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Mujadzic H, Mehta ND, Battle SJ, DiPette DJ. Editorial commentary: Renal denervation for hypertension: A new meta-analysis promotes further discussion. Trends Cardiovasc Med 2023; 33:499-501. [PMID: 35777595 DOI: 10.1016/j.tcm.2022.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 06/26/2022] [Indexed: 11/27/2022]
Affiliation(s)
- Hata Mujadzic
- Department of Internal Medicine, Prisma Health/University of South Carolina and University of South Carolina School of Medicine, 2 Medical Park Road, Suite 402, 29203, Columbia, SC, United States
| | - Neil D Mehta
- Department of Internal Medicine, Prisma Health/University of South Carolina and University of South Carolina School of Medicine, 2 Medical Park Road, Suite 402, 29203, Columbia, SC, United States
| | - Sean J Battle
- Department of Internal Medicine, Prisma Health/University of South Carolina and University of South Carolina School of Medicine, 2 Medical Park Road, Suite 402, 29203, Columbia, SC, United States
| | - Donald J DiPette
- Department of Internal Medicine, University of South Carolina and University of South Carolina School of Medicine, 2 Medical Park Road, Suite 402, 29203, Columbia, South Carolina, United States.
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Park S, Shin J, Ihm SH, Kim KI, Kim HL, Kim HC, Lee EM, Lee JH, Ahn SY, Cho EJ, Kim JH, Kang HT, Lee HY, Lee S, Kim W, Park JM. Resistant hypertension: consensus document from the Korean society of hypertension. Clin Hypertens 2023; 29:30. [PMID: 37908019 PMCID: PMC10619268 DOI: 10.1186/s40885-023-00255-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 10/09/2023] [Indexed: 11/02/2023] Open
Abstract
Although reports vary, the prevalence of true resistant hypertension and apparent treatment-resistant hypertension (aTRH) has been reported to be 10.3% and 14.7%, respectively. As there is a rapid increase in the prevalence of obesity, chronic kidney disease, and diabetes mellitus, factors that are associated with resistant hypertension, the prevalence of resistant hypertension is expected to rise as well. Frequently, patients with aTRH have pseudoresistant hypertension [aTRH due to white-coat uncontrolled hypertension (WUCH), drug underdosing, poor adherence, and inaccurate office blood pressure (BP) measurements]. As the prevalence of WUCH is high among patients with aTRH, the use of out-of-office BP measurements, both ambulatory blood pressure monitoring (ABPM) and home blood pressure monitoring (HBPM), is essential to exclude WUCH. Non-adherence is especially problematic, and methods to assess adherence remain limited and often not clinically feasible. Therefore, the use of HBPM and higher utilization of single-pill fixed-dose combination treatments should be emphasized to improve drug adherence. In addition, primary aldosteronism and symptomatic obstructive sleep apnea are quite common in patients with hypertension and more so in patients with resistant hypertension. Screening for these diseases is essential, as the treatment of these secondary causes may help control BP in patients who are otherwise difficult to treat. Finally, a proper drug regimen combined with lifestyle modifications is essential to control BP in these patients.
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Affiliation(s)
- Sungha Park
- Division of Cardiology, Severance Cardiovascular Hospital, Integrative Research Center for Cerebrovascular and Cardiovascular Diseases, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jinho Shin
- Division of Cardiology, Department of Internal Medicine, Hanyang University Seoul Hospital, Seoul, South Korea
| | - Sang Hyun Ihm
- Division of Cardiology, Department of Internal Medicine, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Bucheon, Republic of Korea.
