Myocardial perfusion and the J curve association between diastolic blood pressure and mortality

Martin G. Schultz, Walter P. Abhayaratna, Thomas H. Marwick, James E Sharman

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Background The J-curve relationship between brachial diastolic blood pressure (DBP) and mortality is believed to be mediated through reduced myocardial perfusion. This study aimed to determine the relationship between DBP and subendocardial perfusion in patients with and without coronary artery disease (CAD) and to examine central hemodynamic variables that may explain the risk associated with low DBP (aortic stiffness, central pulse pressure, and augmentation index). Methods Brachial DBP and radial tonometry were measured in 134 patients with CAD (aged 76±7years; 69% male), 134 individuals without a prior cardiovascular event (control subjects) (aged 77±2years; 69% male) and 47 patients (aged 63±10years) during dobutamine stress echocardiography. Central hemodynamics and subendocardial viability ratio (SEVR), a marker of subendocardial perfusion, were recorded by tonometry. Results There was no difference in DBP or SEVR between control subjects and CAD patients (P > 0.05), nor was there a difference in SEVR across quartiles of DBP in CAD patients (P = 0.07) or control subjects (P = 0.14). After adjustment for age and height, associations between DBP and SEVR in control subjects (r = 0.185; P = 0.03) and CAD patients (r = 0.204; P = 0.02) were attenuated (P = 0.07 and P = 0.11, respectively). There were no significant relationships between DBP and central hemodynamics (P > 0.05 for all). At peak dobutamine stress, SEVR was significantly reduced in patients with inducible ischemia vs. those with nonischemic response (84±17 vs. 101±22%; P = 0.01). However, DBP was not significantly different (65±14 vs. 67±15mm Hg; P = 0.32).ConclusionsBrachial DBP is a poor marker of subendocardial perfusion. The J-curve relationship between DBP and mortality is unlikely attributable to reduced myocardial perfusion or adverse central hemodynamics.

Original languageEnglish
Pages (from-to)557-566
Number of pages10
JournalAmerican Journal of Hypertension
Issue number4
Publication statusPublished - Apr 2013
Externally publishedYes


  • blood pressure
  • hypertension
  • ischemia
  • left ventricle
  • pressure waveform analysis
  • pulse pressure
  • subendocardial viability ratio

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