Viewpoint and Commentary
The J-Curve Between Blood Pressure and Coronary Artery Disease or Essential Hypertension: Exactly How Essential?

https://doi.org/10.1016/j.jacc.2009.05.073Get rights and content
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The topic of the J-curve relationship between blood pressure and coronary artery disease (CAD) has been the subject of much controversy for the past decades. An inverse relationship between diastolic pressure and adverse cardiac ischemic events (i.e., the lower the diastolic pressure the greater the risk of coronary heart disease and adverse outcomes) has been observed in numerous studies. This effect is even more pronounced in patients with underlying CAD. Indeed, a J-shaped relationship between diastolic pressure and coronary events was documented in treated patients with CAD in most large trials that scrutinized this relationship. In contrast to any other vascular bed, the coronary circulation receives its perfusion mostly during diastole; hence, an excessive decrease in diastolic pressure can significantly hamper perfusion. This adverse effect of too low a diastolic pressure on coronary heart disease leaves the practicing physician with the disturbing possibility that, in patients at risk, lowering blood pressure to levels that prevent stroke or renal disease might actually precipitate myocardial ischemia. However, these concerns should not deter physicians from pursuing a more aggressive control of hypertension, because currently blood pressure is brought to recommended target levels in only approximately one-third of patients.

Key Words

coronary artery disease
diastolic pressure
hypertension
valve outcomes
myocardial infarction
pulse pressure
stroke
systolic pressure

Abbreviations and Acronyms

BP
blood pressure
CAD
coronary artery disease
CVD
cardiovascular disease
DBP
diastolic blood pressure
ECG
electrocardiogram
LV
left ventricle/ventricular
LVH
left ventricular hypertrophy
MI
myocardial infarction
SBP
systolic blood pressure

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Dr. Messerli has served as an ad hoc consultant/speaker for GlaxoSmithKline, Novartis, Boehringer Ingelheim, and Daiichi Sankyo and has received grant support from GlaxoSmithKline, Novartis, Forest, Daiichi Sankyo, and Boehringer Ingelheim.