing Project. J Hypertens 10:1273–1278

    Article  CAS  PubMed  Google Scholar 

  29. Anand IS, Rector TS, Kuskowski M, Thomas S, Holwerda NJ, Cohn JN (2008) Effect of baseline and changes in systolic blood pressure over time on the effectiveness of valsartan in the Valsartan Heart Failure Trial. Circ Heart Fail 1:34–42

    Article  CAS  PubMed  Google Scholar 

  30. Franklin SS, Gokhale SS, Chow VH et al (2015) Does low diastolic blood pressure contribute to the risk of recurrent hypertensive cardiovascular disease events? The Framingham Heart Study. Hypertension 65:299–305

    Article  CAS  PubMed  Google Scholar 

  31. Bangalore S, Messerli FH, Wun CC et al (2010) Treating to new targets steering committee and investigators. J-curve revisited: an analysis of blood pressure and cardiovascular events in the Treating to New Targets (TNT) Trial. Eur Heart J 31(23):2897–2908

    Article  CAS  PubMed  Google Scholar 

  32. Dorresteijn JA, van der Graaf Y, Spiering W, Grobbee DE, Bots ML, Visseren FL, Secondary Manifestations of Arterial Disease Study Group (2012) Relation between blood pressure and vascular events and mortality in patients with manifest vascular disease: J-curve revisited. Hypertension 59:14–21

    Article  CAS  PubMed  Google Scholar 

  33. Banach M, Bhatia V, Feller MA et al (2011) Relation of baseline systolic blood pressure and long-term outcomes in ambulatory patients with chronic mild to moderate heart failure. Am J Cardiol 107:1208–1214

    Article  PubMed  PubMed Central  Google Scholar 

  34. Sundström J, Sheikhi R, Ostgren CJ et al (2013) Blood pressure levels and risk of cardiovascular events and mortality in type-2 diabetes: cohort study of 34,009 primary care patients. J Hypertens 31:1603–1610

    Article  CAS  PubMed  Google Scholar 

  35. Bangalore S, Qin J, Sloan S, Murphy SA, Cannon CP, PROVE IT-TIMI 22 Trial Investigators (2010) What is the optimal blood pressure in patients after acute coronary syndromes?: relationship of blood pressure and cardiovascular events in the PRavastatin OR atorVastatin Evaluation and Infection Therapy-Thrombolysis In Myocardial Infarction (PROVE IT-TIMI) 22 trial. Circulation 122:2142–2151

    Article  CAS  PubMed  Google Scholar 

  36. Ogihara T, Saruta T, Rakugi H et al (2010) Valsartan in Elderly Isolated Systolic Hypertension Study Group. Target blood pressure for treatment of isolated systolic hypertension in the elderly: valsartan in elderly isolated systolic hypertension study. Hypertension 56:196–202

    Article  CAS  PubMed  Google Scholar 

  37. Kim J, Gall SL, Nelson MR, Sharman JE, Thrift AG (2014) Lower systolic Blood pressure is associated with poorer survival in long-term survivors of stroke. J Hypertens 32:904–911

    Article  CAS  PubMed  Google Scholar 

  38. Okin PM, Hille DA, Kjeldsen SE, Dahlöf B, Devereux RB (2012) Impact of lower achieved blood pressure on outcomes in hypertensive patients. J Hypertens 30:802–810

    Article  CAS  PubMed  Google Scholar 

  39. Cederholm J, Gudbjörnsdottir S, Eliasson B, Zethelius B, Eeg-Olofsson K, Nilsson PM, NDR (2012) Blood pressure and risk of cardiovascular diseases in type 2 diabetes: further findings from the Swedish National Diabetes Register (NDR-BPII). J Hypertens 30:2020–2030

    Article  CAS  PubMed  Google Scholar 

  40. Investigators ONTARGET, Yusuf S, Teo KK, Pogue J, Dyal L, Copland I et al (2008) Telmisartan, ramipril, or both in patients at high risk for vascular events. N Engl J Med 358:1547–1559