- Catholic Research Institute for Intractable Cardiovascular Disease, College of Medicine, The Catholic University of Korea, Bucheon St. Mary's Hospital327 Sosa-Ro, Wonmi-guGyunggi-do, Bucheon-si, 14647, Republic of Korea.
| | - Kwang-Il Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Hack-Lyoung Kim
- Division of Cardiology, Department of Internal Medicine, Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
| | - Hyeon Chang Kim
- Department of Preventive Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Eun Mi Lee
- Division of Cardiology, Department of Internal Medicine, Wonkwang University Sanbon Hospital, Wonkwang University College of Medicine, Gunpo, Republic of Korea
| | - Jang Hoon Lee
- Department of Internal Medicine, Kyungpook National University Hospital, Daegu, South Korea
- School of Medicine, Kyungpook National University, Daegu, South Korea
| | - Shin Young Ahn
- Division of Nephrology, Department of Internal Medicine, Korea University Guro Hospital, Seoul, South Korea
| | - Eun Joo Cho
- Division of Cardiology, Department of Internal Medicine, The Catholic University of Korea, Seoul, Korea
| | - Ju Han Kim
- Department of Cardiovascular Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Hee-Taik Kang
- Department of Family Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hae-Young Lee
- Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Sunki Lee
- Hallym University, Dongtan Hospital, Gyeonggi-do, Korea
| | - Woohyeun Kim
- Division of Cardiology, Department of Internal Medicine, Hanyang University Seoul Hospital, Seoul, Korea
| | - Jong-Moo Park
- Department of Neurology, Uijeongbu Eulji Medical Center, Eulji University, Uijeongbu, South Korea
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Pathak A, Rudolph UM, Saxena M, Zeller T, Müller-Ehmsen J, Lipsic E, Schmieder RE, Sievert H, Halbach M, Sharif F, Parise H, Fischell TA, Weber MA, Kandzari DE, Mahfoud F. Alcohol-mediated renal denervation in patients with hypertension in the absence of antihypertensive medications. EUROINTERVENTION 2023; 19:602-611. [PMID: 37427416 PMCID: PMC10493775 DOI: 10.4244/eij-d-23-00088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 05/30/2023] [Indexed: 07/11/2023]
Abstract
BACKGROUND Ultrasound and radiofrequency renal denervation (RDN) have been shown to safely lower blood pressure (BP) in hypertension. AIMS The TARGET BP OFF-MED trial investigated the efficacy and safety of alcohol-mediated renal denervation (RDN) in the absence of antihypertensive medications. METHODS This randomised, blinded, sham-controlled trial was conducted in 25 centres in Europe and the USA. Patients with a 24-hour systolic BP of 135-170 mmHg, an office systolic BP 140-180 mmHg and diastolic BP ≥90 mmHg on 0-2 antihypertensive medications were enrolled. The primary efficacy endpoint was the change in mean 24-hour systolic BP at 8 weeks. Safety endpoints included major adverse events up to 30 days. RESULTS A total of 106 patients were randomised; the baseline mean office BP following medication washout was 159.4/100.4±10.9/7.0 mmHg (RDN) and 160.1/98.3±11.0/6.1 mmHg (sham), respectively. At 8 weeks post-procedure, the mean (±standard deviation) 24-hour systolic BP change was â2.9±7.4 mmHg (p=0.009) versus â1.4±8.6 mmHg (p=0.25) in the RDN and sham groups, respectively (mean between-group difference: 1.5 mmHg; p=0.27). There were no differences in safety events between groups. After 12 months of blinded follow-up, with medication escalation, patients achieved similar office systolic BP (RDN: 147.9±18.5 mmHg; sham: 147.8±15.1 mmHg; p=0.68) with a significantly lower medication burden in the RDN group (mean daily defined dose: 1.5±1.5 vs 2.3±1.7; p=0.017). CONCLUSIONS In this trial, alcohol-mediated RDN was delivered safely but was not associated with significant BP differences between groups. Medication burden was lower in the RDN group up to 12 months.
