Renal denervation for hypertensive heart disease and atrial fibrillation

Accumulating evidence supports the efficacy of renal denervation (RDN) as an antihypertensive treatment. Additionally, several RDN clinical studies, including meta-analyses, have suggested that RDN may potentially have beneficial effects on left ventricular hypertrophy, diastolic function, and new-onset/recurrence of atrial fibrillation (AF), although most studies were not randomized sham-controlled. In particular, the effects of RDN on left ventricular hypertrophy and AF recurrence appear to be relatively evident. Sympathetic activation plays a critical role in the development of hypertension, hypertensive heart disease, and AF. Notably, several studies suggest the cardioprotective effects of RDN even in the absence of significant blood pressure reduction, probably due to its sympathoinhibitory effects. It is imperative to establish the efficacy of RDN in patients with hypertensive heart disease and/or AF, focusing on parameters of sympathetic activity in the clinical setting, including randomized sham-controlled trials. Moreover, further basic research is essential to elucidate the therapeutic mechanisms of RDN beyond blood pressure lowering and the renal nerves-linked pathophysiologies of hypertensive heart disease and AF. This review outlines the effects of renal denervation on hypertensive heart disease, particularly on left ventricular hypertrophy and diastolic function, and on atrial fibrillation. The sympathoinhibitory effect of renal denervation, an important potential mechanism of its beneficial effects on heart disease, is also discussed.

Esaxerenone: blood pressure reduction and cardiorenal protection without reflex sympathetic activation in salt-loaded stroke-prone spontaneously hypertensive rats

Mineralocorticoid receptor (MR) is involved in the mechanisms of blood pressure elevation, organ fibrosis, and inflammation. MR antagonists have been used in patients with hypertension, heart failure, or chronic kidney disease. Esaxerenone, a recently approved MR blocker with a nonsteroidal structure, has demonstrated a strong blood pressure-lowering effect. However, blood pressure reduction may lead to sympathetic activation through the baroreflex. The effect of esaxerenone on the sympathetic nervous system remains unclear. We investigated the effect of esaxerenone on organ damage and the sympathetic nervous system in salt-loaded stroke-prone spontaneously hypertensive rats (SHRSP), a well-established model of essential hypertension with sympathoexcitation and organ damage. Three-week administration of esaxerenone or hydralazine successfully attenuated the blood pressure elevation. Both esaxerenone and hydralazine comparably suppressed left ventricular hypertrophy and urinary albumin excretion. However, renal fibrosis and glomerular sclerosis were suppressed by esaxerenone but not hydralazine. Furthermore, plasma norepinephrine level, a parameter of systemic sympathetic activity, was significantly increased by hydralazine but not by esaxerenone. Consistent with these findings, the activity of the control centers of sympathetic nervous system, the parvocellular region of the paraventricular nucleus in the hypothalamus and the rostral ventrolateral medulla, was enhanced by hydralazine but remained unaffected by esaxerenone. These results suggest that esaxerenone effectively lowers blood pressure without inducing reflex sympathetic nervous system activation. Moreover, the organ-protective effects of esaxerenone appear to be partially independent of its blood pressure-lowering effect. In conclusion, esaxerenone demonstrates a blood pressure-lowering effect without concurrent sympathetic activation and exerts organ-protective effects in salt-loaded SHRSP. Esaxerenone has antihypertensive and cardiorenal protective effects without reflex sympathetic activation in salt-loaded stroke-prone spontaneously hypertensive rats.

Triglyceride-Glucose Index Associated with Future Renal Function Decline in the General Population

BACKGROUND

The triglyceride-glucose index (TyG index), calculated as the logarithmic product of fasting triglyceride and glucose concentrations, is recognized as a simple marker of insulin resistance. However, the association between the TyG index and future decline of renal function remains unclear in the general population.

OBJECTIVE

To investigate whether the TyG index was associated with future decline of renal function in the general population who had not progressed to chronic kidney disease stage G2.

DESIGN

Retrospective longitudinal observational cohort study.

PARTICIPANTS

Individuals who received a population-based health checkup at JA Ehime Kouseiren Checkup Center from 2010 to 2019 (n = 134,007). Individuals without data of baseline fasting triglyceride or glucose levels, or baseline and follow-up data of estimated glomerular filtration rate (eGFR), or those with baseline eGFR < 60 mL/min/1.73 m2 were excluded.

