Systolic hypertension is more often associated to cardiovascular events. However, diastolic blood pressure should not be disregarded, since it can also predict even worse outcomes.

Although systolic blood pressure is very frequently associated to adverse cardiovascular events, by no means should diastolic blood pressure be considered unimportant.

Such is the message of this study recently published in NEJM including data from more than 1.3 million outpatients, which shows that both systolic and diastolic hypertension are independently associated to cardiovascular events in the long run (acute myocardial infarction, ischemic or hemorrhagic stroke) regardless the type of blood pressure we might be focusing on.

Diastolic pressure should not be ignored, and we should focus on both BP goals (systolic and diastolic) for both hypertension diagnosis and treatment, to maximize the chances of therapy and effectively reduce population risk. According to the study authors, the AHA/ACC goals are reasonable and well founded, which is why they suggest aggressive treatment, especially when it comes to higher risk patients.

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They believe the J shaped curve should be of no concern.

The analysis included 36.8 million registries on blood pressure automatically measured. Using 140/90 as threshold, 18.9% presented hypertension, but when using 130/80 the incidence increased to 43.5%!!!

Regardless the BP definition we might choose, both systolic and diastolic pressure are independently associated to adverse events at 8 year follow up.

The correlation was stronger for systolic blood pressure.

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The authors also explored the J shape curve previously observed between diastolic BP and events. This non-adjusted analysis showed increased risk both for peak and valley thresholds, but when adjusting by age, race and other comorbidities, the risk at the bottom of the curve disappeared.

According to this study, the J shape in this population (mostly healthy, mean age 53) is not a problem, so we should be more aggressive in trying to reach the proposed goals with no regard of the J curve, since after adjusting for variables, the risk in the lowest quartile disappears.

Título original: Effect of systolic and diastolic blood pressure on cardiovascular outcomes.

Referencia: Flint AC et al. N Engl J Med. 2019;381:243-251.

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