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Affiliation(s)
- Atul Pathak
- Department of Cardiovascular Medicine, Princess Grace Hospital, Principality of Monaco
| | - Ulrike M Rudolph
- Klinik und Poliklinik für Kardiologie, Universitätsklinikum Leipzig, Universität Leipzig, Leipzig, Germany
| | - Manish Saxena
- Barts NIHR Biomedical Research Centre, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Thomas Zeller
- Universitäts-Herzzentrum Bad Krozingen, Bad Krozingen, Germany
| | | | - Erik Lipsic
- Department of Cardiology, University Medical Center Groningen, Groningen, the Netherlands
| | - Roland E Schmieder
- Universitätsklinikum Erlangen, Erlangen, Germany and Friedrich Alexander University Erlangen/Nürnberg, Erlangen, Germany
| | - Horst Sievert
- CardioVasculäres Centrum (CVC) Frankfurt, Frankfurt, Germany
| | - Marcel Halbach
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Clinic III for Internal Medicine, Cologne, Germany and Herzzentrum der Uniklinik Koln, Koln, Germany
| | - Faisal Sharif
- Saolta University Healthcare Group, University Hospital Galway, Galway, Ireland
| | - Helen Parise
- Yale University School of Medicine, New Haven, CT, USA
| | | | - Michael A Weber
- Division of Cardiovascular Medicine, State University of New York (SUNY), New York, NY, USA
| | - David E Kandzari
- Department of Interventional Cardiology, Piedmont Heart Institute, Atlanta, GA, USA
| | - Felix Mahfoud
- Department of Internal Medicine III - cardiology, angiology and internal intensive care medicine, Saarland University Medical Center, Homburg, Germany
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA
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54
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Reyes KRL, Rader F. Long-Term Safety and Antihypertensive Effects of Renal Denervation: Current Insights. Integr Blood Press Control 2023; 16:59-70. [PMID: 37701066 PMCID: PMC10494925 DOI: 10.2147/ibpc.s392410] [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: 06/14/2023] [Accepted: 09/01/2023] [Indexed: 09/14/2023] Open
Abstract
Hypertension is the most potent modifiable risk factor for the development of cardiovascular morbidity and mortality worldwide. Nevertheless, blood pressure (BP) control on a broad scale appears to be insurmountable and has even worsened in the US. Barriers to sustained hypertension control are multifactorial and although lack of patient awareness and socioeconomic barriers to healthcare access may play a role, medication non-compliance and therapeutic inertia are major causes. Renal denervation (RDN) is a minimally invasive procedure that has been the subject of interest in clinical trials for more than a decade and although the first sham-controlled trial could not detect group difference between treated and untreated hypertensives, subsequent, better designed sham-controlled trials clearly demonstrated the BP lowering effect of RDN, as well as its safety. While to-date, RDN is not available for routine clinical practice, one major requirement for broad implementation is that the BP lowering effect is durable. Therefore, this review will summarize the available long-term data of the different RDN modalities with respect to both effectiveness and safety.
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Affiliation(s)
| | - Florian Rader
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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55
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Collard D, Velde LVD, Stegehuis VE, Delewi R, Beijk MAM, Zijlstra IJAJ, de Winter RJ, Vogt L, van den Born BJH. Assessment of renal sympathetic control using invasive pressure and flow velocity measurements in humans. Am J Physiol Renal Physiol 2023; 325:F263-F270. [PMID: 37382495 DOI: 10.1152/ajprenal.00031.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 06/21/2023] [Accepted: 06/22/2023] [Indexed: 06/30/2023] Open
Abstract
Renal sympathetic innervation is important in the control of renal and systemic hemodynamics and is a target for pharmacological and catheter-based therapies. The effect of a physiological sympathetic stimulus using static handgrip exercise on renal hemodynamics and intraglomerular pressure in humans is unknown. We recorded renal arterial pressure and flow velocity in patients with a clinical indication for coronary or peripheral angiography using a sensor-equipped guidewire during baseline, handgrip, rest, and hyperemia following intrarenal dopamine (30 μg/kg). Changes in perfusion pressure were expressed as the change in mean arterial pressure, and changes in flow were expressed as a percentage with respect to baseline. Intraglomerular pressure was estimated using a Windkessel model. A total of 18 patients (61% male and 39% female) with a median age of 57 yr (range: 27-85 yr) with successful measurements were included. During static handgrip, renal arterial pressure increased by 15.2 mmHg (range: 4.2-53.0 mmHg), whereas flow decreased by 11.2%, but with a large variation between individuals (range: -13.4 to 49.8). Intraglomerular pressure increased by 4.2 mmHg (range: -3.9 to 22.1 mmHg). Flow velocity under resting conditions remained stable, with a median of 100.6% (range: 82.3%-114.6%) compared with baseline. During hyperemia, maximal flow was 180% (range: 111%-281%), whereas intraglomerular pressure decreased by 9.6 mmHg (interquartile range: 4.8 to 13.9 mmHg). Changes in renal pressure and flow during handgrip exercise were significantly correlated (ρ = -0.68, P = 0.002). Measurement of renal arterial pressure and flow velocity during handgrip exercise allows the identification of patients with higher and lower sympathetic control of renal perfusion. This suggests that hemodynamic measurements may be useful to assess the response to therapeutic interventions aimed at altering renal sympathetic control.NEW & NOTEWORTHY Renal sympathetic innervation is important in the homeostasis of systemic and renal hemodynamics. We showed that renal arterial pressure significantly increased and that flow decreased during static handgrip exercise using direct renal arterial pressure and flow measurements in humans, but with a large difference between individuals. These findings may be useful for future studies aimed to assess the effect of interventions that influence renal sympathetic control.
