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Paivanas N, Bisognano JD, Gassler JP. Carotid Baroreceptor Stimulation and Arteriovenous Shunts for Resistant Hypertension. Methodist Debakey Cardiovasc J 2016; 11:223-7. [PMID: 27057291 DOI: 10.14797/mdcj-11-4-223] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Pharmacologic therapy for hypertension is effective for the majority of patients with hypertension, but there is a subset of the population with treatment-resistant hypertension who cannot achieve their blood pressure goal despite taking multiple medications. Since these patients are at increased risk of cardiovascular disease and end-organ damage, additional therapies must be considered. This review discusses several novel interventional therapies-including baroreflex activation therapy, baroreceptor stenting, and creation of an arteriovenous shunt-that may provide alternative options for blood pressure control in those with treatment-resistant hypertension. All of these therapies remain investigational, and each has its own strengths and weaknesses that will be critical to assess as they come to market.
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Affiliation(s)
| | | | - John P Gassler
- University of Rochester Medical Center, Rochester, New York
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Baroreflex Activation Therapy in Heart Failure With Reduced Ejection Fraction: Available Data and Future Perspective. Curr Heart Fail Rep 2016; 13:71-6. [PMID: 26879389 DOI: 10.1007/s11897-016-0286-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Progression of heart failure with reduced ejection fraction (HFrEF) is promoted by sympathovagal imbalance. Baroreflex activation therapy, i.e., electrical stimulation of baroreceptors at the carotid sinus, can restore sympathovagal balance. Large animal studies of baroreflex activation therapy revealed improvements in cardiac function, susceptibility to ventricular arrhythmias, and a survival benefit as compared to untreated controls. Recently, the first randomized and controlled trial of optimal medical and device therapy alone or plus baroreflex activation therapy in patients suffering from HFrEF was published. It demonstrated a reasonable safety profile in this severely ill patient population. Moreover, the study found significant improvements in New York Heart Association class, quality of life, 6-min walk distance, and NT-proBNP levels. This review provides an overview on baroreflex activation therapy for the treatment of HFrEF-from the concept and preclinical findings to most recent clinical data and upcoming trials.
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Yoruk A, Bisognano JD, Gassler JP. Baroreceptor Stimulation for Resistant Hypertension. Am J Hypertens 2016; 29:1319-1324. [PMID: 27444637 DOI: 10.1093/ajh/hpw074] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Accepted: 06/27/2016] [Indexed: 11/15/2022] Open
Abstract
Hypertension (HTN) is a worldwide epidemic. When untreated, HTN places patients at an elevated risk for several health conditions, including cardiovascular disease and end-organ damage. This effect is particularly pronounced in a subset of patients who experience treatment-resistant HTN despite the utilization of conventional medication and lifestyle interventions. For these challenging patients, ongoing research efforts continue to explore and develop novel nonpharmacologic therapies for resistant HTN. One such avenue is the regulation of the sympathetic nervous system, a large component of circulatory physiology. Innovative therapies have evolved to harness the ability to deliver electrical stimulation to baroreceptors in an effort to modulate the sympathetic system involvement in HTN. This review discusses baroreflex activation therapy and its role in the management of resistant HTN.
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Affiliation(s)
- Ayhan Yoruk
- University of Rochester Medical Center, Rochester, New York, USA
| | - John D Bisognano
- University of Rochester Medical Center, Rochester, New York, USA
| | - John P Gassler
- University of Rochester Medical Center, Rochester, New York, USA
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Olsen MH, Angell SY, Asma S, Boutouyrie P, Burger D, Chirinos JA, Damasceno A, Delles C, Gimenez-Roqueplo AP, Hering D, López-Jaramillo P, Martinez F, Perkovic V, Rietzschel ER, Schillaci G, Schutte AE, Scuteri A, Sharman JE, Wachtell K, Wang JG. A call to action and a lifecourse strategy to address the global burden of raised blood pressure on current and future generations: the Lancet Commission on hypertension. Lancet 2016; 388:2665-2712. [PMID: 27671667 DOI: 10.1016/s0140-6736(16)31134-5] [Citation(s) in RCA: 586] [Impact Index Per Article: 73.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Michael H Olsen
- Department of Internal Medicine, Holbæk Hospital and Centre for Individualized Medicine in Arterial Diseases (CIMA), Odense University Hospital, University of Southern Denmark, Odense, Denmark; Hypertension in Africa Research Team (HART), North-West University, Potchefstroom, South Africa.
| | - Sonia Y Angell
- Division of Prevention and Primary Care, New York City Department of Health and Mental Hygiene, New York, NY, USA
| | - Samira Asma
- Global NCD Branch, Division of Global Health Protection, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Pierre Boutouyrie
- Department of Pharmacology and INSERM U 970, Georges Pompidou Hospital, Paris Descartes University, Paris, France
| | - Dylan Burger
- Kidney Research Centre, Ottawa Hospital Research Institute, Department of Cellular and Molecular Medicine, University of Ottawa, ON, Canada
| | - Julio A Chirinos
- Department of Medicine at University Hospital of Pennsylvania and Veteran's Administration, PA, USA
| | | | - Christian Delles
- Christian Delles: Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Anne-Paule Gimenez-Roqueplo
- INSERM, UMR970, Paris-Cardiovascular Research Center, F-75015, Paris, France; Paris Descartes University, F-75006, Paris, France; Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Department of Genetics, F-75015, Paris, France
| | - Dagmara Hering
- The University of Western Australia-Royal Perth Hospital, Perth, WA, Australia
| | - Patricio López-Jaramillo
- Direccion de Investigaciones, FOSCAL and Instituto de Investigaciones MASIRA, Facultad de Medicina, Universidad de Santander, Bucaramanga, Colombia
| | - Fernando Martinez
- Hypertension Clinic, Internal Medicine, Hospital Clinico, University of Valencia, Valencia, Spain
| | - Vlado Perkovic
- The George Institute for Global Health, University of Sydney, Sydney, NSW, Australia
| | - Ernst R Rietzschel
- Department of Cardiology, Ghent University and Biobanking & Cardiovascular Epidemiology, Ghent University Hospital, Ghent, Belgium
| | - Giuseppe Schillaci
- Department of Internal Medicine, University of Perugia, Terni University Hospital, Terni, Italy
| | - Aletta E Schutte
- Medical Research Council Unit on Hypertension and Cardiovascular Disease, Hypertension in Africa Research Team (HART), North-West University, Potchefstroom, South Africa
| | - Angelo Scuteri
- Hypertension Center, Hypertension and Nephrology Unit, Department of Medicien, Policlinico Tor Vergata, Rome, Italy
| | - James E Sharman
- Menzies Institute for Medical Research, University of Tasmania, Hobart, TAS, Australia
| | - Kristian Wachtell
- Department of Cardiology, Division of Cardiovascular and Pulmonary Diseases Oslo University Hospital, Oslo, Norway
| | - Ji Guang Wang
- The Shanghai Institute of Hypertension, RuiJin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
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Gronda E, Vanoli E. Autonomic Modulation With Baroreflex Activation Therapy in Heart Failure. Curr Heart Fail Rep 2016; 13:273-280. [DOI: 10.1007/s11897-016-0307-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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Malachias MVB, Rodrigues CIS, Muxfeldt E, Salles GF, Moreno H, Gus M. 7th Brazilian Guideline of Arterial Hypertension: Chapter 13 - Resistant Arterial Hypertension. Arq Bras Cardiol 2016; 107:75-78. [PMID: 27819392 PMCID: PMC5319459 DOI: 10.5935/abc.20160163] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
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First-in-man treatment of severe blood pressure variability with baroreflex activation therapy. Int J Cardiol 2016; 220:577-9. [PMID: 27390993 DOI: 10.1016/j.ijcard.2016.06.308] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Accepted: 06/28/2016] [Indexed: 10/21/2022]
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Device Therapies for Resistant Hypertension. Clin Ther 2016; 38:2152-2158. [DOI: 10.1016/j.clinthera.2016.08.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Revised: 08/21/2016] [Accepted: 08/31/2016] [Indexed: 12/18/2022]
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Paivanas N, Bisognano J. Unilateral Carotid Body Resection in Resistant Hypertension: An Exciting First Step Toward a New Therapy? JACC Basic Transl Sci 2016; 1:325-327. [PMID: 30167522 PMCID: PMC6113422 DOI: 10.1016/j.jacbts.2016.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
| | - John Bisognano
- Reprint requests and correspondence: Dr. John Bisognano, University of Rochester Medical Center, 601 Elmwood Avenue, Box 679-SCA, Rochester, New York 14642.
