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Thus Far and No Further: Should Diastolic Hypotension Limit Intensive Blood Pressure Lowering?
Marcel Ruzicka1,2, Cedric Edwards1, Brendan McCormick1
1Division of Nephrology, The Ottawa Hospital and University of Ottawa, 1967 Riverside Drive, Ottawa, ON, Canada.
Insights
Intensive blood pressure lowering offers benefits for stroke and heart failure but requires caution. Careful consideration of diastolic blood pressure is crucial to avoid potential harm, especially in patients with coronary artery disease.
Area of Science:
- Cardiology and Hypertension Management
- Clinical Trial Analysis
- Epidemiological Research
Background:
- Intensive systolic blood pressure (SBP) lowering (target <120 mmHg) is regaining traction due to trial evidence of reduced stroke and heart failure incidence.
- Growing recognition of diastolic hypotension (DBP <60 mmHg) risks, supported by J-curve analyses and cohort studies, necessitates a balanced approach to blood pressure targets.
Purpose of the Study:
- To provide guidance on the cautious application of intensive systolic blood pressure lowering.
- To highlight the importance of considering diastolic blood pressure levels and patient-specific factors in hypertension management.
- To advocate for shared decision-making in cases where intensive SBP lowering may pose risks.
Main Methods:
- Review and synthesis of recent clinical trial data supporting intensive SBP lowering.
- Analysis of post hoc trial data and epidemiological studies examining the J-curve phenomenon in relation to diastolic blood pressure.
- Expert opinion and clinical consensus on risk stratification and patient management strategies.
Main Results:
- Intensive SBP lowering (<120 mmHg) demonstrates efficacy in reducing stroke and congestive heart failure.
- Diastolic hypotension (<60 mmHg) is associated with increased risks, suggesting a J-curve relationship.
- Caution is advised for intensive SBP lowering in patients with coronary artery disease and DBP between 60-70 mmHg.
Conclusions:
- Intensive systolic blood pressure reduction should be approached cautiously, particularly in patients with existing cardiovascular conditions and specific diastolic pressure ranges.
- Shared decision-making is recommended for patients with SBP not at target but with DBP <60 mmHg, ensuring patient preferences and risks/benefits are discussed.
- Future research focusing on biomarkers and risk models is needed for personalized intensive blood pressure lowering strategies.
Opinion Statement:
Intensive blood pressure lowering to systolic blood pressure thresholds of less than 120 mmHg is making a slow comeback with the publication of trials supporting its benefit, especially in lowering stroke and congestive heart failure. At the same time, there is an increasing awareness of the prevalence and risk of diastolic hypotension, especially at levels of less than 60 mmHg, with support for the existence of a J-curve coming from post hoc analyses of trials and epidemiological data from large cohort studies. Hence, intensive lowering of systolic blood pressure should be done cautiously in those patients who have pre-existing coronary artery disease, and a diastolic blood pressure between 60 and 70 mmHg. Among those with diastolic blood pressure already below 60 mmHg, but whose systolic blood pressure is not at target, we recommend shared decision-making with an explicit discussion of the risks and benefits, and taking patient preferences into account. Further research with biomarkers and risk models exploring heterogeneity of outcomes might allow for more precise targeting of intensive blood pressure lowering in individuals most likely to benefit, with avoiding those most likely to harm.
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