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Affiliation(s)
- Didier Collard
- Department of Internal Medicine, Section Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Lennart van de Velde
- Department of Internal Medicine, Section Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Faculty of Science and Technology, Technical Medical Centre, Multi-Modality Medical Imaging Group, University of Twente, Enschede, The Netherlands
| | - Valerie E Stegehuis
- Heart Center, Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Ronak Delewi
- Heart Center, Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Marcel A M Beijk
- Heart Center, Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - IJsbrand A J Zijlstra
- Department of Radiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Robbert J de Winter
- Heart Center, Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Liffert Vogt
- Department of Internal Medicine, Section Nephrology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Bert-Jan H van den Born
- Department of Internal Medicine, Section Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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56
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Collard D, Velde LVD, Stegehuis VE, Delewi R, Beijk MAM, Zijlstra IJAJ, de Winter RJ, Vogt L, van den Born BJH. Assessment of renal sympathetic control using invasive pressure and flow velocity measurements in humans. Am J Physiol Renal Physiol 2023; 325:F263-F270. [DOI: https:/doi.org/10.1152/ajprenal.00031.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 06/21/2023] [Accepted: 06/22/2023] [Indexed: 11/30/2023] Open
Abstract
Renal sympathetic innervation is important in the homeostasis of systemic and renal hemodynamics. We showed that renal arterial pressure significantly increased and that flow decreased during static handgrip exercise using direct renal arterial pressure and flow measurements in humans, but with a large difference between individuals. These findings may be useful for future studies aimed to assess the effect of interventions that influence renal sympathetic control.
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Affiliation(s)
- Didier Collard
- Department of Internal Medicine, Section Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Lennart van de Velde
- Department of Internal Medicine, Section Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Faculty of Science and Technology, Technical Medical Centre, Multi-Modality Medical Imaging Group, University of Twente, Enschede, The Netherlands
| | - Valerie E. Stegehuis
- Heart Center, Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Ronak Delewi
- Heart Center, Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Marcel A. M. Beijk
- Heart Center, Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Robbert J. de Winter
- Heart Center, Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Liffert Vogt
- Department of Internal Medicine, Section Nephrology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Bert-Jan H. van den Born
- Department of Internal Medicine, Section Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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Filippone EJ, Naccarelli GV, Foy AJ. Controversies in Hypertension IV: Renal Denervation. Am J Med 2023; 136:857-868. [PMID: 37230403 DOI: 10.1016/j.amjmed.2023.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 05/03/2023] [Indexed: 05/27/2023]
Abstract
Renal denervation is not a cure for hypertension. Although more recent sham-controlled trials were positive, a significant minority of patients in each trial were unresponsive. The optimal patient or patients need to be defined. Combined systolic/diastolic hypertension appears more responsive than isolated systolic hypertension. It remains uncertain whether patients with comorbidities associated with higher adrenergic tone should be targeted, including obesity, diabetes, sleep apnea, and chronic kidney disease. No biomarker can adequately predict response. A key to a successful response is the adequacy of denervation, which currently cannot be assessed in real time. It is uncertain what is the optimal denervation methodology: radiofrequency, ultrasound, or ethanol injection. Radiofrequency requires targeting the distal main renal artery plus major branches and accessory arteries. Although denervation appears to be safe, conclusive data on quality of life, improved target organ damage, and reduced cardiovascular events/mortality are required before denervation can be generally recommended.