MAIN MEASURES

Future renal function decline, defined as a ≥ 25% decrease in eGFR from baseline.

KEY RESULTS

Of 10,758 participants, 8,076 were classified into the low TyG index group (TyG index < 8.76, 1st to 3rd quartiles) and 2,682 into the high TyG index group (TyG index ≥ 8.76, 4th quartile). The mean follow-up period was 37.8 ± 23.6 months. The incidence rates of renal function decline were 0.31 and 0.69 per 100 person-years in the low and high TyG index groups, respectively. In multivariate Cox proportional hazard models, high TyG index was significantly associated with future renal function decline (hazard ratio 2.25, 95% CI 1.40-3.60). This association was consistent across subgroups stratified by age, sex, body mass index, baseline eGFR, and diagnosed hypertension, diabetes, or dyslipidemia.

CONCLUSION

In the general population, high TyG index was associated with future renal function decline. The TyG index may be useful in identifying individuals at high risk for future renal function decline in the setting of health checkups.

The effects of renal denervation on blood pressure, cardiac hypertrophy, and sympathetic activity during the established phase of hypertension in spontaneously hypertensive rats

This study aimed to investigate whether renal denervation (RDN) reduces blood pressure and attenuates cardiac hypertrophy with decreasing sympathetic activity in spontaneously hypertensive rats (SHRs), a model of essential hypertension, during the established phase of hypertension. We performed RDN or sham operation in 15-weeks-old SHRs. Thirty days after RDN, mean blood pressure measured by telemetry, heart weight, left ventricular wall thickness assessed by echocardiography, and urinary norepinephrine levels were significantly decreased in the RDN group compared to the Sham group. Furthermore, oxidative stress, as indicated by thiobarbituric acid reactive substances, in the rostral ventrolateral medulla, a pivotal region regulating basal sympathetic tone, was significantly decreased in the RDN group. In conclusion, RDN reduces blood pressure and attenuates cardiac hypertrophy with sympathoinhibition in the established phase of hypertension in SHRs. These findings highlight the sympathoinhibitory effect of RDN and suggest that RDN may be a potential therapy for hypertensive cardiac hypertrophy. Renal denervation reduces blood pressure and attenuates cardiac hypertrophy with sympathoinhibition in the established phase of hypertension in spontaneously hypertensive rats. This study highlights the sympathoinhibitory effect of renal denervation and suggests that renal denervation may be a potential therapy for hypertensive cardiac hypertrophy.

Overview of the 87th Annual Scientific Meeting of the Japanese Circulation Society (JCS2023) - New Challenge With Next Generation

The 87thAnnual Meeting of the Japanese Circulation Society (JCS2023) was held in March 2023 in Fukuoka, Japan, marking the first in-person gathering after the COVID-19 pandemic. With the theme of "New Challenge With Next Generation" the conference emphasized the development of future cardiovascular leaders and technologies such as artificial intelligence (AI). Notable sessions included the Mikamo Lecture on heart failure and the Mashimo Lecture on AI in medicine. Various hands-on sessions and participatory events were well received, promoting learning and networking. Post-event surveys showed high satisfaction among participants, with positive feedback on face-to-face interactions and the overall experience. JCS2023, attended by 17,852 participants, concluded successfully, marking a significant milestone in post-pandemic meetings, and advancing cardiovascular medicine.

Association of baseline electrocardiographic left ventricular hypertrophy with future renal function decline in the general population

Electrocardiographic left ventricular hypertrophy (LVH) could predict adverse renal outcomes in patients with hypertension. This study aimed to investigate the association between electrocardiographic LVH and future decline in renal function in the general population using a dataset of population-based health checkups from 2010 to 2019 including 19,825 participants. Electrocardiographic LVH was defined according to the Minnesota code. Renal function decline was defined as a decrease of ≥ 25% in the estimated glomerular filtration rate from baseline to < 60 mL/min/1.73 m2. Electrocardiographic LVH was found in 1263 participants at the baseline visit. The mean follow-up period was 3.4 ± 1.9 years. The incidence rates of renal function decline were 0.30 and 0.78 per 100 person-years in the non-LVH group and LVH groups, respectively. Electrocardiographic LVH was associated with the risk for renal function decline in the adjusted analysis (hazard ratio 1.69, 95% confidence interval 1.14-2.50, P = 0.009). This association was comparable across subgroups stratified by age, sex, body mass index, diagnosed hypertension, systolic blood pressure, hemoglobin A1c, and urinary protein. This study underscores the usefulness of electrocardiographic LVH to detect high-risk individuals for renal function decline in the setting of health checkups in the general population.

