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VIEWPOINT AND COMMENTARY

The J-Curve Between Blood Pressure and Coronary Artery Disease or Essential Hypertension

Exactly How Essential?

Franz H. Messerli, MD^_*,_* and Gurusher S. Panjrath, MD

^_* Division of Cardiology, St. Luke's-Roosevelt Hospital Center, Columbia University, College of Physicians and Surgeons, New York, New York
Division of Cardiology, The Johns Hopkins Hospital, Baltimore, Maryland

Manuscript received November 11, 2008; revised manuscript received April 10, 2009, accepted May 6, 2009.

^_* Reprint requests and correspondence: Dr. Franz H. Messerli, Division of Cardiology, St. Luke's Roosevelt Hospital Center, 1000 10th Avenue, Suite 3B.30, New York, New York 10019 (Email: FMesserli{at}aol.com).

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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