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The “J Curve” Problem Revisited: Old and New Findings

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Abstract

This paper critically addresses the issue of the “J-curve” paradox—the finding described in studies performed about 30 years ago indicating that treatment-induced systolic blood pressure values below 120 or 125 mm Hg and diastolic blood pressure values below 75 mm Hg are characterized by an increase, rather than a reduction, in the incidence of coronary events. This paper focuses on four major subjects: 1) the benefits of a lower blood pressure target during treatment; 2) the historical background of the “J-curve” phenomenon; 3) the evidence collected in recent clinical trials regarding the existence of a “J-curve” in treated hypertensive patients; and 4) the recent recommendations by the Task Force Committee of the European Society of Hypertension on blood pressure goals to be achieved during treatment.

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References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. •• Mancia G, De Backer G, Dominiczak A, et al.: 2007 Guidelines for the Management of Arterial Hypertension: The Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). J Hypertens 2007, 25:1105–1187. This paper represents the official guidelines for the diagnosis and management of high blood pressure jointly issued by the ESH and ESC.

  2. Zanchetti A, Amery A, Berglund G, et al.: How much should blood pressure be lowered? The problem of the J-shaped curve. J Hypertens Suppl 1989, 7:S338–S348.

    CAS  PubMed  Google Scholar 

  3. •• Mancia G, Laurent S, Agabiti-Rosei E, et al.: Reappraisal of European guidelines on hypertension management: a European Society of Hypertension Task Force document. J Hypertens 2009, 27:2121–2158. The ESH decided in 2009 to update the recommendations on hypertension management, based on the results of major clinical trials published in the period 2007 to 2009.

  4. Collins R, MacMahon S: Blood pressure, antihypertensive drug treatment and the risks of stroke and of coronary heart disease. Br Med Bull 1994, 50:272–298.

    CAS  PubMed  Google Scholar 

  5. Arima H, Chalmers J, Woodward M, et al.: Lower target blood pressures are safe and effective for the prevention of recurrent stroke: the PROGRESS trial. J Hypertens 2006, 24:1201–1208.

    Article  CAS  PubMed  Google Scholar 

  6. Bakris GL, Williams M, Dworkin L, et al.: Preserving renal function in adults with hypertension and diabetes: a consensus approach. National Kidney Foundation Hypertension and Diabetes Executive Committees Working Group. Am J Kidney Dis 2000, 36:646–661.

    CAS  PubMed  Google Scholar 

  7. UK Prospective Diabetes Study Group: Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38. BMJ 1998, 317:703–713.

    Google Scholar 

  8. Berl T, Hunsicker LG, Lewis JB, et al.: Cardiovascular outcomes in the Irbesartan Diabetic Nephropathy Trial of patients with type 2 diabetes and overt nephropathy. Ann Intern Med 2003, 138:542–549.

    CAS  PubMed  Google Scholar 

  9. Estacio RO, Jeffers BW, Gifford N, Schrier RW: Effect of blood pressure control on diabetic microvascular complications in patients with hypertension and type 2 diabetes. Diabetes Care 2000, 23(Suppl 2):B54–B64.

    PubMed  Google Scholar 

  10. Patel A; MacMahon S, Chalmers J, et al.: Effects of a fixed combination of perindopril and indapamide on macrovascular and microvascular outcomes in patients with type 2 diabetes mellitus (the ADVANCE trial): a randomised controlled trial. Lancet 2007, 370:829–840.

    Google Scholar 

  11. Pepine CJ, Handberg EM, Cooper-DeHoff RM, et al.: A calcium antagonist vs a noncalcium antagonist hypertension treatment strategy for patients with coronary artery disease. The International Verapamil-Trandolapril Study (INVEST): a randomized controlled trial. JAMA 2003, 290:2805–2816.

    Article  CAS  PubMed  Google Scholar 

  12. Fox KM, EURopean trial On reduction of cardiac events with Perindopril in stable coronary Artery disease Investigators: Efficacy of perindopril in reduction of cardiovascular events among patients with stable coronary artery disease: randomised, double-blind, placebo-controlled, multicentre trial (the EUROPA study). Lancet 2003, 362:782–788.

    Article  CAS  PubMed  Google Scholar 

  13. Nissen SE, Tuzcu EM, Libby P, et al.: Effect of antihypertensive agents on cardiovascular events in patients with coronary disease and normal blood pressure: the CAMELOT study—a randomized controlled trial. JAMA 2004, 292:2217–2225.