2023 update and perspectives

Total 276 manuscripts were published in Hypertension Research in 2022. Here our editorial members picked up the excellent papers, summarized the current topics from the published papers and discussed future perspectives in the sixteen fields. We hope you enjoy our special feature, 2023 update and perspectives in Hypertension Research.

Impact of avalanche type of transport on internal transport barrier formation in tokamak plasmas

In magnetic fusion plasmas, a transport barrier is essential to improve the plasma confinement. The key physics behind the formation of a transport barrier is the suppression of the micro-scale turbulent transport. On the other hand, long-range transport events, such as avalanches, has been recognized to play significant roles for global profile formations. In this study, we observed the impact of the avalanche-type of transport on the formation of a transport barrier for the first time. The avalanches are found to inhibit the formation of the internal transport barrier (ITB) observed in JT-60U tokamak. We found that (1) ITBs do not form in the presence of avalanches but form under the disappearance of avalanches, (2) the surface integral of avalanche-driven heat fluxe is comparable to the time rate change of stored energy retained at the ITB onset, (3) the mean E × B flow shear is accelerated via the ion temperature gradient that is not sustained under the existence of avalanches, and (4) after the ITB formation, avalanches are damped inside the ITB, while they remain outside the ITB.

Interstitial-fluid shear stresses induced by vertically oscillating head motion lower blood pressure in hypertensive rats and humans

The mechanisms by which physical exercise benefits brain functions are not fully understood. Here, we show that vertically oscillating head motions mimicking mechanical accelerations experienced during fast walking, light jogging or treadmill running at a moderate velocity reduce the blood pressure of rats and human adults with hypertension. In hypertensive rats, shear stresses of less than 1 Pa resulting from interstitial-fluid flow induced by such passive head motions reduced the expression of the angiotensin II type-1 receptor in astrocytes in the rostral ventrolateral medulla, and the resulting antihypertensive effects were abrogated by hydrogel introduction that inhibited interstitial-fluid movement in the medulla. Our findings suggest that oscillatory mechanical interventions could be used to elicit antihypertensive effects.

Emerging topics on basic research in hypertension: interorgan communication and the need for interresearcher collaboration

The pathogenesis of hypertension is multifactorial and highly complex. Basic research plays critical roles in elucidating the complex pathogenesis of hypertension and developing its treatment. This review covers recent topics in basic research related to hypertension in the following six parts: brain/autonomic nervous system, kidney, vascular system, potential treatments, extracellular vesicles, and gut microbiota. The brain receives afferent nerve inputs from peripheral organs, including the heart, kidneys, and adipose tissue, and humoral inputs from circulating factors such as proinflammatory cytokines and leptin, which are involved in the regulation of central sympathetic outflow. In the kidneys, changes in Wnt/β-catenin signaling have been reported in several hypertensive models. New findings on the renin-angiotensin-aldosterone system in the kidneys have also been reported. Sirtuin 6, which participates in various cellular functions, including DNA repair, has been shown to have protective effects on the vascular system. Skin water conservation, mediated by skin vasoconstriction and the accumulation of osmolytes such as sodium, has been found to contribute to hypertension. Studies of rivaroxaban and sodium-glucose cotransporter-2 inhibitors as drug repositioning candidates have been performed. Extracellular vesicles have been shown to be involved in novel diagnostic approaches and treatments for hypertension as well as other diseases. In gut microbiota studies, interactions between microbiota and antihypertensive drugs and potential pathophysiology linking microbiota and COVID-19 have been reported. It can be seen that inter-organ communication has received particular attention from these recent research topics. To truly understand the pathogenesis of hypertension and to develop treatments for conquering hypertension, interresearcher communication and collaboration should be further facilitated. This mini-review focuses on recent topics on basic research in hypertension from the several points of view. The recent topics indicate that inter-organ communication has received particular attention. Interresearcher communication and collaboration should also be further facilitated to truly understand the complex pathogenesis of hypertension and to develop the treatments.

