[Hypertension and cardiovascular risk: the J-curve concept]

The optimization of the pharmacologic treatment in hypertensive patients is encouraged by four reports: the high prevalence of hypertension and more particularly in the elderly, the lack of blood pressure control in more than half of patients, the frequency of the association to other cardiovascular risk factors and the existence of a residual risk under treatment. All these factors are combined to raise the cardiovascular risk in hypertensive patients. Several interventional studies highlighted a reduction of the cardiovascular risk proportional to the reduction of blood pressure under treatment. Thus arose the question of the optimal blood pressure: the guidelines propose values lower than 140/90 mmHg for the non-complicated essential hypertension and lower than 130/80 mmHg in secondary prevention, for the patients with diabetes or renal impairment. However, this strict blood pressure goal for the high cardiovascular risk patients is not confirmed by clinical trials, strict blood pressure goal being potentially deleterious. The concept of «the lower the better» tends to be abandoned. Since more than three decades, the assumption of a paradoxical increase of the cardiovascular morbidity and mortality associated with a high reduction of blood pressure (the «J-Curve» concept) remains the subject of many studies and controversies.