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Affiliation(s)
- Edward J Filippone
- Division of Nephrology, Department of Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pa.
| | - Gerald V Naccarelli
- Department of Medicine, Penn State University Heart and Vascular Institute; Penn State M.S Hershey Medical Center and College of Medicine, Hershey, Pa
| | - Andrew J Foy
- Department of Medicine, Penn State University Heart and Vascular Institute; Penn State M.S Hershey Medical Center and College of Medicine, Hershey, Pa
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Weber MA, Hering D, Nikoleishvili D, Imedadze A, Dughashvili G, Klimiashvili Z, Bekaia E, Shengelia T, Kabalava M, Goguadze O, Emukhvari T, Druker V, Buelna T, Heuser R, Hashemian S, Provanzano R. Durability of the Blood Pressure Effects of Renal Pelvic Denervation in Patients with Hypertension during a 12-Month Observation. Am J Nephrol 2023; 55:319-328. [PMID: 37651994 DOI: 10.1159/000533569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 08/08/2023] [Indexed: 09/02/2023]
Abstract
INTRODUCTION We previously completed a trial of renal pelvic denervation for treating hypertension that reduced blood pressure by the 2-month primary endpoint. However, information on the durability of effectiveness is a critical requirement for device therapy and we now report data up to 12 months. METHODS This was an open-label, single-arm feasibility study in patients with increased blood pressure despite taking an average of 2.7 medications. The key endpoint reported here was ambulatory blood pressure at 12 months following renal pelvic denervation. RESULTS In the 17 patients (mean age: 56) studied, there was a reduction from the baseline of 148 + 8.7 mm Hg in the primary endpoint of mean daytime systolic blood pressure at 12 months of 19.1 (26.7, 11.6) mm Hg, p < 0.001, as compared with the 2-month result of 19.4 (24.9, 14.0) mm Hg. The 24-h systolic blood pressure fell by 19.3 (26.7, 11.9), p < 0.001, and nighttime systolic fell by 18.7 (27.5, 9.8), p < 0.001, mm Hg at 12 months. Diastolic pressures also fell significantly from baseline at 12 months. As well, automated office systolic blood pressure was reduced from the baseline of 156.5 ± 12.3 by 24.8 (33.2, 16.8) mm Hg, p < 0.001, at 12 months as compared with 22.4 (31.5, 13.3) at 2 months. All blood pressure changes at 12 months were not different from those at 2 months, thus confirming the durability of the procedure. There were no serious procedural, clinical, or laboratory adverse events related to the intervention. Serum creatinine fell from 1.03 ± 0.22 to 0.82 ± 0.16 mg/dL, and estimated glomerular filtration rate rose from 79.6 ± 17.8 to 96.3 ± 16.4 mL/min/1.73 m2 by 12 months, again sustaining effects seen at 2 months. CONCLUSION These findings provide evidence that the significant blood pressure-lowering effects of renal pelvic denervation are durable and safe for at least 1 year and provide the basis for a pivotal randomized blinded trial to further define the safety and effectiveness of this procedure.