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Kansal N, Clair DG, Jaye DA, Scheiner A. Carotid baroreceptor stimulation blood pressure response mapped in patients undergoing carotid endarterectomy (C-Map study). Auton Neurosci 2016; 201:60-67. [PMID: 27539629 DOI: 10.1016/j.autneu.2016.07.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Revised: 07/08/2016] [Accepted: 07/29/2016] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Continuous stimulation of the carotid baroreceptors has been shown to evoke a sustained systolic blood pressure (SBP) reduction in hypertensive subjects. This study conducted a detailed mapping of the SBP and heart rate response to electrical stimulus at different locations in the carotid sinus region in patients undergoing a carotid endarterectomy (CEA). METHODS The Carotid Sinus Autonomic Response Mapping (C-Map) Study is a multicenter, prospective, non-randomized, acute feasibility study conducted in 10 hypertensive subjects undergoing CEA. Electrode pairs were placed in multiple locations in the region of the carotid sinus for acute stimulation, and the tests were repeated after plaque removal and vessel repair. RESULTS The configuration that elicited the largest pressure reduction in 8 of 10 patients was with the electrodes arranged longitudinally along the medial (in relation to the bifurcation) wall of the internal carotid artery (ICA) near the bifurcation (11.2±8.1mmHg, p<0.05). There was no difference in average maximum response pre vs. post plaque removal. Spontaneous baroreflex sensitivity increased from 6.0±3.2ms/mmHg pre-CEA to 8.2±5.4ms/mmHg post-CEA (p=0.040). CONCLUSIONS Endarterectomy surgery did not affect maximal acute stimulation response but improved baroreflex sensitivity acutely. Acute extravascular baroreceptor stimulation (BRS) mapping demonstrated that blood pressure reductions are dependent on electrode location and orientation. In most subjects, the largest SBP reductions were elicited in the region of the medial wall of the ICA. This area can be targeted for future BRS lead design and implant.
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Affiliation(s)
- Nikhil Kansal
- University of California, San Diego, VA San Diego Healthcare System, Division of Vascular and Endovascular Surgery, San Diego, CA, United States.
| | - Daniel G Clair
- The Cleveland Clinic Foundation, Department of Vascular Surgery, Cleveland, OH, United States
| | - Deborah A Jaye
- Medtronic plc, Cardiac Rhythm and Heart Failure, Minneapolis, MN, United States
| | - Avram Scheiner
- Medtronic plc, Cardiac Rhythm and Heart Failure, Minneapolis, MN, United States
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Kawada T, Akiyama T, Li M, Zheng C, Turner MJ, Shirai M, Sugimachi M. Acute arterial baroreflex-mediated changes in plasma catecholamine concentrations in a chronic rat model of myocardial infarction. Physiol Rep 2016; 4:4/15/e12880. [PMID: 27495297 PMCID: PMC4985546 DOI: 10.14814/phy2.12880] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Accepted: 06/23/2016] [Indexed: 11/24/2022] Open
Abstract
While it may be predictable that plasma norepinephrine (NE) concentration changes with efferent sympathetic nerve activity (SNA) in response to baroreceptor pressure inputs, an exact relationship between SNA and plasma NE concentration remains to be quantified in heart failure. We examined acute baroreflex-mediated changes in plasma NE and epinephrine (Epi) concentrations in normal control (NC) rats and rats with myocardial infarction (MI) (n = 6 each). Plasma NE concentration correlated linearly with SNA in the NC group (slope: 2.17 ± 0.26 pg mL(-1) %(-1), intercept: 20.0 ± 18.2 pg mL(-1)) and also in the MI group (slope: 19.20 ± 6.45 pg mL(-1) %(-1), intercept: -239.6 ± 200.0 pg mL(-1)). The slope was approximately nine times higher in the MI than in the NC group (P < 0.01). Plasma Epi concentration positively correlated with SNA in the NC group (slope: 1.65 ± 0.79 pg mL(-1) %(-1), intercept: 115.0 ± 69.5 pg mL(-1)) and also in the MI group (slope: 7.74 ± 2.20 pg mL(-1) %(-1), intercept: 24.7 ± 120.1 pg mL(-1)). The slope was approximately 4.5 times higher in the MI than in the NC group (P < 0.05). Intravenous administration of desipramine (1 mg kg(-1)) significantly increased plasma NE concentration but decreased plasma Epi concentration in both groups, suggesting that neuronal NE uptake had contributed to the reduction in plasma NE concentration. These results indicate that high levels of plasma catecholamine in MI rats were still under the influence of baroreflex-mediated changes in SNA, and may provide additional rationale for applying baroreflex activation therapy in patients with chronic heart failure.
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Affiliation(s)
- Toru Kawada
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Tsuyoshi Akiyama
- Department of Cardiac Physiology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Meihua Li
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Can Zheng
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Michael J Turner
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Mikiyasu Shirai
- Department of Cardiac Physiology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Masaru Sugimachi
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center, Osaka, Japan
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Egan BM, Kai B, Wagner CS, Henderson JH, Chandler AH, Sinopoli A. Blood Pressure Control Provides Less Cardiovascular Protection in Adults With Than Without Apparent Treatment-Resistant Hypertension. J Clin Hypertens (Greenwich) 2016; 18:817-24. [PMID: 26856795 PMCID: PMC5837039 DOI: 10.1111/jch.12773] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2015] [Revised: 11/23/2015] [Accepted: 11/23/2015] [Indexed: 01/13/2023]
Abstract
Hypertension control may offer less protection from incident cardiovascular disease (CVDi ) in adults with than without apparent treatment-resistant hypertension (aTRH), ie, blood pressure uncontrolled while taking three or more antihypertensive medications or controlled to <140/<90 mm Hg while taking four or more antihypertensive medications. Electronic health data were matched to health claims for 2006-2012. Patients with CVDi in 2006-2007 or with untreated hypertension were excluded, leaving 118,356 treated hypertensives, including 40,690 with aTRH, and 460,599 observation years. Blood pressure and medication number were determined by all clinic visit means from 2008 to CVDi or end of study. Primary outcome was first CVDi (stroke, coronary heart disease, heart failure) from hospital and emergency department claims. Controlling for age, race, sex, diabetes, chronic kidney disease, and statin use, hypertension control afforded less CVDi protection in patients with aTRH (hazard ratio, 0.87; 95% confidence interval, 0.82-0.93) than without aTRH (hazard ratio, 0.69; 95% confidence interval, 0.65-0.74; P<.001). Strategies beyond hypertension control may prevent more CVDi in patients with aTRH.
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Affiliation(s)
- Brent M. Egan
- Department of MedicineUniversity of South Carolina School of Medicine–GreenvilleGreenvilleSC
- Care Coordination InstituteGreenville Health SystemGreenvilleSC
| | - Bo Kai
- Department of MathematicsCollege of CharlestonCharlestonSC
| | - C. Shaun Wagner
- Care Coordination InstituteGreenville Health SystemGreenvilleSC
| | - Joseph H. Henderson
- Department of MedicineUniversity of South Carolina School of Medicine–GreenvilleGreenvilleSC
| | - Archie H. Chandler
- Department of MedicineUniversity of South Carolina School of Medicine–GreenvilleGreenvilleSC
| | - Angelo Sinopoli
- Department of MedicineUniversity of South Carolina School of Medicine–GreenvilleGreenvilleSC
- Care Coordination InstituteGreenville Health SystemGreenvilleSC
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Li P, Nader M, Arunagiri K, Papademetriou V. Device-Based Therapy for Drug-Resistant Hypertension: An Update. Curr Hypertens Rep 2016; 18:64. [PMID: 27402013 DOI: 10.1007/s11906-016-0671-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Drug-resistant hypertension (RH) remains a significant and common cardiovascular risk despite the availability of multiple potent antihypertensive medications. Uncontrolled resistant hypertension contributes substantially to excessive cardiovascular and renal morbidity and mortality. Clinical and experimental evidence suggest that sympathetic nervous system over-activity is the main culprit for the development and maintenance of drug-resistant hypertension. Both medical and interventional strategies, targeting the sympathetic over-activation, have been designed in patients with hypertension over the past few decades. Minimally invasive, catheter-based, renal sympathetic denervation (RDN) and carotid baroreceptor activation therapy (BAT) have been extensively evaluated in patients with RH in clinical trials. Current trial outcomes, though at times impressive, have been mostly uncontrolled trials in need of validation. Device-based therapy for drug-resistant hypertension has the potential to provide alternative treatment options to certain groups of patients who are refractory or intolerant to current antihypertensive medications. However, more research is needed to prove its efficacy in both animal models and in humans. In this article, we will review the evidence from recent renal denervation, carotid baroreceptor stimulation therapy, and newly emerged central arteriovenous anastomosis trials to pinpoint the weak links, and speculate on potential alternative approaches.
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Affiliation(s)
- Ping Li
- Washington Veterans Affairs Medical Center, 50 Irving Street, N.W., Washington, DC, 20422, USA
- Georgetown University Hospital, Washington, DC, USA
- George Washington University Hospital, Washington, DC, USA
| | - Mark Nader
- Georgetown University Hospital, Washington, DC, USA
| | | | - Vasilios Papademetriou
- Washington Veterans Affairs Medical Center, 50 Irving Street, N.W., Washington, DC, 20422, USA.