Nationwide Temporal Trends in Clinical Characteristics and Treatment of Dilated Cardiomyopathy From 2003 to 2013 in Japan - A Report From Clinical Personal Records

BACKGROUND

Little is known about nationwide temporal trends in the clinical characteristics and treatment of dilated cardiomyopathy (DCM) in Japan.Methods and Results: We collected data regarding demographics, echocardiography, and treatment of DCM between 2003 to 2013 from Clinical Personal Records, a national registry organized by the Japanese Ministry of Health, Labour, and Welfare. Among the 40,794 DCM patients screened, 27,702 with left ventricular ejection fraction (LVEF) <50% and age ≥18 years were enrolled in this study and divided into 3 groups according to registration year: Group 1, 2003-2005 (10,006 patients); Group 2, 2006-2010 (11,252 patients); and Group 3, 2011-2013 (6,444 patients). Over time, there were decreases in age at registration (mean [±SD] 58.6±13.0 vs. 56.8±13.8 vs. 56.2±13.8 years; P<0.001) and LVEF (33.5±10.0% vs. 31.1±9.9% vs. 29.2± 9.7%; P<0.001), and an increase in patients with New York Heart Association Class III-IV (28.2% vs. 35.2% vs. 41.0%; P<0.001). The use of β-blockers (59.1% vs. 79.3% vs. 87.8%; P<0.001) and mineralocorticoid receptor antagonists (30.6% vs. 35.8% vs. 39.7%; P<0.001) increased over time. In multivariate analysis, male sex, systolic blood pressure, chronic kidney disease, hemoglobin, and registration year were positively associated, whereas age and LVEF were negatively associated, with β-blocker prescription.

CONCLUSIONS

Although the clinical characteristics of DCM changed, the implementation of optimal medical therapy for DCM increased from 2003 to 2013 in Japan.

Update on Hypertension Research in 2021

In 2021, 217 excellent manuscripts were published in Hypertension Research. Editorial teams greatly appreciate the authors' contribution to hypertension research progress. Here, our editorial members have summarized twelve topics from published work and discussed current topics in depth. We hope you enjoy our special feature, "Update on Hypertension Research in 2021".

Evaluation of a Webinar for Pharmacists Learning Basic Clinical-Oncology during COVID-19 Pandemic in Japan

It is essential for oncology pharmacists to update their knowledge, skills, and ethical attitudes. The Japanese Society of Pharmaceutical Oncology is an academic society for healthcare professionals involved in cancer treatment. It has conducted in-person seminars every year to cultivate the knowledge necessary for practicing advanced cancer medicine. Owing to the coronavirus disease (COVID-19) pandemic, the society was obligated to conduct a web-based seminar this year. A questionnaire survey was conducted before and after the webinar to explain how it works and to assess the learning attitudes of beginner and moderately skilled pharmacists in the field of oncology. Questionnaire surveys were conducted with the participants before and after watching the webinar. The questionnaires sought to determine participants' perspectives on the webinar and their knowledge of the seven modules. Of the 1756 webinar attendees, 1661 (94.6%) answered the pre-webinar survey and 1586 (90.3%) answered the post-webinar survey. Results indicate that the median post-webinar knowledge score was significantly higher than the median pre-webinar score (p < 0.001) in all modules. Principal component analysis of the degree of knowledge of seven modules revealed that the improved score group consisted of those from younger age groups, with less experience as pharmacists, non-society members, and those with less experience in past society seminars. Moreover, the web-based seminar provided a uniform learning effect throughout the country without distinguishing between urban and rural learners. The web-based educational program was an acceptable educational tool for Japanese oncology pharmacists.

O-272 Letrozole-induced endometrial preparation improved pregnancy outcomes after frozen blastocyst transfer compared to the natural cycle

Study question

Does letrozole-induced endometrial preparation affect pregnancy outcomes, perinatal outcomes, and congenital anomalies after single vitrified-warmed blastocyst transfers (SVBTs) when compared with the natural cycle?

Summary answer

Letrozole-induced endometrial preparation improved live birth rate without any adverse effects on perinatal outcomes and congenital anomalies after SVBTs.

What is known already

Letrozole treatment is considered an effective option in endometrial preparation for frozen embryo transfers in patients with ovulation disorders or irregular menstruation; however, the effectiveness of letrozole-induced endometrial preparation is still unclear in ovulatory patients. Furthermore, there is no comparative study reporting on pregnancy complications and congenital anomalies after frozen embryo transfers comparing natural and letrozole-assisted cycles.

