The Diastolic Blood Pressure J-Curve in Hypertension Management: Links and Risk for Cardiovascular Disease

Purpose of Review: The treatment of hypertension has changed dramatically over the last century, with recent trials informing clinical guidelines that recommend aiming for lower blood pressure (BP) targets than ever before. However, a "J"- or "U-shaped curve" in the association between diastolic BP and cardiovascular events has been observed in epidemiological studies, suggesting that both high diastolic BPs and diastolic BPs below a certain nadir are associated with higher risk of cardiovascular disease (CVD) events. Despite the potential for confounding and reverse causation, this association may caution against overly intensive BP lowering in some hypertensive adults who also have a low baseline diastolic BP. Recent Findings: Recent post-hoc analyses of the landmark Systolic Blood Pressure Intervention Trial (SPRINT) appear to contradict these J-curve concerns, finding that the benefit of more intensive BP treatment did not differ based on baseline blood pressure. Similarly, sensitivity analyses of The Strategy of Blood Pressure Intervention in the Elderly Hypertensive Patients (STEP) randomized controlled trial found that patients experienced similar benefits from an intensive BP goal, regardless of whether their diastolic BP was above or below 60 mm Hg. Finally, several Mendelian randomization analyses, which are less susceptible to confounding and reverse causation, demonstrated a clear linear relationship between diastolic BP and cardiovascular events. These studies indicate that a potential reduction in CVD risk is possible, irrespective of baseline diastolic BP values. Summary: Sufficient recent evidence indicates that low diastolic BP is not causal of worse cardiovascular outcomes but rather represents confounding or reverse causation. Therefore, while low diastolic BP can be considered a marker of CVD risk, this risk is not expected to increase with further BP lowering when necessary to control concomitant elevations of systolic BP. Indeed, BP reduction in this setting appears beneficial.