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Affiliation(s)
- Michael A Weber
- Downstate Medical Center, State University of New York, Brooklyn, New York, USA
| | - Dagmara Hering
- College of Health Solutions, Arizona State University, Phoenix, Arizona, USA
- Department of Hypertension and Diabetology, Medical University of Gdansk, Gdansk, Poland
| | | | | | | | | | - Eter Bekaia
- Israeli-Georgian Medical Research Clinic Helsicore, Tbilisi, Georgia
| | | | - Mamuka Kabalava
- Israeli-Georgian Medical Research Clinic Helsicore, Tbilisi, Georgia
| | | | - Tamar Emukhvari
- Israeli-Georgian Medical Research Clinic Helsicore, Tbilisi, Georgia
| | | | | | - Richard Heuser
- College of Health Solutions, Arizona State University, Phoenix, Arizona, USA
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Wagener M, Dolan E, Arnous S, Galvin J, Murphy AW, Casserly I, Eustace J, O’Connor S, McCreery C, Shand J, Wall C, Matiullah S, Sharif F. Renal Denervation as a Complementary Treatment Option for Uncontrolled Arterial Hypertension: A Situation Assessment. J Clin Med 2023; 12:5634. [PMID: 37685701 PMCID: PMC10488551 DOI: 10.3390/jcm12175634] [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: 07/23/2023] [Revised: 08/20/2023] [Accepted: 08/25/2023] [Indexed: 09/10/2023] Open
Abstract
Uncontrolled arterial hypertension is a major global health issue. Catheter-based renal denervation has shown to lower blood pressure in sham-controlled trials and represents a device-based, complementary treatment option for hypertension. In this situation assessment, the authors, who are practicing experts in hypertension, nephrology, general practice and cardiology in the Republic of Ireland, discuss the current evidence base for the BP-lowering efficacy and safety of catheter-based renal denervation with different modalities. Although important questions remain regarding the identification of responders, and long-term efficacy and safety of the intervention, renal denervation has the potential to provide much-needed help to address hypertension and its adverse consequences. The therapeutic approach needs to be multidisciplinary and personalised to take into account the perspective of patients and healthcare professionals in a shared decision-making process.
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Affiliation(s)
- Max Wagener
- University Hospital Galway, University of Galway, H91 TK33 Galway, Ireland
| | - Eamon Dolan
- Stroke and Hypertension Unit, Connolly Hospital, D15 X40D Dublin, Ireland
| | - Samer Arnous
- University Hospital Limerick, V94 F858 Limerick, Ireland
| | - Joseph Galvin
- The Mater Misericordiae University Hospital, D07 R2WY Dublin, Ireland
| | - Andrew W. Murphy
- Turloughmore Medical Centre, University of Galway, H91 TK33 Galway, Ireland
| | - Ivan Casserly
- The Mater Misericordiae University Hospital, D07 R2WY Dublin, Ireland
| | | | | | | | - James Shand
- St. Vincent’s University Hospital, D04 T6F4 Dublin, Ireland
| | | | | | - Faisal Sharif
- University Hospital Galway, University of Galway, H91 TK33 Galway, Ireland
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Dybiec J, Krzemińska J, Radzioch E, Szlagor M, Wronka M, Młynarska E, Rysz J, Franczyk B. Advances in the Pathogenesis and Treatment of Resistant Hypertension. Int J Mol Sci 2023; 24:12911. [PMID: 37629095 PMCID: PMC10454510 DOI: 10.3390/ijms241612911] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 07/25/2023] [Accepted: 08/16/2023] [Indexed: 08/27/2023] Open
Abstract
Hypertension is a prevalent chronic disease associated with an increased risk of cardiovascular (CV) premature death, and its severe form manifests as resistant hypertension (RH). The accurate prevalence of resistant hypertension is difficult to determine due to the discrepancy in data from various populations, but according to recent publications, it ranges from 6% to 18% in hypertensive patients. However, a comprehensive understanding of the pathogenesis and treatment of RH is essential. This review emphasizes the importance of identifying the causes of treatment resistance in antihypertensive therapy and highlights the utilization of appropriate diagnostic methods. We discussed innovative therapies such as autonomic neuromodulation techniques like renal denervation (RDN) and carotid baroreceptor stimulation, along with invasive interventions such as arteriovenous anastomosis as potential approaches to support patients with inadequate medical treatment and enhance outcomes in RH.
