Author + information
- Yonit Marcus, MD, PhD,
- Esther Osher, MD, PhD and
- Naftali Stern, MD∗ ()
- ↵∗Institute of Endocrinology, Metabolism and Hypertension, Tel Aviv-Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, 6 Weizmann Street, Tel Aviv 64239, Israel
In the treatment of hypertension, lowering of diastolic pressure to <70 mm Hg is often unavoidable. McEvoy et al. (1) examined the association of diastolic blood pressure (DBP) with coronary heart disease (CHD), stroke and death using the ARIC (Atherosclerosis Risk In Communities) study cohort. They noted increased CHD risk of 1.5, 1.2, and 1.2 for DBP <60, 70, and 80 mm Hg, respectively. A similar relationship was seen in subjects treated for hypertension at baseline. The authors concluded that in the treatment of hypertension it may be prudent to ensure that DBP levels do not fall to <70 mm Hg. In our opinion, the linkage between DBP <80 mm Hg and CHD in the setting of an observational study has been unduly extrapolated by the authors to a practical advice on BP treatment.
Lowering of BP to <80 mm Hg to 70 mm Hg in the treatment of hypertension is usually not a treatment goal. It is, however, rather often, an inevitable outcome of effective systolic lowering. There is indeed a dual problem with the aspiration to keep the diastolic pressure during treatment at ∼80 mm Hg: 1) isolated systolic hypertension is common in the older population segment; and 2) DBP declines precipitously with age in normotensive and hypertensive subjects alike, and is further lowered by any pharmacological treatment of hypertension.
In the standard treatment arms of the SPRINT (Systolic Blood Pressure Intervention Trial) (2) and ACCORD (Action to Control Cardiovascular Risk in Diabetes) (3) hypertension treatment trials, the achieved DBP was ∼73 mm Hg and 70.5 mm Hg, respectively. Keeping in mind the standard deviation of the mean, this indicates that a significant fraction of patients treated to the standard goal of <140 over 90 mm Hg end up with a DBP <70 mm Hg. In older trials, where the treatment paradigm focused on DBP goal <90 mm Hg, the achieved SP was more than 140 mm Hg. Are we prepared to pay the systolic price?
The potential harm of excessive diastolic lowering in terms of CHD must be weighed against the expected rise in stroke and renal disease associated with uncontrolled systolic pressure. Treatment advice should be given based on interventional trials considering outcome on multiorgan endpoints, not on observational studies with a limited focus.
Please note: The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- 2017 American College of Cardiology Foundation