- Georgetown University Hospital, Washington, DC, USA.
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Epstein M, Duprez DA. Resistant Hypertension and the Pivotal Role for Mineralocorticoid Receptor Antagonists: A Clinical Update 2016. Am J Med 2016; 129:661-6. [PMID: 26899747 DOI: 10.1016/j.amjmed.2016.01.039] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Revised: 01/29/2016] [Accepted: 01/29/2016] [Indexed: 01/12/2023]
Abstract
True resistant hypertension must be distinguished from apparent resistant hypertension, of which important causes include medication nonadherence, illicit drug use, and alcoholism. Ambulatory blood pressure monitoring should be considered to rule out white coat hypertension. The pathogenesis is multifactorial, but the 2 pivotal factors include volume excess and the myriad effects of aldosterone. Aldosterone increases vascular tone because of endothelial dysfunction and enhances the pressor response to catecholamines. It also plays a crucial role in vascular remodeling of small and large arteries. Aldosterone also promotes collagen synthesis, which leads to increased arterial stiffness and elevation of blood pressure. Because aldosterone has been demonstrated to modulate baroreflex resetting, in cases of severe hypertension, there would be fewer compensatory mechanisms available to offset the blood pressure elevation.
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Affiliation(s)
- Murray Epstein
- Division of Nephrology and Hypertension, University of Miami Miller School of Medicine, Fla.
| | - Daniel A Duprez
- Cardiovascular Division, Medical School, University of Minnesota, Minneapolis
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Baroreflex Activation Therapy in Congestive Heart Failure: Novel Findings and Future Insights. Curr Hypertens Rep 2016; 18:60. [DOI: 10.1007/s11906-016-0667-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Soto M, Sampietro-Colom L, Sagarra J, Brugada-Terradellas J. InnovaSEC en acción: coste-efectividad de Barostim para el tratamiento de la hipertensión arterial refractaria en España. Rev Esp Cardiol 2016. [DOI: 10.1016/j.recesp.2015.11.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Gronda E, Brambilla G, Seravalle G, Maloberti A, Cairo M, Costantino G, Lovett E, Vanoli E, Mancia G, Grassi G. Effects of chronic carotid baroreceptor activation on arterial stiffness in severe heart failure. Clin Res Cardiol 2016; 105:838-46. [PMID: 27120329 DOI: 10.1007/s00392-016-0992-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Accepted: 04/22/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND Heart failure with reduced ejection fraction (HFrEF) is characterized by activation of the sympathetic nervous system and increased arterial stiffness, leading to an impaired ventricular-vascular coupling. Baroreflex activation therapy (BAT) has been shown to reduce muscle sympathetic nerve activity (MSNA) and improve clinical status of patients with HFrEF. The purpose of this investigation was to determine the effects of BAT on arterial stiffness in HFrEF. METHODS AND RESULTS MSNA, clinical variables, and parameters of central blood pressure (BP) and arterial stiffness were collected in 18 NYHA Class III HFrEF patients, nine receiving BAT and nine continuing with optimal medical management alone. Patients were followed for 3 months, with measurements at that time compared to baseline evaluation. Baseline characteristics of the groups were well matched. At 3 months, BAT did not improve central BP and arterial stiffness despite a significant amelioration of MSNA, NYHA class, Minnesota living with heart failure questionnaire score, number of heart failure medications and six-minute walking distance. The control group exhibited no significant changes in all the measured variables. CONCLUSIONS Despite significant reductions in MSNA and clinical improvement, BAT does not appear to chronically modify arterial stiffness within this HFrEF cohort. Additional study is required to determine if this result applies to the HFrEF population as a whole.
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Affiliation(s)
- Edoardo Gronda
- Cardiovascular Department, IRCCS Multimedica, Sesto San Giovanni, Milan, Italy
| | - GianMaria Brambilla
- Clinica Medica, University of Milano-Bicocca, Via Pergolesi 33, 20090, Monza, Italy
| | | | - Alessandro Maloberti
- Clinica Medica, University of Milano-Bicocca, Via Pergolesi 33, 20090, Monza, Italy
| | - Matteo Cairo
- Clinica Medica, University of Milano-Bicocca, Via Pergolesi 33, 20090, Monza, Italy
| | - Giuseppe Costantino
- Cardiovascular Department, IRCCS Multimedica, Sesto San Giovanni, Milan, Italy
| | | | - Emilio Vanoli
- Cardiovascular Department, IRCCS Multimedica, Sesto San Giovanni, Milan, Italy
| | | | - Guido Grassi
- Cardiovascular Department, IRCCS Multimedica, Sesto San Giovanni, Milan, Italy. .,Clinica Medica, University of Milano-Bicocca, Via Pergolesi 33, 20090, Monza, Italy.
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Smith S, Rossignol P, Willis S, Zannad F, Mentz R, Pocock S, Bisognano J, Nadim Y, Geller N, Ruble S, Linde C. Neural modulation for hypertension and heart failure. Int J Cardiol 2016; 214:320-30. [PMID: 27085120 DOI: 10.1016/j.ijcard.2016.03.078] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Accepted: 03/19/2016] [Indexed: 01/08/2023]
Abstract
Hypertension (HTN) and heart failure (HF) have a significant global impact on health, and lead to increased morbidity and mortality. Despite recent advances in pharmacologic and device therapy for these conditions, there is a need for additional treatment modalities. Patients with sub-optimally treated HTN have increased risk for stroke, renal failure and heart failure. The outcome of HF patients remains poor despite modern pharmacological therapy and with established device therapies such as CRT and ICDs. Therefore, the potential role of neuromodulation via renal denervation, baro-reflex modulation and vagal stimulation for the treatment of resistant HTN and HF is being explored. In this manuscript, we review current evidence for neuromodulation in relation to established drug and device therapies and how these therapies may be synergistic in achieving therapy goals in patients with treatment resistant HTN and heart failure. We describe lessons learned from recent neuromodulation trials and outline strategies to improve the potential for success in future trials. This review is based on discussions between scientists, clinical trialists, and regulatory representatives at the 11th annual CardioVascular Clinical Trialist Forum in Washington, DC on December 5-7, 2014.
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Affiliation(s)
- S Smith
- The Ohio State University Wexner Medical Center, Department of Internal Medicine and Division of Cardiology, Columbus, OH, USA.
| | - P Rossignol
- Inserm, CIC 1433, Centre Hospitalier Universitaire, Universite´ de Lorraine, F-CRIN INI-CRCT, Nancy, France
| | - S Willis
- The Ohio State University Wexner Medical Center, Department of Internal Medicine and Division of Cardiology, Columbus, OH, USA
| | - F Zannad
- Inserm, CIC 1433, Centre Hospitalier Universitaire, Universite´ de Lorraine, F-CRIN INI-CRCT, Nancy, France
| | - R Mentz
- Department of Medicine, Division of Cardiology, Duke University Medical Center, Durham, NC, USA
| | - S Pocock
- Medical Statistics Unit LSHTM, London, UK
| | - J Bisognano
- University of Rochester Medical Center, Department of Medicine, Cardiology, Rochester, NY, USA
| | - Y Nadim
- CVRx, Inc, Minneapolis, MN, USA
| | - N Geller
- Office of Biostatistics Research, Division of Cardiovascular Sciences, NHLBI, National Institutes of Health, Bethesda, MD, USA
| | - S Ruble
- Boston Scientific CRV, St. Paul, MN, USA
| | - C Linde
- Institution of Internal Medicine, Karolinska Institutet and Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden.
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Wallbach M, Lehnig LY, Schroer C, Lüders S, Böhning E, Müller GA, Wachter R, Koziolek MJ. Effects of Baroreflex Activation Therapy on Ambulatory Blood Pressure in Patients With Resistant Hypertension. Hypertension 2016; 67:701-9. [DOI: 10.1161/hypertensionaha.115.06717] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2015] [Accepted: 01/19/2016] [Indexed: 11/16/2022]
Abstract
Baroreflex activation therapy (BAT) has been demonstrated to decrease office blood pressure (BP) in the randomized, double-blind Rheos trial. There are limited data on 24-hour BP changes measured by ambulatory BP measurements (ABPMs) using the first generation rheos BAT system suggesting a significant reduction but there are no information about the effect of the currently used, unilateral BAT neo device on ABPM. Patients treated with the BAT neo device for uncontrolled resistant hypertension were prospectively included into this study. ABPM was performed before BAT implantation and 6 months after initiation of BAT. A total of 51 patients were included into this study, 7 dropped out from analysis because of missing or insufficient follow-up. After 6 months, 24-hour ambulatory systolic (from 148±17 mm Hg to 140±23 mm Hg,
P
<0.01), diastolic (from 82±13 mm Hg to 77±15 mm Hg,
P
<0.01), day- and night-time systolic and diastolic BP (all
P
≤0.01) significantly decreased while the number of prescribed antihypertensive classes could be reduced from 6.5±1.5 to 6.0±1.8 (
P
=0.03). Heart rate and pulse pressure remained unchanged. BAT was equally effective in reducing ambulatory BP in all subgroups of patients. This is the first study demonstrating a significant BP reduction in ABPM in patients undergoing chronically stimulation of the carotid sinus using the BAT neo device. About that BAT-reduced office BP and improved relevant aspects of ABPM, BAT might be considered as a new therapeutic option to reduce cardiovascular risk in patients with resistant hypertension. Randomized controlled trials are needed to evaluate BAT effects on ABPM in patients with resistant hypertension accurately.