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Affiliation(s)
- Jill Dybiec
- Department of Nephrocardiology, Medical University of Lodz, ul. Zeromskiego 113, 90-549 Łódź, Poland; (J.D.); (J.K.); (E.R.); (M.S.); (M.W.); (B.F.)
| | - Julia Krzemińska
- Department of Nephrocardiology, Medical University of Lodz, ul. Zeromskiego 113, 90-549 Łódź, Poland; (J.D.); (J.K.); (E.R.); (M.S.); (M.W.); (B.F.)
| | - Ewa Radzioch
- Department of Nephrocardiology, Medical University of Lodz, ul. Zeromskiego 113, 90-549 Łódź, Poland; (J.D.); (J.K.); (E.R.); (M.S.); (M.W.); (B.F.)
| | - Magdalena Szlagor
- Department of Nephrocardiology, Medical University of Lodz, ul. Zeromskiego 113, 90-549 Łódź, Poland; (J.D.); (J.K.); (E.R.); (M.S.); (M.W.); (B.F.)
| | - Magdalena Wronka
- Department of Nephrocardiology, Medical University of Lodz, ul. Zeromskiego 113, 90-549 Łódź, Poland; (J.D.); (J.K.); (E.R.); (M.S.); (M.W.); (B.F.)
| | - Ewelina Młynarska
- Department of Nephrocardiology, Medical University of Lodz, ul. Zeromskiego 113, 90-549 Łódź, Poland; (J.D.); (J.K.); (E.R.); (M.S.); (M.W.); (B.F.)
| | - Jacek Rysz
- Department of Nephrology, Hypertension and Family Medicine, Medical University of Lodz, ul. Żeromskiego 113, 90-549 Łódź, Poland;
| | - Beata Franczyk
- Department of Nephrocardiology, Medical University of Lodz, ul. Zeromskiego 113, 90-549 Łódź, Poland; (J.D.); (J.K.); (E.R.); (M.S.); (M.W.); (B.F.)
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Rosch S, Rommel K, Blazek S, Kresoja K, Schöber A, von Roeder M, Desch S, Thiele H, Lurz P, Fengler K. Twenty-Four-Month Blood Pressure Results After Renal Denervation Using Endovascular Ultrasound. J Am Heart Assoc 2023; 12:e030767. [PMID: 37581398 PMCID: PMC10492948 DOI: 10.1161/jaha.123.030767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 07/13/2023] [Indexed: 08/16/2023]
Abstract
BACKGROUND Renal denervation has proven its efficacy to lower blood pressure in comparison to sham treatment in recent randomized clinical trials. Although there is a large body of evidence for the durability and safety of radiofrequency-based renal denervation, there are a paucity of data for endovascular ultrasound-based renal denervation (uRDN). We aimed to assess the long-term efficacy and safety of uRDN in a single-center cohort of patients. METHODS AND RESULTS Data from 2 previous studies on uRDN were pooled. Ambulatory 24-hour blood pressure measurements were taken before as well as 3, 6, 12, and 24 months after treatment with uRDN. A total of 130 patients (mean age 63±9 years, 24% women) underwent uRDN. After 3, 6, 12, and 24 months, systolic mean 24-hour ambulatory blood pressure values were reduced by 10±12, 10±14, 8±15, and 10±15 mm Hg, respectively, when compared with baseline (P<0.001). Corresponding diastolic values were reduced by 6±8, 6±8, 5±9, and 6±9 mm Hg, respectively (P<0.001). Periprocedural adverse events occurred in 16 patients, and all recovered without sequelae. CONCLUSIONS In this single-center study, uRDN effectively lowered blood pressure up to 24 months after treatment.