    Article  Google Scholar 

  41. Sleight P, Redon J, Verdecchia P et al (2009) 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 27:1360–1369

    Article  CAS  PubMed  Google Scholar 

  42. Böhm M, Schumacher H, Teo KK, Lonn EM, Mahfoud F, Mann JFE et al (2017) Achieved blood pressure and cardiovascular outcomes in high-risk patients: results from ONTARGET and TRANSCEND trials. Lancet 389:2226–2237

    Article  PubMed  Google Scholar 

  43. Jamerson K, Weber MA, Bakris GL et al (2008) Benazepril plus amlodipine or hydrochlorothiazide for hypertension in high-risk patients. N Engl J Med 359:2417–2428

    Article  CAS  PubMed  Google Scholar 

  44. Weber MA, Bakris GL, Hester A, Weir MR, Hua TA, Zappe D et al (2013) Systolic blood pressure and cardiovascular outcomes during treatment of hypertension. Am J Med 126:501–508

    Article  PubMed  Google Scholar 

  45. Tinetti ME, Han L, McAvay GJ, Lee DS, Peduzzi P, Dodson JA, Gross CP et al (2014) Anti-hypertensive medications and cardiovascular events in older adults with multiple chronic conditions. PLoS One 9(3):e90733

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  46. Liu L, Zhang Y, Liu G, Li W, Zhang X, Zanchetti A, FEVER Study Group (2005) The Felodipine Event Reduction (FEVER) Study: a randomized long-term placebo-controlled trial in Chinese hypertensive patients. J Hypertens 23(12):2157–2172

    Article  CAS  PubMed  Google Scholar 

  47. Nissen SE, Tuzcu EM, Libby P et al (2004) CAMELOT Investigators. Effect of antihypertensive agents on cardiovascular events in patients with coronary disease and normal blood pressure: the CAMELOT study: a randomized controlled trial. JAMA 292:2217–2225

    Article  CAS  PubMed  Google Scholar 

  48. Rakugi H, Ogihara T, Goto Y, Ishii M, JATOS Study Group (2010) Comparison of strict-and mild-blood pressure control in elderly hypertensive patients: a per-protocol analysis of JATOS. Hypertens Res 33:1124–1128

    Article  PubMed  Google Scholar 

  49. Cushman WC, Evans GW, Byington RP, Goff DC Jr, Grimm RH Jr, Cutler JA, ACCORD Study Group et al (2010) Effects of intensive blood-pressure control in type 2 diabetes mellitus. N Engl J Med 362:1575–1585

    Article  CAS  PubMed  Google Scholar 

  50. SPRINT Research Group, Wright JT Jr, Williamson JD, Whelton PK, Snyder JK, Sink KM, Rocco MV, Reboussin DM, Rahman M, Oparil S, Lewis CE, Kimmel PL, Johnson KC, Goff DC Jr, Fine LJ, Cutler JA, Cushman WC, Cheung AK, Ambrosius WT (2015) A randomized trial of intensive versus standard blood-pressure control. N Engl J Med 373:2103–2116

    Article  CAS  Google Scholar 

  51. Viazzi F, Piscitelli P, Ceriello A, Fioretto P, Giorda C, Guida P et al (2017) Resistant hypertension, time-updated blood pressure values and renal outcome in type 2. Diabetes Mellitus J Am Heart Assoc 6:e006745. https://doi.org/10.1161/JAHA.117.006745

    Article  PubMed  Google Scholar 

  52. Robles NR, Hernandez Gallego R, Fici F, Grassi G (2017) Does a j curve exist for chronic kidney disease (CKD) patients? J Clin Hypertens 19:764–770

    Article  Google Scholar 

  53. Agabiti Rosei E (2016) Target blood pressure for treatment: should current recommendations be changed? Hypertension 68(2):263–265

    Article  CAS  PubMed  Google Scholar 

  54. Lacey B, Lewington S, Clarke R, Kong XL, Chen Y, Guo Y et al (2018) Age-specific association between blood pressure and vascular and non-vascular chronic diseases in 0·5 million adults in China: a prospective cohort study. Lancet Glob Health 6:e641–e649

    Article  PubMed  PubMed Central  Google Scholar 

  55. Ettehad D, Emdin CA, Kiran A, Anderson SG, Callender T, Emberson J et al (2016) Blood pressure lowering for prevention of cardiovascular disease and death: a systematic review and meta-analysis. Lancet 387:957–967