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Affiliation(s)
- Manuel Wallbach
- From the Department of Nephrology and Rheumatology (M.W., L.-Y.L., C.S., E.B., G.A.M., M.J.K.) and Department of Cardiology and Pulmonology (R.W.), Georg-August-University Göttingen, Göttingen, Germany; and St. Josefs Hospital, Cloppenburg, Germany (S.L.)
| | - Luca-Yves Lehnig
- From the Department of Nephrology and Rheumatology (M.W., L.-Y.L., C.S., E.B., G.A.M., M.J.K.) and Department of Cardiology and Pulmonology (R.W.), Georg-August-University Göttingen, Göttingen, Germany; and St. Josefs Hospital, Cloppenburg, Germany (S.L.)
| | - Charlotte Schroer
- From the Department of Nephrology and Rheumatology (M.W., L.-Y.L., C.S., E.B., G.A.M., M.J.K.) and Department of Cardiology and Pulmonology (R.W.), Georg-August-University Göttingen, Göttingen, Germany; and St. Josefs Hospital, Cloppenburg, Germany (S.L.)
| | - Stephan Lüders
- From the Department of Nephrology and Rheumatology (M.W., L.-Y.L., C.S., E.B., G.A.M., M.J.K.) and Department of Cardiology and Pulmonology (R.W.), Georg-August-University Göttingen, Göttingen, Germany; and St. Josefs Hospital, Cloppenburg, Germany (S.L.)
| | - Enrico Böhning
- From the Department of Nephrology and Rheumatology (M.W., L.-Y.L., C.S., E.B., G.A.M., M.J.K.) and Department of Cardiology and Pulmonology (R.W.), Georg-August-University Göttingen, Göttingen, Germany; and St. Josefs Hospital, Cloppenburg, Germany (S.L.)
| | - Gerhard A. Müller
- From the Department of Nephrology and Rheumatology (M.W., L.-Y.L., C.S., E.B., G.A.M., M.J.K.) and Department of Cardiology and Pulmonology (R.W.), Georg-August-University Göttingen, Göttingen, Germany; and St. Josefs Hospital, Cloppenburg, Germany (S.L.)
| | - Rolf Wachter
- From the Department of Nephrology and Rheumatology (M.W., L.-Y.L., C.S., E.B., G.A.M., M.J.K.) and Department of Cardiology and Pulmonology (R.W.), Georg-August-University Göttingen, Göttingen, Germany; and St. Josefs Hospital, Cloppenburg, Germany (S.L.)
| | - Michael J. Koziolek
- From the Department of Nephrology and Rheumatology (M.W., L.-Y.L., C.S., E.B., G.A.M., M.J.K.) and Department of Cardiology and Pulmonology (R.W.), Georg-August-University Göttingen, Göttingen, Germany; and St. Josefs Hospital, Cloppenburg, Germany (S.L.)
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71
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Pinto TOCT, Lataro RM, Castania JA, Durand MT, Silva CAA, Patel KP, Fazan R, Salgado HC. Electrical stimulation of the aortic depressor nerve in conscious rats overcomes the attenuation of the baroreflex in chronic heart failure. Am J Physiol Regul Integr Comp Physiol 2016; 310:R612-8. [DOI: 10.1152/ajpregu.00392.2015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Accepted: 01/14/2016] [Indexed: 11/22/2022]
Abstract
Chronic heart failure (CHF) is characterized by autonomic dysfunction combined with baroreflex attenuation. The hypotensive and bradycardic responses produced by electrical stimulation of the aortic depressor nerve (ADN) were examined in conscious CHF and control male Wistar rats (12–13 wk old). Furthermore, the role of parasympathetic and sympathetic nervous system in mediating the cardiovascular responses to baroreflex activation was evaluated by selective β1-adrenergic and muscarinic receptor antagonists. CHF was induced by myocardial infarction. After 6 wk, the subjects were implanted with electrodes for ADN stimulation. Twenty-four hours later, electrical stimulation of the ADN was applied for 20 s using five different frequencies (5, 15, 30, 60, and 90 Hz), while the arterial pressure was recorded by a catheter implanted into the femoral artery. Electrical stimulation of the ADN elicited progressive and similar hypotensive and bradycardic responses in control ( n = 12) and CHF ( n = 11) rats, while the hypotensive response was not affected by methylatropine. Nevertheless, the reflex bradycardia was attenuated by methylatropine in control, but not in CHF rats. Atenolol did not affect the hypotensive or bradycardic response in either group. The ADN function was examined under anesthesia through electroneurographic recordings. The arterial pressure-ADN activity relationship was attenuated in CHF rats. In conclusion, despite the attenuation of baroreceptor function in CHF rats, the electrical stimulation of the ADN elicited a stimulus-dependent hypotension and bradycardia of similar magnitude as observed in control rats. Therefore, electrical activation of the aortic baroreflex overcomes both the attenuation of parasympathetic function and the sympathetic overdrive.
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Affiliation(s)
- Tomás O. C. Teixeira Pinto
- Department of Physiology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Renata M. Lataro
- Department of Physiology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Jaci A. Castania
- Department of Physiology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Marina T. Durand
- Department of Medicine, University of Ribeirão Preto, Ribeirão Preto, São Paulo, Brazil; and
| | - Carlos A. A. Silva
- Department of Physiology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Kaushik P. Patel
- Department of Cellular and Integrative Physiology, University of Nebraska Medical Center, Omaha, Nebraska
| | - Rubens Fazan
- Department of Physiology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Helio C. Salgado
- Department of Physiology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
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72
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Effects of baroreflex activation therapy on arterial stiffness and central hemodynamics in patients with resistant hypertension. J Hypertens 2016; 33:181-6. [PMID: 25232758 DOI: 10.1097/hjh.0000000000000361] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND High central blood pressure, augmentation index and pulse wave velocity are independent cardiovascular risk factors. Little is known of the effect of baroreflex activation therapy on central hemodynamics. METHOD In this prospective clinical trial, radial artery applanation tonometry and pulse wave analysis were used to derive central aortic pressure and hemodynamic indices (i.e. augmentation pressure, augmentation index, pulse wave velocity, systolic and diastolic pressure time integral, subendocardial viability index) at baseline and 6 months after starting baroreflex activation therapy in 25 patients with resistant hypertension. RESULTS Apart from peripheral blood pressure reduction, 6 months of baroreflex activation therapy significantly reduced mean central aortic blood pressure from 109.7 ± 20.5 to 97.4 ± 18.8 mm Hg (P < 0.01) and aortic pulse pressure from 62.9 ± 18.6 to 55.2 ± 16.0 mm Hg (P < 0.01). Aortic augmentation pressure and augmentation index at a heart rate of 75 b.p.m. were significantly reduced by 4.3 ± 7.9 mm Hg (P = 0.01) and 3.5 ± 6.8% (P = 0.02). Additionally, pulse wave velocity decreased from 10.3 ± 2.6 to 8.6 ± 1.3 m/s (P < 0.01) 6 months after starting baroreflex activation therapy. Systolic pressure time integral was significantly reduced (P = 0.03), whereas subendocardial viability index remained unchanged. CONCLUSION Apart from peripheral blood pressure, baroreflex activation therapy reduces central blood pressure, augmentation index at a heart rate of 75 b.p.m. and pulse wave velocity in patients with resistant hypertension, suggesting strong potential to reduce cardiovascular risk.
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73
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Abstract
The autonomic nervous system plays a pivotal role in the development of hypertension and organ damage complicating hypertension. The US company CVRx developed medical devices (first generation Rheos™ and second generation Neo™) aimed to electronically activate baroreceptors, which signal the brain to orchestrate a multisystemic response to address chronic diseases such as hypertension and heart failure. This review presents available clinical trial data on carotid barostimulation in the treatment of resistant hypertension.
