Thus Far and No Further: Should Diastolic Hypotension Limit Intensive Blood Pressure Lowering?

Intensive blood pressure lowering to systolic blood pressure thresholds of less than 120 mmHg is making a slow comeback with the publication of trials supporting its benefit, especially in lowering stroke and congestive heart failure. At the same time, there is an increasing awareness of the prevalence and risk of diastolic hypotension, especially at levels of less than 60 mmHg, with support for the existence of a J-curve coming from post hoc analyses of trials and epidemiological data from large cohort studies. Hence, intensive lowering of systolic blood pressure should be done cautiously in those patients who have pre-existing coronary artery disease, and a diastolic blood pressure between 60 and 70 mmHg. Among those with diastolic blood pressure already below 60 mmHg, but whose systolic blood pressure is not at target, we recommend shared decision-making with an explicit discussion of the risks and benefits, and taking patient preferences into account. Further research with biomarkers and risk models exploring heterogeneity of outcomes might allow for more precise targeting of intensive blood pressure lowering in individuals most likely to benefit, with avoiding those most likely to harm.