    Article  CAS  PubMed  Google Scholar 

  14. Yusuf S, Sleight P, Pogue J, et al.: Effects of an angiotensin-converting-enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients. The Heart Outcomes Prevention Evaluation Study Investigators. N Engl J Med 2000, 342:145–153.

    Article  CAS  PubMed  Google Scholar 

  15. PROGRESS Collaborative Study Group: Randomised trial of a perindopril-based blood-pressure-lowering regimen among 6,105 individuals with previous stroke or transient ischaemic attack. Lancet 2001, 358:1033–1041.

    Article  Google Scholar 

  16. PATS Collaborating Group: Post-stroke antihypertensive treatment study. A preliminary result. Chin Med J (Engl) 1995, 108:710–717.

    Google Scholar 

  17. Zanchetti A: To what level should blood pressure be brought by antihypertensive treatment? High Blood Press 1992, 1:197–200.

    Google Scholar 

  18. Stewart IM: Relation of reduction in pressure to first myocardial infarction in patients receiving treatment for severe hypertension. Lancet 1979, 1(8121):861–865.

    Article  CAS  PubMed  Google Scholar 

  19. Cruickshank JM, Thorp JM, Zacharias FJ: Benefits and potential harm of lowering high blood pressure. Lancet 1987, 1(8533):581–584.

    Article  CAS  PubMed  Google Scholar 

  20. Alderman MH, Ooi WL, Madhavan S, Cohen H: Treatment-induced blood pressure reduction and the risk of myocardial infarction. JAMA 1989, 262:920–924.

    Article  CAS  PubMed  Google Scholar 

  21. Samuelsson O, Wilhelmsen L, Andersson OK, et al.: Cardiovascular morbidity in relation to change in blood pressure and serum cholesterol levels in treated hypertension. Results from the primary prevention trial in Göteborg, Sweden. JAMA 1987, 258:1768–1776.

    Article  CAS  PubMed  Google Scholar 

  22. Yusuf S, Diener HC, Sacco RL, et al.: Telmisartan to prevent recurrent stroke and cardiovascular events. N Engl J Med 2008, 359:1225–1237.

    Article  CAS  PubMed  Google Scholar 

  23. Telmisartan Randomised AssessmeNt Study in ACE iNtolerant subjects with cardiovascular Disease (TRANSCEND) Investigators: Effects of the angiotensin-receptor blocker telmisartan on cardiovascular events in high-risk patients intolerant to angiotensin-converting enzyme inhibitors: a randomised controlled trial. Lancet 2008, 372:1174–1183.

    Article  Google Scholar 

  24. Julius S, Kjeldsen SE, Weber M, et al. Outcomes in hypertensive patients at high cardiovascular risk treated with regimens based on valsartan or amlodipine: the VALUE randomised trial. Lancet 2004, 363:2022–2031.

    Article  CAS  PubMed  Google Scholar 

  25. Messerli FH, Mancia G, Conti CR, et al.: Dogma disputed: Can aggressively lowering blood pressure in hypertensive patients with coronary artery disease be dangerous? Ann Intern Med 2006, 144:884–893.

    PubMed  Google Scholar 

  26. • Sleight P, Redon J, Verdecchia P, et al.: Prognostic value of blood pressure in patients with high vascular risk in the Ongoing Telmisartan Alone and in combination with Ramipril Global Endpoint Trial study. J Hypertens 2009, 27:1360–1369. This paper provides a new evaluation of the ONTARGET Study, analyzing the blood pressure goal data in relation to cardiovascular events in high-risk individuals.

  27. Bangalore S, Messerli FH, Wun C, et al.: J-Curve revisited: an analysis of the Treating to New Targets (TNT) Trial [poster 1039-70]. J Am Coll Cardiol 2009, 53:A217.

    Google Scholar 

  28. Lewington S, Clarke R, Qizilbash N, et al.: Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. Lancet 2002, 360:1903–1913.

    Article  PubMed  Google Scholar 

  29. •• Zanchetti A, Mancia G, Black HR, et al.: Facts and fallacies of blood pressure control in recent trials: implications in the management of patients with hypertension. J Hypertens 2009, 27:673–679. This editorial addresses some of the current clinical problems in hypertension management, with particular emphasis on the position of beta blockers.

