The Tale of an Innocent
Intensive Treatment and the J-Curve in the SPRINT Trial (Systolic Blood Pressure Intervention Trial)
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Article, see p 2220
Does an intensive reduction in blood pressure (BP) induced by lifestyle measures and drug treatment confer a benefit or, conversely, an added risk to patients? Following the early observations by Cruickshank et al,1 several studies addressed the paradoxical increase in the risk of major cardiovascular events and death in hypertensive patients achieving very low BP values (the so-called J-curve phenomenon). However, placebo-controlled trials did not show any significant increase in the risk of cardiovascular events, with perhaps a rise in the risk of noncardiovascular mortality, in association with very low levels of achieved BP.2 Thus, it became crucial to uncouple the BP-lowering effect of antihypertensive treatment from the impact of several potential conditions associated with low BP and adverse outcome (reverse causality). Among these conditions, cancer and congestive heart failure may be potent inducers of hypotension and poor prognosis, regardless of the antihypertensive treatment to which patients are exposed. Unfortunately, adjustment for confounders had not always been addressed satisfactorily in studies focusing on the J-curve phenomenon.
In some analyses, the J-curve phenomenon occurred mostly in patients with coronary artery disease.1–3 An excessive reduction in diastolic BP could theoretically lead to coronary hypoperfusion, in particular, in the presence of significant stenosis. Because most of these studies …