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J Curve and Cuff Artefact, and Diagnostic Inertia in Resistant Hypertension.

See related article, pp 63–69 

In this issue of Hypertension , Odden et al1 have reported on achieved blood pressures in the Secondary Prevention of Small Subcortical Strokes (SPS3) study. After a mean follow-up of 3.7 (SD, 2.0) years, they found a J-shaped association between achieved blood pressure and outcomes, with the lowest risk at ≈124 mm Hg systolic and 67 mm Hg diastolic. The study randomized patients after a lacunar stroke to 2 systolic blood pressure (SBP) targets: <130 mm Hg or 130 to 149 mm Hg. Patients were also randomized to aspirin 325 mg alone or aspirin plus clopidogrel. In the intention-to-treat analysis2 of the 2 blood pressure target groups, the only significant difference was a reduction of intracerebral hemorrhage with lower blood pressures. There was an excess of bleeding with dual antiplatelet therapy.

In this commentary, we address 2 key issues arising from this study: the J-shaped curve and poorer blood pressure control with a near doubling of stroke risk among black participants.

In this analysis of achieved blood pressures, both ischemic and hemorrhagic strokes declined with lower blood pressures down to 124/67 and then increased with further lowering of SBP. The authors suggest that lower blood pressure may increase the risk of both ischemic and hemorrhagic strokes. However, it is not biologically plausible that lower blood pressure would increase the risk of hemorrhagic stroke. Hypertensive intracerebral hemorrhage in the vascular centrencephalon—the basal ganglia, thalamus, brain stem, and cerebellum—is clearly caused by high blood pressure per se,3 whereas subarachnoid hemorrhage and lobar hemorrhage because of amyloid angiopathy or vascular malformation are not. In this study, the type of intracranial hemorrhage was not specified. Furthermore, in this study, the number of hemorrhagic strokes was small (27), and they were twice as common (18 …