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Affiliation(s)
- Patrick Rossignol
- Inserm U1116, centre d'investigations cliniques-plurithématique 14-33, 4, rue du Morvan, 54500 Vandœuvre-lès-Nancy, France; Institut lorrain du cœur et des vaisseaux Louis-Mathieu, CHRU de Nancy, 4, rue du Morvan, 54500 Vandœuvre-lès-Nancy, France; Université de Lorraine, 34, cours Léopold, 54000 Nancy, France; Association Lorraine de traitement de l'insuffisance rénale (Altir), 4, rue du Morvan, 54511 Vandœuvre-lès-Nancy, France; F-CRIN INI-CRCT (Cardiovascular and renal clinical trialists), 4, rue du Morvan, 54500 Vandœuvre-lès-Nancy, France.
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74
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Soto M, Sampietro-Colom L, Sagarra J, Brugada-Terradellas J. InnovaSEC in Action: Cost-effectiveness of Barostim in the Treatment of Refractory Hypertension in Spain. ACTA ACUST UNITED AC 2016; 69:563-71. [PMID: 26907729 DOI: 10.1016/j.rec.2015.11.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2015] [Accepted: 11/11/2015] [Indexed: 12/14/2022]
Abstract
INTRODUCTION AND OBJECTIVES In Spain, 0.3% of patients with hypertension are refractory to conventional treatment. The complications resulting from deficient control of this condition can lead to poor quality of life for the patient and considerable health care costs. Barostim is an implantable device designed to lower blood pressure in these patients. The aim of this study was to analyze the cost-effectiveness of Barostim compared with drug therapy in hypertensive patients refractory to conventional treatment (at least 3 antihypertensive drugs, including 1 diuretic agent). METHODS We used a Markov model adapted to the epidemiology of the Spanish population to simulate the natural history of a cohort of patients with refractory hypertension over their lifetime. Data on the effectiveness of the treatments studied were obtained from the literature, and data on costs were taken from hospital administrative databases and official sources. Deterministic and probabilistic sensitivity analyses were conducted. RESULTS Barostim increased the number of quality-adjusted life years by 0.78 and reduced the number of hypertension-associated clinical events. The incremental cost-effectiveness ratio in a cohort of men reached 68 726 euros per year of quality-adjusted life. One of the main elements that makes this technology costly is the need for battery replacement. The results were robust. CONCLUSIONS Barostim is not a cost-effective strategy for the treatment of refractory hypertension in Spain. The cost-effectiveness ratio could be improved by future reductions in the cost of the battery.
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Affiliation(s)
- Marcelo Soto
- Fundació Clínic per a la Recerca Biomèdica, Barcelona, Spain.
| | - Laura Sampietro-Colom
- Unidad de Evaluación de Innovaciones y Nuevas Tecnologías, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Joan Sagarra
- Institut Clínic del Tòrax (ICT), Hospital Clínic de Barcelona, Barcelona, Spain
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75
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Brognara F, Dias DPM, Castania JA, Fazan R, Lewis SJ, Salgado HC. Cardiovascular responses elicited by continuous versus intermittent electrical stimulation of the aortic depressor nerve in conscious rats. Life Sci 2016; 148:99-105. [PMID: 26876918 DOI: 10.1016/j.lfs.2016.02.033] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Revised: 01/29/2016] [Accepted: 02/08/2016] [Indexed: 12/01/2022]
Abstract
AIMS Short-term (seconds or minutes) continuous electrical activation of the aortic depressor nerve (ADN) in conscious rats has been successfully used to investigate baroafferent function in experimental hypertension, heart failure, and peripheral inflammation. The aim of this study was to characterize the hemodynamic responses elicited by longer periods (60min) of continuous or intermittent electrical baroreflex activation. MAIN METHODS Wistar rats were implanted with an electrode around the left ADN and a catheter into a femoral artery. The systolic, diastolic and mean arterial pressure and heart rate were recorded in subjects randomly assigned to continuous or intermittent electrical stimulation. The time-course of cardiovascular responses in conscious rats was examined during longer-term (60min) continuous (n=6) or intermittent (5s ON/3s OFF; n=10) electrical stimulation (0.5mA; 0.25ms; 30Hz) of the ADN. KEY FINDINGS The prompt (20s) hypotensive response was greater under continuous stimulation, but no difference was detected in the bradycardic response. The hypotensive response was sustained only by continuous stimulation while no sustained bradycardia was observed in either protocol. SIGNIFICANCE These findings indicate that continuous stimulation of the ADN is more effective in reducing arterial pressure over a longer period (60min) of stimulation. Nevertheless, both protocols - continuous or intermittent - were unable to elicit a sustained bradycardia.
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Affiliation(s)
- Fernanda Brognara
- Department of Physiology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, SP, Brazil
| | - Daniel P Martins Dias
- Department of Physiology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, SP, Brazil
| | - Jaci A Castania
- Department of Physiology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, SP, Brazil
| | - Rubens Fazan
- Department of Physiology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, SP, Brazil
| | - Stephen J Lewis
- Department of Pediatrics, Division of Pulmonology, Allergy and Immunology, Department of Pharmacology, School of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Helio C Salgado
- Department of Physiology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, SP, Brazil.
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76
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Abstract
Heart failure has emerged as one of the most important diseases of the past century. The understanding and treatment of heart failure has evolved significantly over the years. As we move further into the era of device therapy, attention has turned to the idea of sympathetic nervous system modulation through renal denervation to treat heart failure. In this review, we summarize the background research, denervation technique, and current studies on renal denervation for the treatment of heart failure. We also compare and contrast the work on carotid barostimulation.
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Affiliation(s)
- Michael W Fong
- Division of Cardiovascular Medicine, Department of Medicine, Keck School of Medicine, University of Southern California, 1520 San Pablo Street, Suite 320, Los Angeles, CA, 90033, USA,
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77
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Cogan SF, Ludwig KA, Welle CG, Takmakov P. Tissue damage thresholds during therapeutic electrical stimulation. J Neural Eng 2016; 13:021001. [PMID: 26792176 DOI: 10.1088/1741-2560/13/2/021001] [Citation(s) in RCA: 198] [Impact Index Per Article: 24.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE Recent initiatives in bioelectronic modulation of the nervous system by the NIH (SPARC), DARPA (ElectRx, SUBNETS) and the GlaxoSmithKline Bioelectronic Medicines effort are ushering in a new era of therapeutic electrical stimulation. These novel therapies are prompting a re-evaluation of established electrical thresholds for stimulation-induced tissue damage. APPROACH In this review, we explore what is known and unknown in published literature regarding tissue damage from electrical stimulation. MAIN RESULTS For macroelectrodes, the potential for tissue damage is often assessed by comparing the intensity of stimulation, characterized by the charge density and charge per phase of a stimulus pulse, with a damage threshold identified through histological evidence from in vivo experiments as described by the Shannon equation. While the Shannon equation has proved useful in assessing the likely occurrence of tissue damage, the analysis is limited by the experimental parameters of the original studies. Tissue damage is influenced by factors not explicitly incorporated into the Shannon equation, including pulse frequency, duty cycle, current density, and electrode size. Microelectrodes in particular do not follow the charge per phase and charge density co-dependence reflected in the Shannon equation. The relevance of these factors to tissue damage is framed in the context of available reports from modeling and in vivo studies. SIGNIFICANCE It is apparent that emerging applications, especially with microelectrodes, will require clinical charge densities that exceed traditional damage thresholds. Experimental data show that stimulation at higher charge densities can be achieved without causing tissue damage, suggesting that safety parameters for microelectrodes might be distinct from those defined for macroelectrodes. However, these increased charge densities may need to be justified by bench, non-clinical or clinical testing to provide evidence of device safety.
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Affiliation(s)
- Stuart F Cogan
- The Department of Bioengineering, The University of Texas at Dallas, Richardson, TX, USA
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78
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Skrzypecki J, Ufnal M. Drug resistant hypertension – no simple way out. Kidney Blood Press Res 2016; 40:66-76. [PMID: 25791632 DOI: 10.1159/000368483] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/20/2015] [Indexed: 11/19/2022] Open
Abstract
Hypertension poses growing challenge for health policy-makers and doctors worldwide. Recently published results of Symplicity-III trial (HTN-3), the first blinded, randomized, multicenter study on the efficacy of renal denervation for the treatment of resistant hypertension did not show a significant reduction of BP in patients with resistant hypertension 6 months after renal-artery denervation, as compared with controls. In this paper we review clinical and experimental studies on renal denervation. In order to identify causes of inconsistent results in renal denervation studies we look at basic science support for renal denervation and at designs of clinical trials.
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79
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Hering D, Schlaich M. The Role of Central Nervous System Mechanisms in Resistant Hypertension. Curr Hypertens Rep 2016; 17:58. [PMID: 26070453 DOI: 10.1007/s11906-015-0570-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Arterial hypertension remains a primary global health problem with significant impact on cardiovascular morbidity and mortality. The low rate of hypertension control and failure to achieve target blood pressure levels particularly among high-risk patients with resistant hypertension has triggered renewed interest in unravelling the underlying mechanisms to implement therapeutic approaches for better patient management. Here, we summarize the crucial role of neurogenic mechanisms in drug-resistant hypertension, with a specific focus on central control of blood pressure, the factors involved in central integration of afferent signalling to increase sympathetic drive in resistant hypertension, and briefly review recently introduced interventional strategies distinctively targeting sympathetic activation.
