What causes low diastolic blood pressure
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Causes of Low Diastolic Blood Pressure
Arterial Stiffness and Atherosclerosis
One of the primary causes of low diastolic blood pressure (DBP) is arterial stiffness, often linked to atherosclerosis. As arteries stiffen, they lose their ability to expand and contract effectively, leading to a lower DBP. This condition is particularly prevalent in elderly individuals, where a J-shaped association between carotid atherosclerosis and DBP has been observed. Specifically, diastolic pressures below 60 mm Hg are associated with increased intima-media thickness, indicating more severe atherosclerosis2. This stiffening of the arteries compromises coronary blood flow, which can exacerbate cardiovascular risks2 5.
Cardiovascular Disease and Mortality
Low DBP is also associated with higher mortality rates, especially in older adults with pre-existing cardiovascular conditions. Studies have shown that a DBP below 70 mm Hg can significantly increase the risk of all-cause mortality and major adverse cardiac events (MACE). This risk is even more pronounced in individuals with pre-existing cardiovascular disease7. The relationship between low DBP and increased mortality is often attributed to the reduced perfusion pressure, which can impair coronary blood flow and lead to adverse cardiac outcomes5 7.
Cognitive Impairment and Functional Decline
In the very old, low DBP has been linked to cognitive impairment and limitations in daily activities. These conditions can both contribute to and result from low DBP. For instance, cognitive impairment may lead to a decline in overall health, which in turn can lower DBP. Conversely, low DBP can exacerbate cognitive decline by reducing cerebral perfusion6. This bidirectional relationship complicates the management of low DBP in elderly populations, as both cognitive and functional declines need to be addressed6.
Aggressive Antihypertensive Treatment
Aggressive treatment of hypertension can also lead to excessively low DBP. While lowering blood pressure is crucial for managing hypertension, overly aggressive treatment can result in DBP falling below safe levels. This is particularly dangerous for patients with coronary artery disease, as it can lead to a paradoxical increase in morbidity and mortality, known as the J-curve phenomenon. Studies have shown that diastolic pressures below 70 mm Hg are associated with higher risks of myocardial infarction and all-cause death5. Therefore, careful management of antihypertensive therapy is essential to avoid excessively low DBP1 4 5.
Conclusion
Low diastolic blood pressure can result from a variety of factors, including arterial stiffness, cardiovascular disease, cognitive impairment, and aggressive antihypertensive treatment. Each of these factors can independently or synergistically contribute to the risks associated with low DBP, particularly in elderly populations. Understanding these underlying causes is crucial for developing effective management strategies to mitigate the associated health risks.
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Most relevant research papers on this topic
Effects of intensive blood-pressure lowering and low-dose aspirin in patients with hypertension: principal results of the Hypertension Optimal Treatment (HOT) randomised trial
Lowering diastolic blood pressure to 82.6 mm Hg and using low-dose aspirin effectively reduces the risk of major cardiovascular events in patients with hypertension.
RCT
Large Human Trial
Highly CitedLow diastolic blood pressure and atherosclerosis in elderly subjects. The Rotterdam study.
Low diastolic blood pressure in elderly subjects may be a reflection of widespread atherosclerosis.
Observational StudyHighly CitedRELATIONSHIP BETWEEN LOW DIASTOLIC BLOOD PRESSURE, ALL-CAUSE MORTALITY AND CARDIOVASCULAR OUTCOMES
Low diastolic blood pressure is associated with increased mortality and worse cardiovascular outcomes, but the exact relationship remains unclear.
Systematic Review
Very Rigorous JournalValue of low dose combination treatment with blood pressure lowering drugs: analysis of 354 randomised trials
Combining low dose blood pressure lowering drugs at half standard dose can effectively lower blood pressure and reduce the risk of stroke and ischemic heart disease events by 63% and 46% at age 60-69.
Meta-Analysis
Rigorous JournalHighly CitedDogma Disputed: Can Aggressively Lowering Blood Pressure in Hypertensive Patients with Coronary Artery Disease Be Dangerous?
Excessive lowering of diastolic blood pressure in hypertensive patients with coronary artery disease may increase the risk of death and myocardial infarction, potentially compromising vital organ perfusion.
Highly CitedLow blood pressure and five-year mortality in a Stockholm cohort of the very old: possible confounding by cognitive impairment and other factors.
Low blood pressure in the very old may be linked to increased mortality due to preexisting cardiovascular disease, limitations in daily living, and cognitive impairment.
Observational StudyAbstract 15010: Relationship Between Low Diastolic Blood Pressure, All-Cause Mortality and Cardiovascular Outcomes: A Meta-Analysis
Reduction of diastolic blood pressure below 70mmHg, particularly below 60mmHg, is associated with an increased risk of mortality, particularly in patients with pre-existing cardiovascular disease.
Meta-AnalysisDiastolic Blood Pressure and Mortality in the Elderly With Cardiovascular Disease
In the frail elderly, a diastolic blood pressure 60 mm Hg is associated with reduced survival, suggesting a need for more rational antihypertensive therapy, not just based on systolic pressure levels.
Observational StudyHighly CitedAssociation of low diastolic blood pressure with all‐cause death among US adults with normal systolic blood pressure
Low diastolic blood pressure (60 mmHg) is associated with a higher risk of all-cause death, but additional reduction of DBP after antihypertensive drugs treatment does not increase the pre-existing risk.
Observational StudyWorldwide trends in blood pressure from 1975 to 2015: a pooled analysis of 1479 population-based measurement studies with 19·1 million participants
From 1975 to 2015, the highest worldwide blood pressure levels have shifted to central and eastern Europe, sub-Saharan Africa, and south Asia, with the global increase in the number of adults with raised blood pressure largely in low-income and middle-income countries.
Meta-AnalysisRigorous JournalHighly Cited