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Antihypertensive treatment and the J-curve

J M Cruickshank1

  • 1Oxonian Cardiovascular Consultancy, Long Melford, Suffolk, UK. johndtl@aol.com

Cardiovascular Drugs and Therapy
|September 22, 2000
PubMed

Insights

Lowering diastolic blood pressure (DBP) too much in hypertensive patients, especially those with coronary stenosis, can cause myocardial ischemia. Optimal DBP targets vary, with ischemic patients needing higher levels to prevent heart attacks.

Area of Science:

  • Cardiology
  • Hypertension Research
  • Vascular Physiology

Background:

  • The heart's oxygen extraction is near maximal at rest, making it vulnerable to reduced coronary filling pressure.
  • Antihypertensive therapy lowering diastolic blood pressure (DBP) below autoregulation limits can precipitate myocardial ischemia, particularly with coronary stenosis (>85%) and left ventricular hypertrophy (LVH).
  • Ischemic episodes in treated hypertensives are often preceded by hypotension, highlighting the critical role of DBP management.

Purpose of the Study:

  • To examine the relationship between diastolic blood pressure (DBP) management and myocardial infarction (MI) risk in hypertensive patients.
  • To clarify the existence and implications of the "J-curve" phenomenon in the context of antihypertensive treatment.
  • To determine optimal DBP targets for preventing ischemic events in different hypertensive patient subgroups.

Main Methods:

  • Review and analysis of existing clinical studies, including the MRFIT and HOT trials, focusing on DBP levels and cardiovascular events.
  • Comparison of outcomes in hypertensive patients with and without evidence of myocardial ischemia or LVH.
  • Evaluation of the "J-curve" hypothesis, distinguishing between treatment-induced and naturally occurring associations.

Main Results:

  • Patients with ischemic heart disease or LVH experienced excess coronary events when DBP was lowered significantly, suggesting a J-curve effect in this subgroup.
  • Studies like HOT indicate optimal MI prevention in ischemic hypertensives when DBP is maintained in the mid- to low 80s mmHg.
  • Non-ischemic hypertensives can safely have DBP lowered below these levels, with no significant MI prevention benefit but also without increased risk.

Conclusions:

  • A treatment-induced J-curve exists for DBP in ischemic hypertensive patients, where excessively low DBP increases MI risk.
  • Ischemic patients require careful DBP management, avoiding levels below the mid- to low 80s mmHg to prevent myocardial ischemia and MI.
  • For non-ischemic hypertensives, lowering DBP below the mid- to low 80s offers minimal additional MI prevention benefit but is generally safe.

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