Physicians' Academy for Cardiovascular Education

Increased risk of CV events when diastolic BP falls below 55 mmHg

Effect of Lowering Diastolic Pressure in Patients With and Without Cardiovascular Disease Analysis of the SPRINT (Systolic Blood Pressure Intervention Trial)

Literature - Khan NA, Rabkin SW, Zhao Y, et al. - Hypertension. 2018; published online ahead of print

Introduction and Methods

The exact blood pressure (BP) threshold, at which the J-curve phenomenon appears, is not known, and it is not clear whether this threshold differs in patients with obstructive coronary disease [1,2].

In this analysis of SPRINT (Systolic Blood Pressure Intervention Trial), the relationship between lower systolic (SBP) and diastolic BP (DBP) and the risk for CV events was examined in those with and without CV disease. Moreover, clinical predictors for developing low diastolic BP were investigated.

SPRINT was a randomized, open-label, controlled trial that included 9,361 patients aged >50 years with a screening systolic BP of 130 to 180 mmHg and an increased CV risk. Patients with diabetes mellitus, a history of stroke or heart failure were excluded [3,4]. Further exclusion criteria for the present analysis were: patients with a CV event within 30 days of randomization, lack of recorded BPs after randomization, or missing key baseline characteristics.

Patients were stratified by history of clinical CV disease and randomized 1:1 to intensive BP lowering to a systolic target of <120 mmHg versus standard systolic BP lowering of 135 to 139 mmHg. The study was originally planned for a 5-year follow-up, but ended early because of clear evidence of treatment benefit. The median follow-up was 3.26 years. The primary endpoint was a composite of myocardial infarction, acute coronary syndrome, stroke, acute decompensated heart failure, or CV death.

Main results


This post-hoc analysis of SPRINT suggests that intensive BP lowering in patients with hypertension, but not diabetes mellitus, stroke, or heart failure, may increase CV risk if DBP falls to <55 mmHg. These data suggest caution when intensive BP targets are targeted, especially in patients at high risk to develop very low diastolic BP.


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