    Article  PubMed  Google Scholar 

  56. Prospective Studies Collaboration (2002) Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. Lancet 360:1903–1913

    Article  Google Scholar 

  57. Owens P, O’Brien E (1999) Hypotension in patients with coronary disease: can profound hypotensive events cause myocardial ischaemic events? Heart 82:477–481

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  58. Vidal-Petiot E, Ford I, Greenlaw I, Ferrari R, Fox KM, Tardif JC, Tendera M et al (2016) Cardiovascular event rates and mortality according to achieved systolic and diastolic blood pressure in patients with stable coronary artery disease: an international cohort study. Lancet 388:2142–2152

    Article  PubMed  Google Scholar 

  59. Shu W, jing J, Fu LC et al (2013) The relationship between diastolic pressure and coronary collateral circulation in patients with stable angina pectoris and chronic total occlusion. Am J Hypertens 26:630e5

    Article  Google Scholar 

  60. Shu W, Da WJ, Fu LC, Jing J, Jun G, Hong FZ et al (2014) The J-curve relationship between diastolic pressure and coronary colateral circulation in patients with single chronic total occlusion. Atherosclerosis 232:220–223

    Article  CAS  PubMed  Google Scholar 

  61. Satish S, Zhang DD, Goodwin JS (2001) Clinical significance of falling blood pressure among older adults. J Clin Epidemiol 54:961–967

    Article  CAS  PubMed  Google Scholar 

  62. Langer RD, Criqui MH, Barrett-Connor EL, Klauber MR, Ganiats TG (1993) Blood pressure change and survival after age 75. Hypertension 22:551–559

    Article  CAS  PubMed  Google Scholar 

  63. Greenberg JA (2003) Removing confounders from the relationship between mortality risk and systolic blood pressure at low and moderately increased systolic blood pressure. J Hypertens 21:49–56

    Article  CAS  PubMed  Google Scholar 

  64. Kannel WB, Wilson PW, Nam BH et al (2004) A likely explanation for the J-curve blood pressure cardiovascular risk. Am J Cardiol 94:380–384

    Article  PubMed  Google Scholar 

  65. Madhavan S, Ooi WL, Cohen H, Alderman MH (1994) Relation of pulse pressure and Blood pressure reduction to the incidence of myocardial infarction. Hypertension 23:395–401

    Article  CAS  PubMed  Google Scholar 

  66. Wang TD et al (2017) Increased all-cause mortality with intensive blood-pressure control in patients with a baseline systolic bloodpressure of> 160 mmHg and a Lower Framingham risk score: a cautionary note from SPRINT. European Society of Cardiology 2017 Congress. August 28, Barcelona, Spain, Abstract 3828

  67. Zanchetti A, Liu L, Mancia G, Parati G, Grassi G, Stramba-Badiale M et al (2014) Blood pressure and LDL-cholesterol targets for prevention of recurrent strokes and cognitive decline in the hypertensive patient: design of the European Society of Hypertension-Chinese Hypertension League Stroke in Hypertension Optimal Treatment randomized trial. J Hypertens 32:1888–1897

    Article  CAS  PubMed  Google Scholar 

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Authors and Affiliations

  1. Unidad de Hipertensión, Hospital Infanta Cristina, Carretera de Portugal s/n, 06070, Badajoz, Spain

    Nicolás Roberto Robles & Francesco Fici

  2. University of Salamanca School of Medicine, Salamanca, Spain

    Nicolás Roberto Robles & Francesco Fici

  3. University of Salamanca School of Medicine, Salamanca, Spain

    Francesco Fici

  4. Clinica Medica, Università Milano-Bicocca, Milan, Italy

    Guido Grassi

  5. IRCCS MultiMedica, Sesto San Giovanni, Milan, Italy

    Guido Grassi

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  1. Nicolás Roberto Robles
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Correspondence to Nicolás Roberto Robles.

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Robles, N.R., Fici, F. & Grassi, G. J-shaped curve for cardiovascular mortality: systolic or diastolic blood pressure?. J Nephrol 32, 347–353 (2019). https://doi.org/10.1007/s40620-018-0535-x

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