New evidence for the diastolic J‐curve effect challenges the safety of intensive blood pressure control

The recently published Systolic Blood Pressure Intervention (SPRINT) study has revolutionized the concept of the effective treatment of hypertension.1 The findings showed that aggressive systolic blood pressure (SBP) control to <120 mm Hg was associated with significant reduction of the primary composite outcome of myocardial infarction (MI), other coronary syndromes, stroke, heart failure (HF), or death from cardiovascular (CV) causes in both older men and women and even those 75 years and older.2 These findings have prompted plans to revise the blood pressure (BP) treatment guidelines according to SPRINT. However, aggressive treatment of SBP to <120 mm Hg could also reduce diastolic BP (DBP) to ≤70 or <60 mm Hg. Such lowering of DBP could reduce coronary blood flow, particularly in highrisk patients with preexisting coronary artery disease (CAD), and hypertension with or without left ventricular hypertrophy (LVH) and cause myocardial ischemia, MI, or CV death due to the Jcurve effect.3–5 In a recent paper I wrote regarding the impact of SPRINT on the future treatment of hypertension, I alluded to the possibility of adverse CV events from the aggressive control of BP due to the Jcurve effect from the low DBP.6 This prediction is supported by two recent publications7,8 reporting on the myocardial damage from the Jcurve effect due to low DBP by measuring serial blood levels of highsensitivity cardiac troponin T (hscTnT). This commentary addresses these two publications as well as other recent studies questioning the longterm safety of aggressive SBP and DBP control.