June 14, 2026Journal of the American College of Cardiology
The J-Curve Between Blood Pressure and Coronary Artery Disease or Essential Hypertension
Key result
Low DBP linked to a J-shaped risk of cardiac events, potentially precipitating ischemia in CAD.
Why the study?
The J-curve relationship between blood pressure and CAD has been controversial, raising concern that lowering diastolic pressure could precipitate myocardial ischemia in at-risk patients.
Does excessive lowering of diastolic blood pressure increase the risk of coronary events in patients with coronary artery disease or essential hypertension?
Key Points
- This research aims to explore the relationship between blood pressure levels and the risk of coronary artery disease or essential hypertension.
- Reviewed existing literature on blood pressure and coronary artery disease
- Analyzed data on cardiovascular outcomes related to various blood pressure levels
- Identified patterns indicative of a j-curve relationship
- Found a significant j-curve relationship where both low and high blood pressure correlate with increased coronary artery disease risk
- Indicated optimal blood pressure levels that minimize disease occurrence
- Suggested new treatment thresholds for managing hypertension
Structured PICO
Does excessive lowering of diastolic blood pressure increase the risk of coronary events in patients with coronary artery disease or essential hypertension?
P
Population
Patients with coronary artery disease or essential hypertension
E
Exposure
Blood pressure lowering
O
Outcome
Coronary heart disease and adverse cardiac ischemic events
While a J-curve relationship exists where very low diastolic blood pressure may increase coronary risk in CAD patients, this should not deter physicians from pursuing recommended blood pressure targets.
Key expert perspectives
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“the diastolic blood pressure J-curve may have little to do with diastolic blood pressure itself and more to do with other parameters like vascular stiffness or vascular calcification that are the true culprits in the observation between increased risk and low diastolic blood pressure”
“We can partially, I think, explain this mystery that is called the J-curve phenomenon in hypertension.”
“In the case of patients who have established coronary artery disease, we have brought beta-blockers from limbo—where they have been consigned—to center stage”
Implication
May inform BP targets in CAD; leaves open need for randomized confirmation.
Abstract
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.
Discussion
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Cite This Study
Messerli et al. (2009) conducted a review in Coronary Artery Disease and Essential Hypertension. Low diastolic blood pressure was evaluated on Adverse cardiac ischemic events. Low diastolic blood pressure exhibits a J-shaped relationship with adverse cardiac ischemic events, potentially precipitating myocardial ischemia in patients with underlying coronary artery disease.