The J-Curve Phenomenon in Hypertension

Almost immediately after antihypertensive therapy was proven effective in preventing cardiovascular events, the J-curve issue emerged as a hot topic. The Hypertension Optimal Treatment (HOT) trial attempted to address this question (diastolic blood pressure <80, <85, and <90 mm Hg) but ended up with a post hoc analysis indicating a nadir of 138.5 mm Hg systolic and 82.6 mm Hg diastolic blood pressure. Nevertheless, this observational finding was supported by the results of observational studies in the general population and by post hoc analyses of antihypertensive treatment trials. The currently ongoing Systolic Hypertension Optimal Treatment (SHOT) trial investigates whether the relationship between systolic blood pressure and stroke recurrence is linear or J-shaped by treating systolic blood pressure to <125, <135, and <145 mm Hg in patients with a history of recent stroke. This trial may provide additional but probably inconclusive evidence, because optimal blood pressure might differ between individuals and across outcomes. Nevertheless, a universal beneficial, instead of optimal, level of blood pressure for antihypertensive treatment may exist approximating 130/80 mm Hg and should be investigated by comparing 130/80 mm Hg with 140/90 mm Hg as a target blood pressure in hypertensive patients with the simultaneous use of modern blood pressure measuring techniques, such as home and ambulatory blood pressure monitoring.