Study design, size, duration

This retrospective study, at a major academic fertility centre, analysed a total of 14,611 clinical records of women who underwent SVBTs comprising both natural and letrozole-assisted cycles between July 2015 and June 2020. The cycle characteristics, pregnancy outcomes (clinical pregnancy, ongoing pregnancy, and live birth), and the incidence of pregnancy complications and congenital anomalies were statistically compared between the natural and letrozole groups.

Participants/materials, setting, methods

The study reviewed ovulatory patients who underwent their first SVBT during the study period. Some patients took letrozole during the early proliferative phase to promote follicular development and maturation (letrozole group). Ovulation was triggered by GnRH agonist and SVBTs were performed on day five after ovulation. Propensity score matching was performed to reduce any bias from patient characteristics. Multivariate logistic analysis was performed to evaluate the effects of letrozole administration on pregnancy and perinatal outcomes.

Main results and the role of chance

After propensity score matching, the characteristics of patients and transferred blastocysts were comparable between groups. The serum progesterone level was also significantly increased in the letrozole group (P &lt; 0.0001). Although no difference was observed regarding implantation rate between groups, the rates of clinical pregnancy, ongoing pregnancy, and delivery in the letrozole group were all significantly higher than that in the natural group (P = 0.0273, P = 0.0162, P = 0.0479, respectively). The incidence of early pregnancy loss, miscarriage, and stillbirth were comparable between groups. Multivariate logistic regression analysis also demonstrated that the administration of letrozole during an SVBT cycle significantly improved the live birth rate (AOR, 1.160; P = 0.0355). The incidence of pregnancy complications was comparable between groups. The caesarean section rate was significantly lower in the letrozole group than that in the natural group (P = 0.0464). Gestational age, birth length, birth weight, and infant sex, as well as the incidence of pregnancy complications and birth defects, were statistically comparable between groups. Furthermore, multivariate logistic regression analysis showed that perinatal outcomes were not affected by letrozole-induced endometrial preparation, although the incidence of caesarean section was decreased in the letrozole group (AOR, 0.788; P = 0.0355).

Limitations, reasons for caution

Our findings are not compared with reported incidences of pregnancy complications and congenital anomalies in natural pregnancy. Furthermore, the study was retrospective in nature, and further multicentre studies are required to ascertain the generalisability of these findings for other clinics with different protocols and/or patient demographics.

Wider implications of the findings

Letrozole administration both extended the proliferative phase and increased luteal function, resulting in an improvement of live birth rates without any adverse effects. Therefore, letrozole-induced endometrial preparation might be a safe and more effective strategy for patients with shortened proliferative phase or insufficient luteal function.

Trial registration number

not applicable

Rats learn to prefer the late-consumed flavor over the early-consumed flavor in a multi-flavored meal paired with oral glucose and corn oil

Conditioned flavor preference (CFP) is established by association: where a neutral flavor (conditioned stimulus, CS) is paired with orosensory and post-ingestive components of nutrients, including sugar and fat (unconditioned stimulus, US). A previous study reported that rats can learn to prefer flavors that they consumed earlier and later in a multi-flavored solution paired with an intragastric infusion of glucose, but they expressed only a preference for a late-consumed flavor when they were tested after feeding (Myers and Whitney, 2011). This paradigm can be a suitable rodent model to explain how humans acquire a selective preference for routinely late-served "dessert" foods and why these foods remain attractive even in the absence of hunger. Here, we examined whether oral glucose (Experiment 1) or fat (Experiment 2) acts as a US for flavor preference learning processes in this paradigm. In Experiment 1, adult female rats under food restriction were trained in 16 daily sessions with two distinct flavor CSs in succession per session; eight CS(+) sessions in which two distinct flavor CSs (early(+), late(+)) were sequentially presented for 8 min each with oral glucose (12%) as a US, and eight CS(-) sessions in which different CSs (early(-), late(-)) were unpaired with the US. In the 30-minute two-bottle choice test, rats preferred late(+) over late(-) only when tested 90 min after consumption of normal chow (fed test) but not after overnight deprivation (hungry test). Early(+) was not preferred over early(-) in both tests. Moreover, a significant preference for late(+) over early(+) was observed only in the fed test, which is a unique feature of oral glucose-CFP. These results indicate that taste sensations of oral glucose promote a rewarding effect of late-onset glucose nutrients. In Experiment 2, separate rats were trained with the same conditioning paradigm, but used a caloric matched fat solution (5.3% corn oil) for a US. The results showed that they expressed stronger preferences for early(+) and late(+) relative to their respective CS(-) flavors in both tests. Similar to Experiment 1, it was observed in the fed test that there was a preference for late(+) over early(+) in oral fat-CFP. Taken together, the present results suggest that routine timing arrangements can cause qualitative differences in conditioned preferences between multiple flavors within a sugar or fat-containing meal in rats, and that rats prefer the late-consumed flavor over the early-consumed flavor in the absence of hunger.