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Affiliation(s)
- Dagmara Hering
- School of Medicine and Pharmacology - Royal Perth Hospital Unit, The University of Western Australia, Level 3 MRF Building, Rear 50 Murray Street, Perth, WA, 6000 MDBP: M570, Australia,
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80
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Abstract
Resistant hypertension despite compliance with pharmacologic therapies continues to hamper optimal blood pressure control. Vagal modulation via direct stimulation of the body's parasympathetic nervous system is proving a promising therapeutic modality to help patients achieve their blood pressure goals. In this article, we review some of the key concepts of different vagal modulations for resistant hypertension including baroreflex activation therapy, renal sympathetic denervation, and direct vagal nerve stimulation.
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81
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Kawada T, Sugimachi M. Open-loop static and dynamic characteristics of the arterial baroreflex system in rabbits and rats. J Physiol Sci 2016; 66:15-41. [PMID: 26541155 PMCID: PMC4742515 DOI: 10.1007/s12576-015-0412-5] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Accepted: 09/30/2015] [Indexed: 02/07/2023]
Abstract
The arterial baroreflex system is the most important negative feedback system for stabilizing arterial pressure (AP). This system serves as a key link between the autonomic nervous system and the cardiovascular system, and is thus essential for understanding the pathophysiology of cardiovascular diseases and accompanying autonomic abnormalities. This article focuses on an open-loop systems analysis using a baroreceptor isolation preparation to identify the characteristics of two principal subsystems of the arterial baroreflex system, namely, the neural arc from pressure input to efferent sympathetic nerve activity (SNA) and the peripheral arc from SNA to AP. Studies on the static and dynamic characteristics of the two arcs under normal physiological conditions and also under various interventions including diseased conditions are to be reviewed. Quantitative understanding of the arterial baroreflex function under diseased conditions would help develop new treatment strategies such as electrical activation of the carotid sinus baroreflex for drug-resistant hypertension.
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Affiliation(s)
- Toru Kawada
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center, 5-7-1 Fujishirodai, Suita, Osaka, 565-8565, Japan.
| | - Masaru Sugimachi
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center, 5-7-1 Fujishirodai, Suita, Osaka, 565-8565, Japan
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82
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Turner MJ, Kawada T, Shimizu S, Fukumitsu M, Sugimachi M. Differences in the dynamic baroreflex characteristics of unmyelinated and myelinated central pathways are less evident in spontaneously hypertensive rats. Am J Physiol Regul Integr Comp Physiol 2015; 309:R1397-405. [DOI: 10.1152/ajpregu.00315.2015] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Accepted: 09/09/2015] [Indexed: 11/22/2022]
Abstract
The aim of the study was to identify the contribution of myelinated (A-fiber) and unmyelinated (C-fiber) baroreceptor central pathways to the baroreflex control of sympathetic nerve activity (SNA) and arterial pressure (AP) in anesthetized Wistar-Kyoto (WKY; n = 8) and spontaneously hypertensive rats (SHR; n = 8). The left aortic depressor nerve (ADN) was electrically stimulated with two types of binary white noise signals designed to preferentially activate A-fibers (A-BRx protocol) or C-fibers (C-BRx protocol). In WKY, the central arc transfer function from ADN stimulation to SNA estimated by A-BRx showed strong derivative characteristics with the slope of dynamic gain between 0.1 and 1 Hz ( Gslope) of 14.63 ± 0.89 dB/decade. In contrast, the central arc transfer function estimated by C-BRx exhibited nonderivative characteristics with Gslope of 0.64 ± 1.13 dB/decade. This indicates that A-fibers are important for rapid baroreflex regulation, whereas C-fibers are likely important for more sustained regulation of SNA and AP. In SHR, the central arc transfer function estimated by A-BRx showed higher Gslope (18.46 ± 0.75 dB/decade, P < 0.01) and that estimated by C-BRx showed higher Gslope (8.62 ± 0.64 dB/decade, P < 0.001) with significantly lower dynamic gain at 0.01 Hz (6.29 ± 0.48 vs. 2.80 ± 0.36%/Hz, P < 0.001) compared with WKY. In conclusion, the dynamic characteristics of the A-fiber central pathway are enhanced in the high-modulation frequency range (0.1–1 Hz) and those of the C-fiber central pathway are attenuated in the low-modulation frequency range (0.01–0.1 Hz) in SHR.
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Affiliation(s)
- Michael J. Turner
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center, Osaka, Japan; and
| | - Toru Kawada
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center, Osaka, Japan; and
| | - Shuji Shimizu
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center, Osaka, Japan; and
| | - Masafumi Fukumitsu
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center, Osaka, Japan; and
- Department of Artificial Organ Medicine, Faculty of Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Masaru Sugimachi
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center, Osaka, Japan; and
- Department of Artificial Organ Medicine, Faculty of Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
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83
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Gronda E, Vanoli E. Baroreflex activation therapy for the treatment of heart failure. Interv Cardiol 2015. [DOI: 10.2217/ica.15.44] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
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84
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Chobanyan-Jürgens K, Jordan J. Electrical carotid sinus stimulation: chances and challenges in the management of treatment resistant arterial hypertension. Curr Hypertens Rep 2015. [PMID: 26208917 DOI: 10.1007/s11906-015-0587-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Treatment resistant arterial hypertension is associated with excess cardiovascular morbidity and mortality. Electrical carotid sinus stimulators engaging baroreflex afferent activity have been developed for such patients. Indeed, baroreflex mechanisms contribute to long-term blood pressure control by governing efferent sympathetic and parasympathetic activity. The first-generation carotid sinus stimulator applying bilateral bipolar stimulation reduced blood pressure in a controlled clinical trial but nevertheless failed to meet the primary efficacy endpoint. The second-generation device utilizes smaller unilateral unipolar electrodes, thus decreasing invasiveness of the implantation while saving battery. An uncontrolled clinical study suggested improvement in blood pressure with the second-generation device. We hope that these findings as well as preliminary observations suggesting cardiovascular and renal organ protection with electrical carotid sinus stimulation will be confirmed in properly controlled clinical trials. Meanwhile, we should find ways to better identify patients who are most likely to benefit from electrical carotid sinus stimulation.
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Affiliation(s)
- Kristine Chobanyan-Jürgens
- Institute of Clinical Pharmacology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany,
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85
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Halbach M, Fritz T, Madershahian N, Pfister R, Reuter H. [Baroreflex activation therapy. A novel interventional approach to treat heart failure with reduced ejection fraction]. Herz 2015; 40:959-65. [PMID: 26525523 DOI: 10.1007/s00059-015-4361-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Sympathovagal imbalance plays an important role in the progression of heart failure with reduced ejection fraction. Baroreflex activation therapy (BAT), i. e. electrical stimulation of baroreceptors located at the carotid sinus, can reduce sympathetic and enhance parasympathetic tone. Large animal studies on BAT demonstrated improvements in cardiac function, arrhythmogenic risk and a survival benefit compared to untreated controls. The recently published Neo Randomized Heart Failure Study, the first multicenter, randomized and controlled trial of optimal medical and device therapy alone or plus BAT in patients with a left ventricular ejection fraction ≤ 35 %, demonstrated a reasonable safety profile of BAT in this severely ill patient population and no relevant interactions with other devices. The study found significant improvements in the New York Heart Association (NYHA) class of heart failure, quality of life as well as 6 min walking distance and data pointed to a reduction in hospitalization rates. Moreover, N-terminal pro-brain natriuretic peptide (NT-proBNP) levels were significantly reduced. This review gives an overview on BAT for the treatment of heart failure with reduced ejection fraction, from the rationale and animal experiments to the most recent clinical data and future perspectives.
