Aggressive Blood Pressure Lowering Is Dangerous: The J-Curve

Abstract

Controversies in Hypertension 37B lood pressure (Bp) is poorly controlled in the popula- tion, a phenomenon with adverse prognostic impact. 1 However, a more aggressive approach toward Bp lowering has been tempered over the last 2 to 3 decades by some reports suggesting a paradoxical increase in morbidity and mortality associated with an excessive reduction in Bp, the so-called J-shaped curve hypothesis.3][4][5] We conducted an updated critical review of the most relevant studies and metaanalysis from our and other groups.We recognize that there is some evidence that a diastolic Bp target <80 mm Hg, 6 or an achieved diastolic Bp <70 mm Hg, 7 might be associated with an increased risk of myocardial infarction 6 (Mi) or total cardiovascular events 7 in hypertensive patients with established coronary artery disease (CAD).However, with the possible exception of hypertensive patients with CAD, there are no convincing data behind the conclusion that an aggressive reduction of Bp could be a direct cause of adverse outcome.][4][5] in particular, several clinical conditions including, but not limited to, heart failure, previous Mi, and cancer might have been the dominant and direct cause of adverse outcome in these patients, antihypertensive treatment being thus a sort of innocent bystander.As an implication of this line of thinking, dangerous would not be the excessive reduction in Bp but rather the excessively low Bp. the difference is not trivial.Insight From Direct Epidemiology in subjects with or without risk factors, but free from overt cardiovascular disease, the log-linear relation between Bp and rate of mortality from CAD or stroke appears to begin at values around 115/75 mm Hg, without any J-shaped relation. 8ndeed, these values are rarely reached in treated hypertensive patients.the risk of end-stage renal disease also showed a direct linear relation with Bp, with no evidence of a J-curve. 9in patients with history of stroke, a J-shaped relation between Bp and recurrent stroke has been noted during the first 3 to 6 months after the index event, 10 but not later. 11With increasing time elapsed from acute stoke, patients may be more stable and their cerebral circulation less vulnerable to the effects of Bp lowering.