Home-based cardiac rehabilitation using information and communication technology for heart failure patients with frailty

AIMS

Cardiac rehabilitation (CR) is an evidence-based, secondary preventive strategy that improves mortality and morbidity rates in patients with heart failure (HF). However, the implementation and continuation of CR remains unsatisfactory, particularly for outpatients with physical frailty. This study investigated the efficacy and safety of a comprehensive home-based cardiac rehabilitation (HBCR) programme that combines patient education, exercise guidance, and nutritional guidance using information and communication technology (ICT).

METHODS AND RESULTS

This study was a single-centre, open-label, randomized, controlled trial. Between April 2020 and November 2020, 30 outpatients with chronic HF (New York Heart Association II-III) and physical frailty were enrolled. The control group (n = 15) continued with standard care, while the HBCR group (n = 15) also received comprehensive, individualized CR, including ICT-based exercise and nutrition guidance using ICT via a Fitbit® device for 3 months. The CR team communicated with each patient in HBCR group once a week via the application messaging tool and planned the training frequency and intensity of training individually for the next week according to each patient's symptoms and recorded pulse data during exercise. Dietitians conducted a nutritional assessment and then provided individual nutritional advice using the picture-posting function of the application. The primary outcome was the change in the 6 min walking distance (6MWD). The participants' mean age was 63.7 ± 10.1 years, 53% were male, and 87% had non-ischaemic heart disease. The observed change in the 6MWD was significantly greater in the HBCR group (52.1 ± 43.9 m vs. -4.3 ± 38.8 m; P < 0.001) at a 73% of adherence rate. There was no significant change in adverse events in either group.

CONCLUSIONS

Our comprehensive HBCR programme using ICT for HF patients with physical frailty improved exercise tolerance and improved lower extremity muscle strength in our sample, suggesting management with individualized ICT-based programmes as a safe and effective approach. Considering the increasing number of HF patients with frailty worldwide, our approach provides an efficient method to keep patients engaged in physical activity in their daily life.

Catheter-based ultrasound renal denervation in patients with resistant hypertension: the randomized, controlled REQUIRE trial

Renal denervation is a promising new non-pharmacological treatment for resistant hypertension. However, there is a lack of data from Asian patients. The REQUIRE trial investigated the blood pressure-lowering efficacy of renal denervation in treated patients with resistant hypertension from Japan and South Korea. Adults with resistant hypertension (seated office blood pressure ≥150/90 mmHg and 24-hour ambulatory systolic blood pressure ≥140 mmHg) with suitable renal artery anatomy were randomized to ultrasound renal denervation or a sham procedure. The primary endpoint was change from baseline in 24-hour ambulatory systolic blood pressure at 3 months. A total of 143 patients were included (72 renal denervation, 71 sham control). Reduction from baseline in 24-hour ambulatory systolic blood pressure at 3 months was not significantly different between the renal denervation (-6.6 mmHg) and sham control (-6.5 mmHg) groups (difference: -0.1, 95% confidence interval -5.5, 5.3; p = 0.971). Reductions from baseline in home and office systolic blood pressure (differences: -1.8 mmHg [p = 0.488] and -2.0 mmHg [p = 0.511], respectively), and medication load, did not differ significantly between the two groups. The procedure-/device-related major adverse events was not seen. This study did not show a significant difference in ambulatory blood pressure reductions between renal denervation and a sham procedure in treated patients with resistant hypertension. Although blood pressure reduction after renal denervation was similar to other sham-controlled studies, the sham group in this study showed much greater reduction. This unexpected blood pressure reduction in the sham control group highlights study design issues that will be addressed in a new trial. CLINICAL TRIAL REGISTRATION: NCT02918305 ( http://www.clinicaltrials.gov ).