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Affiliation(s)
- M Halbach
- Klinik III für Innere Medizin, Herzzentrum, Uniklinik Köln, Kerpener Str. 62, 50937, Köln, Deutschland.
| | - T Fritz
- Klinik III für Innere Medizin, Herzzentrum, Uniklinik Köln, Kerpener Str. 62, 50937, Köln, Deutschland
| | - N Madershahian
- Klinik für Herz- und Thoraxchirurgie, Herzzentrum, Uniklinik Köln, Köln, Deutschland
| | - R Pfister
- Klinik III für Innere Medizin, Herzzentrum, Uniklinik Köln, Kerpener Str. 62, 50937, Köln, Deutschland
| | - H Reuter
- Klinik III für Innere Medizin, Herzzentrum, Uniklinik Köln, Kerpener Str. 62, 50937, Köln, Deutschland
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86
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The Baroreflex Mechanism Revisited. Bull Math Biol 2015; 77:1521-38. [PMID: 26394627 DOI: 10.1007/s11538-015-0094-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Accepted: 08/11/2015] [Indexed: 10/23/2022]
Abstract
We state that the autonomic part of the brain controls the blood pressure (BP) and the heart rate (HR) via the baroreflex mechanism in all situations of human activity (at sleep, at rest, during exercise, fright etc.), in a way which is not, as was hitherto assumed, a mere homeostatic tool or even a resetting device, designed to bring these variables on the road to preset values. The baroreflex is rather a continuous feedback mechanism commanded by the autonomic part of the brain, leading to values appropriate to the situation at hand. Feasibility of this assertion is demonstrated here by using the Seidel-Herzel feedback system outside of its regular practice. Results show indeed that the brain can, and we claim that it does, control the HR and BP throughout life. New responses are demonstrated, e.g., to a sudden fear or apnea. In this event, large BP and HR overshoots are expected before the variables can relax to a new level. Response to abrupt downward change in the controlling parameter shows an undershoot in HR and just a gradual resetting in the BP. The relaxation from sudden external changes to various expected states are calculated and discussed and properties of the Rheos test are explained. Experimental findings for orthostatic tests and for babies under translations and rotations reveal complete qualitative agreement with our model and show no need to invoke the operation of additional body systems. Our method should be the preferred one by the Occam Razor approach. The outcomes may lead to beneficial clinical implication.
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87
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Alnima T, de Leeuw PW, Kroon AA. Baropacing as a new option for treatment of resistant hypertension. Eur J Pharmacol 2015; 763:23-7. [DOI: 10.1016/j.ejphar.2015.03.097] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2015] [Revised: 02/16/2015] [Accepted: 03/19/2015] [Indexed: 11/16/2022]
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90
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Annoni EM, Xie X, Lee SW, Libbus I, KenKnight BH, Osborn JW, Tolkacheva EG. Intermittent electrical stimulation of the right cervical vagus nerve in salt-sensitive hypertensive rats: effects on blood pressure, arrhythmias, and ventricular electrophysiology. Physiol Rep 2015; 3:3/8/e12476. [PMID: 26265746 PMCID: PMC4562562 DOI: 10.14814/phy2.12476] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Hypertension (HTN) is the single greatest risk factor for potentially fatal cardiovascular diseases. One cause of HTN is inappropriately increased sympathetic nervous system activity, suggesting that restoring the autonomic nervous balance may be an effective means of HTN treatment. Here, we studied the potential of vagus nerve stimulation (VNS) to treat chronic HTN and cardiac arrhythmias through stimulation of the right cervical vagus nerve in hypertensive rats. Dahl salt-sensitive rats (n = 12) were given a high salt diet to induce HTN. After 6 weeks, rats were randomized into two groups: HTN-Sham and HTN-VNS, in which VNS was provided to HTN-VNS group for 4 weeks. In vivo blood pressure and electrocardiogram activities were monitored continuously by an implantable telemetry system. After 10 weeks, rats were euthanized and their hearts were extracted for ex vivo electrophysiological studies using high-resolution optical mapping. Six weeks of high salt diet significantly increased both mean arterial pressure (MAP) and pulse pressure, demonstrating successful induction of HTN in all rats. After 4 weeks of VNS treatment, the increase in MAP and the number of arrhythmia episodes in HTN-VNS rats was significantly attenuated when compared to those observed in HTN-Sham rats. VNS treatment also induced changes in electrophysiological properties of the heart, such as reduction in action potential duration (APD) during rapid drive pacing, slope of APD restitution, spatial dispersion of APD, and increase in conduction velocity of impulse propagation. Overall, these results provide further evidence for the therapeutic efficacy of VNS in HTN and HTN-related heart diseases.
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Affiliation(s)
- Elizabeth M Annoni
- Department of Biomedical Engineering, University of Minnesota, Minneapolis, MN, USA
| | - Xueyi Xie
- Department of Biomedical Engineering, University of Minnesota, Minneapolis, MN, USA
| | - Steven W Lee
- Department of Biomedical Engineering, University of Minnesota, Minneapolis, MN, USA
| | | | - Bruce H KenKnight
- Department of Biomedical Engineering, University of Minnesota, Minneapolis, MN, USA Cyberonics Inc., Houston, TX, USA
| | - John W Osborn
- Department of Integrative Biology and Physiology, University of Minnesota, Minneapolis, MN, USA
| | - Elena G Tolkacheva
- Department of Biomedical Engineering, University of Minnesota, Minneapolis, MN, USA
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91
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Acute on/off effects and chronic blood pressure reduction after long-term baroreflex activation therapy in resistant hypertension. J Hypertens 2015; 33:1697-703. [DOI: 10.1097/hjh.0000000000000586] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Lambert EA, Straznicky NE, Dixon JB, Lambert GW. Should the sympathetic nervous system be a target to improve cardiometabolic risk in obesity? Am J Physiol Heart Circ Physiol 2015; 309:H244-58. [DOI: 10.1152/ajpheart.00096.2015] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Accepted: 05/11/2015] [Indexed: 02/03/2023]
Abstract
The sympathetic nervous system (SNS) plays a key role in both cardiovascular and metabolic regulation; hence, disturbances in SNS regulation are likely to impact on both cardiovascular and metabolic health. With excess adiposity, in particular when visceral fat accumulation is present, sympathetic activation commonly occurs. Experimental investigations have shown that adipose tissue releases a large number of adipokines, cytokines, and bioactive mediators capable of stimulating the SNS. Activation of the SNS and its interaction with adipose tissue may lead to the development of hypertension and end-organ damage including vascular, cardiac, and renal impairment and in addition lead to metabolic abnormalities, especially insulin resistance. Lifestyle changes such as weight loss and exercise programs considerably improve the cardiovascular and metabolic profile of subjects with obesity and decrease their cardiovascular risk, but unfortunately weight loss is often difficult to achieve and sustain. Pharmacological and device-based approaches to directly or indirectly target the activation of the SNS may offer some benefit in reducing the cardiometabolic consequences of obesity. Preliminary evidence is encouraging, but more trials are needed to investigate whether sympathetic inhibition could be used in obesity to reverse or prevent cardiometabolic disease development. The purpose of this review article is to highlight the current knowledge of the role that SNS plays in obesity and its associated metabolic disorders and to review the potential benefits of sympathoinhibition on metabolic and cardiovascular functions.
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Affiliation(s)
- Elisabeth A. Lambert
- Human Neurotransmitters Laboratory, Baker IDI Heart and Diabetes Institute, Melbourne, Australia
- Department of Physiology, Monash University, Clayton, Australia
| | - Nora E. Straznicky
- Human Neurotransmitters Laboratory, Baker IDI Heart and Diabetes Institute, Melbourne, Australia
| | - John B. Dixon
- Clinical Obesity Research Laboratory, Baker IDI Heart and Diabetes Institute, Melbourne, Australia; and
| | - Gavin W. Lambert
- Human Neurotransmitters Laboratory, Baker IDI Heart and Diabetes Institute, Melbourne, Australia
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Australia
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94
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Abstract
Resistant hypertension defined as requiring 3 or more complementary antihypertensive drugs at maximally tolerated doses accounts for approximately 3% to 4% of all cases of hypertension. Its increased incidence over the past decade is related to the increase in obesity in the Western world. There are a number of dietary factors that affect sympathetic tone including sodium intake apart from increased body mass. This article discusses the mechanisms of sympathetic stimulation and activation in the context of animal models and human studies. In addition, there is a review of clinical trials with and without device therapy that summarizes the clinical findings. Effective management should be based on pathophysiologic principles and a focus on blood pressure reduction to levels well below 150/90 mm Hg because outcome trial evidence and Food and Drug Administration guidance supports this construct. The key to success of device-based therapy depends on identifying the cohort with true resistant hypertension that can benefit from therapies that are adjuncts to pharmacotherapy. Physicians need to concentrate on educating the patient on lifestyle modifications and themselves on use of proper combinations of antihypertensive medications. If this approach fails to result in a safe level of blood pressure then the patient should be referred to a board-certified clinical hypertension specialist.
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95
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Lantelme P, Harbaoui B, Courand PY. [Resistant hypertension and carotid baroreceptors stimulation]. Presse Med 2015; 44:730-6. [PMID: 26144275 DOI: 10.1016/j.lpm.2015.03.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Accepted: 03/09/2015] [Indexed: 11/29/2022] Open
Abstract
Resistant hypertension remains a frequent and difficult situation; its management has been recently clarified by guidelines from the French Society of Hypertension. Baroreceptor stimulation (BAROSTIM) is an emerging technique aimed at decreasing blood pressure in resistant hypertension. BAROSTIM interferes with baroreflex loop by stimulating baroreceptors and afferences of the baroreflex. There is only one randomized control trial with this technique which showed a modest but apparently durable blood pressure reduction. More evidences are required to refine the place of BAROSTIM, particularly with new devices. Together with renal denervation, BAROSTIM belongs to a new family of interventional techniques which should be considered as potential add-on therapies while optimal medical therapy remains the cornerstone of hypertension management.
