Response by Kalkman et al to Letter Regarding Article, “J Curve in Patients Randomly Assigned to Different Systolic Blood Pressure Targets: An Experimental Approach to an Observational Paradigm”
Authors: Deborah N. Kalkman, Tom F. Brouwer, Bert-Jan H. van den Born
Journal: Circulation (2018)

American College of Cardiology/American Heart Association hypertension guideline.In this new guideline, the systolic blood pressure (SBP) target is set to <130 mm Hg for all patients, a significant reduction compared with the previous target that was aimed at reducing SBP to <140 mm Hg. 2 The new SBP target also applies to high-risk patients, such as patients with diabetes mellitus and advanced age.We agree with Dr Koh that the benefit of further blood pressure-lowering treatment should be balanced against an increased risk of adverse events, particularly in older patients.In our article, we show that the J-curve in patients receiving standard and intensive blood pressure lowering treatment is independent of the absolute SBP target, suggesting that other factors are responsible for the observed association between lower SBP levels and increased risk of cardiovascular disease and all-cause mortality.The implication is that the optimal blood pressure target can only be assessed with prospective randomized trials. 1 In the aggregated data set of the SPRINT (Systolic Blood Pressure Intervention Trial) and ACCORD-BP (Action to Control Cardiovascular Risk in Diabetes) trials, the intensive blood pressurelowering group had fewer cardiovascular events and lower all-cause mortality.Results of a benefit with intensive SBP lowering were found to be consistent in all patient subgroups, including patients with diabetes mellitus and those aged ≥75 years, who even had a larger reduction of the primary end point. 3,4Moreover, in a recently published secondary analysis of SPRINT, patient-reported outcomes measured through physical and mental health-related questionnaires were not different between treatment arms. 5 Intensive blood pressure-lowering therapy was associated with hypotension and other serious adverse events, such as syncope, electrolyte abnormalities, and acute kidney failure, but the absolute increase was <2% for each individual adverse event type.Furthermore, these adverse events are almost always reversible by adjusting the blood pressure target or by changes in the medication regimen, whereas this is not true for the benefits of intensive treatment: Damage caused by myocardial infarction or stroke is often not reversible.That said, SPRINT dealt with a nondiabetic ambulant elderly population who were relatively well controlled before randomization.Therefore, it may be difficult to extrapolate the findings to other elderly patients who are less ambulant or less well controlled.The task of the treating physicians is to weigh the benefits and risks of blood pressure lowering in the individual patient.Once intensive treatment is initiated, the tolerability of the treatment should be evaluated and adjusted where needed.Patient-tailored therapy will be required for patients with multiple comorbidities.In these patients optimal hypertension treatment will never be one-size-fits-all.