  30. Boutitie F, Gueyffier F, Pocock S, et al.: J-shaped relationship between blood pressure and mortality in hypertensive patients: new insights from a meta-analysis of individual-patient data. Ann Intern Med 2002, 136:438–448.

    PubMed  Google Scholar 

  31. •• Zanchetti A, Grassi G, Mancia G: When should antihypertensive drug treatment be initiated and to what levels should systolic blood pressure be lowered? A critical reappraisal. J Hypertens 2009, 27:923–934. This is an updated analysis of the results of major clinical trials aimed at defining blood pressure levels at which antihypertensive treatment should start and blood pressure goals.

  32. Guideline Committee: 2003 European Society of Hypertension-European Society of Cardiology guidelines for the management of arterial hypertension. J Hypertens 2003, 21:1011–1053.

    Google Scholar 

  33. Liu L, Zhang Y, Liu G, et al.: The Felodipine Event Reduction (FEVER) Study: a randomized long-term placebo-controlled trial in Chinese hypertensive patients. J Hypertens 2005, 23:2157–2172.

    Article  CAS  PubMed  Google Scholar 

  34. Hypertension, Detection and Follow-up Program Cooperative Group: Five-year findings of the Hypertension Detection and Follow-up Program. III. Reduction in stroke incidence among persons with high blood pressure. JAMA 1982, 247:633–638.

    Article  Google Scholar 

  35. Medical Research Council Working Party: MRC trial of treatment of mild hypertension: principal results. Br Med J 1985, 291:97–104.

    Article  Google Scholar 

  36. Helgeland A: Treatment of mild hypertension: a five year controlled drug trial. The Oslo study. Am J Med 1980, 69:725–732.

    Article  CAS  PubMed  Google Scholar 

  37. Hansson L, Zanchetti A, Carruthers SG, et al.: Effects of intensive blood pressure lowering and low-dose aspirin in patients with hypertension: principal results of the Hypertension Optimal Treatment (HOT) randomised trial. Lancet 1998, 351:1755–1762.

    Article  CAS  PubMed  Google Scholar 

  38. JATOS Study Group: Principal results of the Japanese trial to assess optimal systolic blood pressure in elderly hypertensive patients (JATOS). Hypertens Res 2008, 31:2115–2127.

    Article  Google Scholar 

  39. Schrier RW, Estacio RO, Esler A, Mehler P: Effects of aggressive blood pressure control in normotensive type 2 diabetic patients on albuminuria, retinopathy and stroke. Kidney Int 2002, 61:1086–1097.

    Article  PubMed  Google Scholar 

  40. The Heart Outcomes Prevention Evaluation (HOPE) Study investigators: Effects of ramipril on cardiovascular and microvascular outcomes in MICROHOPE substudy. Lancet 2000, 355:253–259.

    Article  Google Scholar 

  41. Pitt B, Byington RP, Furberg CD, et al.: Effect of amlodipine on the progression of atherosclerosis and the occurrence of clinical events. Circulation 2000, 102:1503–1510.

    CAS  PubMed  Google Scholar 

  42. Poole-Wilson PA, Lubsen J, Kirwan BA, et al.: Effect of long-acting nifedipine on mortality and cardiovascular morbidity in patients with stable angina requiring treatment (ACTION trial): randomised controlled trial. Lancet 2004, 364:849–857.

    Article  CAS  PubMed  Google Scholar 

  43. The PEACE Trial Investigators: Angiotensin-converting-enzyme inhibition in stable coronary disease. N Engl J Med 2004, 351:2058–2068.

    Article  Google Scholar 

  44. Schrader J, Luders S, Kulschewski A, et al.: The ACCESS Study: evaluation of Acute Candesartan Cilexetil Therapy in Stroke Survivors. Stroke 2003, 34:1699–1703.

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Clinica Medica, Ospedale S. Gerardo dei Tintori, Via Pergolesi 33, 20052, Monza, Milan, Italy

    Guido Grassi, Fosca Quarti-Trevano, Raffaella Dell’Oro & Giuseppe Mancia

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  1. Guido Grassi
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  2. Fosca Quarti-Trevano
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  3. Raffaella Dell’Oro
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  4. Giuseppe Mancia
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Correspondence to Guido Grassi.

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Grassi, G., Quarti-Trevano, F., Dell’Oro, R. et al. The “J Curve” Problem Revisited: Old and New Findings. Curr Hypertens Rep 12, 290–295 (2010). https://doi.org/10.1007/s11906-010-0121-7

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