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Affiliation(s)
- Pierre Lantelme
- Hospices civils de Lyon, fédération de cardiologie Croix-Rousse - Lyon-Sud, European Society of Hypertension Excellence Center, 69004 Lyon, France; Université Lyon-1, 69100 Villeurbanne, France.
| | - Brahim Harbaoui
- Hospices civils de Lyon, fédération de cardiologie Croix-Rousse - Lyon-Sud, European Society of Hypertension Excellence Center, 69004 Lyon, France; Université Lyon-1, 69100 Villeurbanne, France
| | - Pierre-Yyes Courand
- Hospices civils de Lyon, fédération de cardiologie Croix-Rousse - Lyon-Sud, European Society of Hypertension Excellence Center, 69004 Lyon, France; Université Lyon-1, 69100 Villeurbanne, France
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97
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Jordan J. CrossTalk opposing view: Which technique for controlling resistant hypertension? Carotid sinus stimulation. J Physiol 2015; 592:3933-5. [PMID: 25225251 DOI: 10.1113/jphysiol.2013.268078] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Affiliation(s)
- Jens Jordan
- Institute of Clinical Pharmacology, Hannover Medical School, Carl-Neuberg-Straße 1, 30625 Hannover, Germany
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98
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Ratcliffe LEK, Pijacka W, McBryde FD, Abdala AP, Moraes DJ, Sobotka PA, Hart EC, Narkiewicz K, Nightingale AK, Paton JFR. CrossTalk opposing view: Which technique for controlling resistant hypertension? Carotid chemoreceptor denervation/modulation. J Physiol 2015; 592:3941-4. [PMID: 25225253 DOI: 10.1113/jphysiol.2013.268227] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Affiliation(s)
- L E K Ratcliffe
- CardioNomics Research Group, Clinical Research and Imaging Centre and School of Physiology and Pharmacology, University of Bristol, Bristol, BS8 1TD, UK
| | - W Pijacka
- CardioNomics Research Group, Clinical Research and Imaging Centre and School of Physiology and Pharmacology, University of Bristol, Bristol, BS8 1TD, UK
| | - F D McBryde
- Department of Physiology, University of Auckland, Auckland, New Zealand
| | - A P Abdala
- CardioNomics Research Group, Clinical Research and Imaging Centre and School of Physiology and Pharmacology, University of Bristol, Bristol, BS8 1TD, UK
| | - D J Moraes
- Department of Physiology, School of Medicine of Ribeirão Preto, University of São Paulo, Ribeirão Preto, 14049-900, SP, Brazil
| | - P A Sobotka
- The Ohio State University, 2015 Marywood Lane West, St Paul, MN, 55118, USA
| | - E C Hart
- CardioNomics Research Group, Clinical Research and Imaging Centre and School of Physiology and Pharmacology, University of Bristol, Bristol, BS8 1TD, UK
| | - K Narkiewicz
- Department of Hypertension and Diabetology, Medical University of Gdansk, Debinki 7c, 80-952, Gdansk, Poland
| | - A K Nightingale
- CardioNomics Research Group, Clinical Research and Imaging Centre and School of Physiology and Pharmacology, University of Bristol, Bristol, BS8 1TD, UK
| | - J F R Paton
- CardioNomics Research Group, Clinical Research and Imaging Centre and School of Physiology and Pharmacology, University of Bristol, Bristol, BS8 1TD, UK
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O'Callaghan EL, McBryde FD, Burchell AE, Ratcliffe LEK, Nicolae L, Gillbe I, Carr D, Hart EC, Nightingale AK, Patel NK, Paton JFR. Deep brain stimulation for the treatment of resistant hypertension. Curr Hypertens Rep 2015; 16:493. [PMID: 25236853 DOI: 10.1007/s11906-014-0493-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Hypertension is a leading risk factor for the development of several cardiovascular diseases. As the global prevalence of hypertension increases, so too has the recognition of resistant hypertension. Whilst figures vary, the proportion of hypertensive patients that are resistant to multiple drug therapies have been reported to be as high as 16.4 %. Resistant hypertension is typically associated with elevated sympathetic activity and abnormal homeostatic reflex control and is termed neurogenic hypertension because of its presumed central autonomic nervous system origin. This resistance to conventional pharmacological treatment has stimulated a plethora of medical devices to be investigated for use in hypertension, with varying degrees of success. In this review, we discuss a new therapy for drug-resistant hypertension, deep brain stimulation. The utility of deep brain stimulation in resistant hypertension was first discovered in patients with concurrent neuropathic pain, where it lowered blood pressure and improved baroreflex sensitivity. The most promising central target for stimulation is the ventrolateral periaqueductal gray, which has been well characterised in animal studies as a control centre for autonomic outflow. In this review, we will discuss the promise and potential mechanisms of deep brain stimulation in the treatment of severe, resistant hypertension.
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Affiliation(s)
- Erin L O'Callaghan
- School of Physiology & Pharmacology, University of Bristol, Bristol, BS8 1TD, UK
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100
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Alnima T, Goedhart EJ, Seelen R, van der Grinten CP, de Leeuw PW, Kroon AA. Baroreflex Activation Therapy Lowers Arterial Pressure Without Apparent Stimulation of the Carotid Bodies. Hypertension 2015; 65:1217-22. [DOI: 10.1161/hypertensionaha.114.04354] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2014] [Accepted: 03/30/2015] [Indexed: 12/21/2022]
Abstract
Carotid baroreflex activation therapy produces a sustained fall in blood pressure in patients with resistant hypertension. Because the activation electrodes are implanted at the level of the carotid sinus, it is conceivable that the nearby located carotid body chemoreceptors are stimulated as well. Physiological stimulation of the carotid chemoreceptors not only stimulates respiration but also increases sympathetic activity, which may counteract the effects of baroreflex activation. The aim of this exploratory study is to investigate whether there is concomitant carotid chemoreflex activation during baroreflex activation therapy. Fifteen participants with the Rheos system were included in this single-center study. At arrival at the clinic, the device was switched off for 2 hours while patients were at rest. Subsequently, the device was switched on at 6 electric settings of high and low frequencies and amplitudes. Respiration and blood pressure measurements were performed during all device activation settings. Multilevel statistical models were adjusted for age, sex, body mass index, antihypertensive therapeutic index, sleep apnea, coronary artery disease, systolic blood pressure, and heart rate. There was no change in end-tidal carbon dioxide, partial pressure of carbon dioxide, breath duration, and breathing frequency during any of the electric settings with the device. Nevertheless, mean arterial pressure showed a highly significant decrease during electric activation (
P
<0.001). Carotid baroreflex activation therapy using the Rheos system did not stimulate respiration at several electric device activation energies, which suggests that there is no appreciable coactivation of carotid body chemoreceptors during device therapy.
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Affiliation(s)
- Teba Alnima
- From the Department of Internal Medicine (T.A., E.J.B.M.G., R.S., P.W.d.L., A.A.K.) and Department of Respiratory Medicine (C.P.M.v.d.G.), Maastricht University Medical Center, Maastricht, The Netherlands
| | - Emilie J.B.M. Goedhart
- From the Department of Internal Medicine (T.A., E.J.B.M.G., R.S., P.W.d.L., A.A.K.) and Department of Respiratory Medicine (C.P.M.v.d.G.), Maastricht University Medical Center, Maastricht, The Netherlands
| | - Randy Seelen
- From the Department of Internal Medicine (T.A., E.J.B.M.G., R.S., P.W.d.L., A.A.K.) and Department of Respiratory Medicine (C.P.M.v.d.G.), Maastricht University Medical Center, Maastricht, The Netherlands
| | - Chris P.M. van der Grinten
- From the Department of Internal Medicine (T.A., E.J.B.M.G., R.S., P.W.d.L., A.A.K.) and Department of Respiratory Medicine (C.P.M.v.d.G.), Maastricht University Medical Center, Maastricht, The Netherlands
| | - Peter W. de Leeuw
- From the Department of Internal Medicine (T.A., E.J.B.M.G., R.S., P.W.d.L., A.A.K.) and Department of Respiratory Medicine (C.P.M.v.d.G.), Maastricht University Medical Center, Maastricht, The Netherlands
| | - Abraham A. Kroon
- From the Department of Internal Medicine (T.A., E.J.B.M.G., R.S., P.W.d.L., A.A.K.) and Department of Respiratory Medicine (C.P.M.v.d.G.), Maastricht University Medical Center, Maastricht, The Netherlands
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