Isolated Diastolic Hypertension and Risk of Cardiovascular Disease: Controversies in Hypertension—Con Side of the Argument

ARTICLE: Isolated Diastolic Hypertension and Risk of Cardiovascular Disease: Controversies in Hypertension—Con Side of the Argument

AUTHORS: Alan P Jacobsen, Myles McKittrick, Natalie Daya, Mahmoud Al Rifai, John W McEvoy

JOURNAL: Hypertension. 2022 Aug;79(8):1571-1578. doi: 10.1161/HYPERTENSIONAHA.122.18458. Epub 2022 Jul 13.


Isolated diastolic hypertension (IDH) is a blood pressure (BP) phenotype that is less commonly encountered than isolated systolic hypertension or combined systolic diastolic hypertension (SDH). While the association of elevated BP with incident cardiovascular disease (CVD) events is unquestionable,1 particularly in the case of elevated systolic BP,2,3 whether isolated elevation in diastolic BP in the presence of normal systolic BP (ie, IDH) is associated with CVD has been less clear.4,5 This uncertainty has only come more into focus since the release of the 2017 American College of Cardiology/American Heart Association Task Force (ACC/AHA) High BP Guideline, which redefined IDH as a diastolic BP ≥80 mm Hg with a systolic BP <130 mm Hg.6,7

Establishing a clear and consistent association between IDH and CVD events is important because hypertension guidelines do not distinguish between IDH, isolated systolic hypertension, or SDH when providing treatment recommendations. Specifically, guidelines define hypertension as either a systolic BP above threshold or a diastolic BP above threshold or both. As such, they provide the same weight of importance and same treatment recommendation to the following 3 example BPs; 135/75, 125/85, and 135/85 mm Hg. According to the 2017 ACC/AHA high BP guideline, these 3 BPs represent isolated systolic hypertension, IDH, and SDH, respectively, and all 3 require antihypertensive drug treatment in the presence of elevated risk for CVD. But are these 3 BPs the same in terms of their prognostic significance and do they all have the same level of evidence favoring antihypertensive drug treatment from randomized clinical trials? The simple answer is no.

In this con argument, we will review prognostic data describing the associations between the 2017 ACC/AHA definition of IDH and CVD events. We hope to convince readers that the lack of a consistent and clinically meaningful association between this definition of IDH and CVD events challenges the current ACC/AHA guideline, which recommends that clinicians (1) commence antihypertensive treatment among persons with IDH (ie, isolated diastolic BP≥80 mm Hg) and 10-year CVD risk of ≥10% and (2) target an on-treatment diastolic BP of <80 mm Hg among all persons receiving antihypertensive therapy irrespective of their CVD risk. Indeed, unlike isolated systolic hypertension and SDH, there has never been a clinical trial exclusively among adults with IDH that has demonstrated benefit for antihypertensive drug treatment.8 As such, the burden of proof informing the need for drug treatment in IDH is based solely on prognostic observational data and expert opinion.

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