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task force considers patients with both severe valvular heart disease and symptomatic heart failure to also be at sufficiently high risk. We also note that, whether used for angina control or BP control, a betablocker should not be combined with a non-dihydropyridine CCB.

9.8.2 Coronary artery disease with particular

reference to the blood pressure J-curve Important considerations in patients with coronary artery disease are: (i) the BP J-curve (an observation suggesting that over-intensive BP lowering may increase CVD risk in some patients), and (ii) compelling indications for specific classes of BP-lowering medications. The J-curve phenomenon describes increased risk for CVD observed among patients with the lowest and highest BP in the dataset, with the best CVD outcome rates typically observed among those with BP in the normal range (e.g. systolic BP of 100–120 mmHg and diastolic BP of 60–80 mmHg). For this reason, the J-curve is sometimes also called the U-curve, with both terms typically used interchangeably.697,783,784 However, observational data do not consistently demonstrate a BP J-curve with CVD risk.697 It is more commonly observed among patients with established clinical CVD, such as those with coronary artery disease, or in secondary prevention cohorts.785,786 Furthermore, the J-curve is more commonly observed when analysing diastolic BP values vs. systolic BP values, though it has been described for both.114,697 This stronger relationship with diastolic BP has informed the hypothesis that the J-curve may be caused by reduced perfusion of major organs at low BP, which is particularly operative for diastolic BP in the coronary vasculature when considering ischaemic heart disease events (since coronary blood flow is largely confined to diastole).786,787 If excessive lowering of BP causes CVD events, this needs to be addressed in treatment recommendations provided by BP management guidelines. The 2018 ESC/ESH Guidelines on the management of arterial hypertension introduced, for the first time, lower bounds of BP-lowering treatment targets, implying that treatment be de-intensified for patients with on-treatment BP below these bounds (i.e. <120 mmHg systolic or <70 mmHg diastolic).1 The 2023 ESH document also makes this argument.788 However, since 2018, compelling evidence has demonstrated that the BP J-curve evident in observational datasets is highly unlikely to reflect a causal process and can instead be attributed to residual confounding and/or reverse causation.33,114,115,546,697,789–793 Accordingly, while low BP can indicate a high-risk state, particularly among older adults and those with comorbidities, there is no evidence that this is a causal phenomenon. Indeed, if there is another indication for BP-lowering therapy (e.g. in a patient with wide pulse pressure and a baseline systolic BP of >140 mmHg but diastolic BP of <60 mmHg), the evidence suggests that such therapy should be provided if tolerated to reduce CVD risk. There is a limit to how low BP can be treated without potentially tipping the scales in favour of CVD harm vs. CVD benefit. However, it is not clear what that limit is and how much it differs based on comorbidities. Currently, the data do not suggest that risk for CVD can be causally increased by treating any patient to the recommended intensive BP target outlined in these guidelines of as low as 120/70 mmHg. We also do not recommend stopping or de-intensifying BP-lowering medication among asymptomatic patients with on-treatment BP of <120/70 mmHg. It should be recognized, though, that there are no robust data demonstrating that an on-treatment systolic BP of <90 mmHg or an on-treatment diastolic BP of <50 mmHg is safe from a CVD perspective and there is clear potential for harm. Furthermore, it must be emphasized that the above discussion of the BP J-curve relates solely to CVD risk and does not consider the known non-CVD side effects of BP-lowering drugs, like, e.g. orthostatic hypotension, syncope, and renal injury. We do know that patients treated to a more intensive BP target of 120/70 mmHg are at increased risk for these side effects,550

which is why these guidelines stress that this more intensive target should only be pursued among those in whom treatment is being tolerated (Section 8). The second consideration in managing BP in patients with coronary artery disease is the recommended use of BP-lowering medications with compelling indications based on outcomes trials that demonstrated CVD outcomes benefits in the setting of coronary artery disease. These recommendations are provided in the recommendation table below.

9.8.3 Valvular heart disease

Most patients with both severe heart valve disease and heart failure, defined by the 2021 ESC/European Association for Cardio-Thoracic Surgery (EACTS) Guidelines for the management of valvular heart disease,794 can be considered at increased risk of CVD. Accordingly, it is recommended they are treated with BP-lowering therapy for confirmed baseline BP of >130/80 mmHg, and their recommended target of treatment is BP of 120–129/70–79 mmHg, provided treatment is tolerated. Persons with mild-to-moderate heart valve disease should have a CVD risk assessment prior to deciding their BP-lowering treatment threshold and target. Vasodilating ARBs/ACE inhibitors are preferable over vasodilating dihydropyridine CCBs because of the link between valvular heart disease and subsequent heart failure and given the stronger efficacy evidence for ARBs/ACE inhibitors in the setting of heart failure once manifested.795 In aortic valve stenosis, concomitant hypertension influences both the aortic root, the aortic valve, and the left ventricular structure and function.796 In this subgroup, treatment preferably with ARBs/ACE inhibitors should be considered. A beta-blocker may be added if BP remains >140/90 mmHg.796,797

9.8.4 Heart failure

Patients with symptomatic heart failure are at increased risk of CVD. Therefore, it is recommended that these patients are treated with BP-lowering therapy for confirmed baseline BP of >130/80 mmHg and their recommended treatment target is BP of 120–129/70–79 mmHg, provided treatment is tolerated and with out-of-office confirmation of on-treatment BP. Of note, many patients with systolic heart failure on maximal heart failure therapies have BP of <120/70 mmHg, and we do not recommend de-intensifying such treatment unless indicated by symptomatic side effects. Besides referencing the new evidence for ARNi and SGLT2 inhibitor therapies,795 our 2024 recommendations for heart failure are largely unchanged from the 2018 ESC/ESH Guidelines on the management of arterial hypertension. Non-dihydropyridine CCBs should not be used in heart failure. Frailty and hypotension risk should be assessed in older heart failure patients being considered for ARNi and SGLT2 inhibitor therapies, and older patients should be closely followed to ensure they are tolerating such treatments. For more information on the management of heart failure, we direct readers to the latest ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure.798

ESC Guidelines                                                                                                                                                                                          3977

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