Diastolic Blood Pressure J-Curve Phenomenon in a Tertiary-Care Hypertension Clinic

Hypertension. 2019 Oct;74(4):767-775. doi: 10.1161/HYPERTENSIONAHA.119.12787. Epub 2019 Aug 19.

Abstract

Concerns exist regarding the potential increased cardiovascular risk from lowering diastolic blood pressure (DBP) in hypertensive patients. We analyzed 30-year follow-up data of 10 355 hypertensive patients attending the Glasgow Blood Pressure Clinic. The association between blood pressure during the first 5 years of treatment and cause-specific hospital admissions or mortality was analyzed using multivariable adjusted Cox proportional hazard models. The primary outcome was a composite of cardiovascular admissions and deaths. DBP showed a U-shaped association (nadir, 92 mm Hg) for the primary cardiovascular outcome hazard and a reverse J-shaped association with all-cause mortality (nadir, 86 mm Hg) and noncardiovascular mortality (nadir, 92 mm Hg). The hazard ratio for the primary cardiovascular outcome after adjustment for systolic blood pressure was 1.38 (95% CI, 1.18-1.62) for DBP <80 compared with DBP of 80 to 89.9 mm Hg (referrant), and the subdistribution hazard ratio after accounting for competing risk was 1.33 (1.17-1.51) compared with DBP ≥80 mm Hg. Cause-specific nonfatal outcome analyses showed a reverse J-shaped relationship for myocardial infarction, ischemic heart disease, and heart failure admissions but a U-shaped relationship for stroke admissions. Age-stratified analyses showed DBP had no independent effect on stroke admissions among the older patient subgroup (≥60 years of age), but the younger subgroup showed a clear U-shaped relationship. Intensive blood pressure reduction may lead to unintended consequences of higher healthcare utilization because of increased cardiovascular morbidity, and this merits future prospective studies. Low on-treatment DBP is associated with increased risk of noncardiovascular mortality, the reasons for which are unclear.

Keywords: blood pressure; heart failure; humans; hypertension; myocardial ischemia.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Aged
  • Antihypertensive Agents / therapeutic use
  • Blood Pressure / physiology*
  • Blood Pressure Determination
  • Diastole / physiology*
  • Female
  • Humans
  • Hypertension / drug therapy
  • Hypertension / mortality
  • Hypertension / physiopathology*
  • Male
  • Middle Aged
  • Myocardial Infarction / mortality
  • Myocardial Infarction / physiopathology*
  • Risk Factors
  • Survival Rate
  • Tertiary Healthcare

Substances

  • Antihypertensive Agents