Blood pressure targets of antihypertensive treatment: up and down the J-shaped curve

Abstract

This editorial refers to ‘Effects of a fixed combination of perindopril and indapamide in patients with type 2 diabetes and chronic kidney disease’[†][1], by H.J. Lambers Heerspink et al. , on page 2888 and ‘J-curve revisited: an analysis of blood pressure and cardiovascular events in the Treating to New Targets (TNT) Trial’[‡][2], by S. Bangalore et al. , on page 2897 The solid evidence (mostly from placebo-controlled trials) that lowering blood pressure (BP) in hypertensives is accompanied by reduced incidence of cardiovascular outcomes generated the opinion that the lower the BP achieved the greater the outcome reduction. It has also been inferred that the direct relationship between BP and incident outcomes, down to at least 115 mmHg systolic BP (SBP) and 75 mmHg diastolic BP (DBP), described in uncomplicated individuals,1 can also be observed in treated hypertensives, and high-risk individuals might benefit from further BP lowering even if initially normotensives. These opinions and recommendations have recently been reappraised by a Task Force document of the European Society of Hypertension (ESH) on the basis of a critical analysis of available evidence from trials.2 It has been concluded that there is no solid evidence in favour of the recommendation that high-risk patients should require a SBP target below 130 mmHg and should receive antihypertensive agents even when their BP is in the high-normal range.2 Furthermore, several groups of authors have recently revisited the hypothesis of a J-shaped relationship between BP achieved by treatment and incident cardiovascular events. This hypothesis continues to be widely popular for several reasons: (i) common sense indicates a threshold BP must exist below which survival is impaired (at 0 mmHg all would be dead); (ii) physiology has shown there is a low (as well as high) BP threshold for organ blood flow autoregulation, and this threshold can … *Corresponding author. Tel: +39 02 50320484, Fax: +39 02 50320480, Email: alberto.zanchetti{at}unimi.it or alberto.zanchetti{at}auxologico.it [1]: #fn-2 [2]: #fn-3