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World J Hypertens. Feb 23, 2017; 7(1): 1-9
Published online Feb 23, 2017. doi: 10.5494/wjh.v7.i1.1
Reduction of diastolic blood pressure: Should hypertension guidelines include a lower threshold target?
Steven Tringali, Jian Huang
Steven Tringali, Jian Huang, Department of Medicine, University of California San Francisco-Fresno Medical Education Program, Fresno, CA 93701, United States
Jian Huang, Department of Medicine, Veterans Administration Central California Health Care System, Fresno, CA 93703, United States
Author contributions: All the authors contributed to the manuscript.
Conflict-of-interest statement: Authors declare no conflict of interests for this article.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Jian Huang, MD, Department of Medicine, Veterans Administration Central California Health Care System, 2615 E Clinton Ave, Fresno, CA 93703, United States. jian.huang@va.gov
Telephone: +1-559-2256100 Fax: +1-559-2416484
Received: August 30, 2016
Peer-review started: September 1, 2016
First decision: October 26, 2016
Revised: November 20, 2016
Accepted: December 16, 2016
Article in press: December 18, 2016
Published online: February 23, 2017
Processing time: 171 Days and 4.3 Hours
Abstract

Reduction of diastolic blood pressure to less than 60-80 mmHg does not improve mortality and may lead to adverse cardiovascular events in high risk patient populations. Despite a growing body of evidence supporting the J-curve phenomenon, no major society guidelines on hypertension include a lower threshold target for diastolic blood pressure. Many major society guidelines for hypertension have been updated in the last 5 years. Some guidelines include goals specific to age and co-morbid conditions. The Sixth Joint Task Force of the European Society of Cardiology and the Canadian Hypertension Education Program are the only guidelines to date that have recommended a lower threshold target, with the Canadian guidelines recommending a caution against diastolic blood pressure less than or equal to 60 mmHg in patients with coronary artery disease. While systolic blood pressure has been proven to be the overriding risk factor in hypertensive patients over the age of 50 years, diastolic blood pressure is an important predictor of mortality in younger adults. Post hoc data analysis of previous clinical trials regarding safe lower diastolic blood pressure threshold remains inconsistent. Randomized clinical trials designed to determine the appropriate diastolic blood pressure targets among different age groups and populations with different comorbidities are warranted. Hypertension guideline goals should be based on an individual’s age, level of risk, and certain co-morbid conditions, especially coronary artery disease, stroke, chronic kidney disease, and diabetes.

Keywords: Blood pressure; Guideline; J-curve; Hypertension; Diastolic pressure

Core tip: Reduction of diastolic blood pressure to less than 60-80 mmHg appears to lead to adverse cardiovascular events in high risk patient populations. Currently, only two major society guidelines on hypertension include a minimum threshold for diastolic blood pressure. Available studies demonstrating adverse events at lower diastolic blood pressure vary in their cutoff values and patient populations. Randomized controlled trials comparing outcomes across different diastolic blood pressure targets are limited. Hypertension guideline goals should be based on an individual’s age, level of risk, and certain co-morbid conditions, especially coronary artery disease, stroke, chronic kidney disease, and diabetes.