[Hypertension, coronary heart disease and stroke: should the blood pressure J-curve be a concern?]

Area of Science:

• Cardiology
• Hypertension Management
• Clinical Outcomes Research

Context:

• The J-curve describes a paradoxical increase in cardiovascular events with treatment-induced low blood pressure (BP), particularly in hypertensive patients with coronary artery disease (CAD).
• This phenomenon contradicts some observational studies and remains controversial despite recent clinical trials.
• The diastolic J-curve is often more pronounced than the systolic J-curve.

Purpose:

• To review the evidence for the J-curve phenomenon in cardiovascular disease.
• To explore the reasons for the J-curve's impact on coronary artery disease versus stroke.
• To provide evidence-based recommendations for BP management in high-risk patients.

Summary:

• Recent large trials and meta-analyses support the existence of J-curves for both systolic and diastolic BP, with diastolic BP often showing a more significant effect.
• Unlike cardiovascular events, stroke risk did not consistently follow a J-curve pattern, likely due to differences in autoregulation and coronary perfusion occurring during diastole.
• The review suggests avoiding systolic BP below 120-125 mmHg and diastolic BP below 70-75 mmHg in hypertensive patients with CAD or high risk for impaired coronary blood flow.

Impact:

• Highlights the importance of individualized BP targets in hypertensive patients with CAD.
• Recommends specific BP thresholds to mitigate the risk of cardiovascular events associated with overly aggressive BP lowering.
• Informs clinical practice guidelines for managing hypertension in patients with established or high-risk coronary artery disease.