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Affiliation(s)
- Sebastian Rosch
- Department of CardiologyHeart Center Leipzig at University of LeipzigLeipzigGermany
| | - Karl‐Philipp Rommel
- Department of CardiologyHeart Center Leipzig at University of LeipzigLeipzigGermany
| | - Stephan Blazek
- Department of CardiologyHeart Center Leipzig at University of LeipzigLeipzigGermany
| | - Karl‐Patrik Kresoja
- Department of CardiologyHeart Center Leipzig at University of LeipzigLeipzigGermany
| | - Anne Schöber
- Department of CardiologyHeart Center Leipzig at University of LeipzigLeipzigGermany
| | | | - Steffen Desch
- Department of CardiologyHeart Center Leipzig at University of LeipzigLeipzigGermany
| | - Holger Thiele
- Department of CardiologyHeart Center Leipzig at University of LeipzigLeipzigGermany
| | - Philipp Lurz
- Department of CardiologyHeart Center Leipzig at University of LeipzigLeipzigGermany
| | - Karl Fengler
- Department of CardiologyHeart Center Leipzig at University of LeipzigLeipzigGermany
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Nistor M, Schmidt M, Klingner C, Klingner C, Schwab M, Bischoff SJ, Matziolis G, Rodríguez-González GL, Schiffner R. Renal Glucose Release after Unilateral Renal Denervation during a Hypoglycemic Clamp in Pigs with an Altered Hypothalamic Pituitary Adrenal Axis after Late-Gestational Dexamethasone Injection. Int J Mol Sci 2023; 24:12738. [PMID: 37628918 PMCID: PMC10454812 DOI: 10.3390/ijms241612738] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Revised: 08/10/2023] [Accepted: 08/11/2023] [Indexed: 08/27/2023] Open
Abstract
Previously, we demonstrated in pigs that renal denervation halves glucose release during hypoglycaemia and that a prenatal dexamethasone injection caused increased ACTH and cortisol concentrations as markers of a heightened hypothalamic pituitary adrenal axis (HPAA) during hypoglycaemia. In this study, we investigated the influence of an altered HPAA on renal glucose release during hypoglycaemia. Pigs whose mothers had received two late-gestational dexamethasone injections were subjected to a 75 min hyperinsulinaemic-hypoglycaemic clamp (<3 mmol/L) after unilateral surgical denervation. Para-aminohippurate (PAH) clearance, inulin, sodium excretion and arterio-venous blood glucose difference were measured every fifteen minutes. The statistical analysis was performed with a Wilcoxon signed-rank test. PAH, inulin, the calculated glomerular filtration rate and plasma flow did not change through renal denervation. Urinary sodium excretion increased significantly (p = 0.019). Side-dependent renal net glucose release (SGN) decreased by 25 ± 23% (p = 0.004). At 25 percent, the SGN decrease was only half of that observed in non-HPAA-altered animals in our prior investigation. The current findings may suggest that specimens with an elevated HPAA undergo long-term adaptations to maintain glucose homeostasis. Nonetheless, the decrease in SGN warrants further investigations and potentially caution in performing renal denervation in certain patient groups, such as diabetics at risk of hypoglycaemia.
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Affiliation(s)
- Marius Nistor
- Orthopaedic Department, Jena University Hospital, Campus Eisenberg, 07607 Eisenberg, Germany; (M.N.)
| | - Martin Schmidt
- Institute for Biochemistry II, Jena University Hospital, 07743 Jena, Germany
| | - Carsten Klingner
- Department of Neurology, Jena University Hospital, 07747 Jena, Germany (M.S.)
| | - Caroline Klingner
- Department of Neurology, Jena University Hospital, 07747 Jena, Germany (M.S.)
| | - Matthias Schwab
- Department of Neurology, Jena University Hospital, 07747 Jena, Germany (M.S.)
| | | | - Georg Matziolis
- Orthopaedic Department, Jena University Hospital, Campus Eisenberg, 07607 Eisenberg, Germany; (M.N.)
| | | | - René Schiffner
- Orthopaedic Department, Jena University Hospital, Campus Eisenberg, 07607 Eisenberg, Germany; (M.N.)
- Emergency Department, Otto-von-Guericke University, 39120 Magdeburg, Germany
- Emergency Department, Helios University Clinic Wuppertal, 42283 Wuppertal, Germany
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63
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Becker BK, Grady CM, Markl AE, Torres Rodriguez AA, Pollock DM. Elevated renal afferent nerve activity in a rat model of endothelin B receptor deficiency. Am J Physiol Renal Physiol 2023; 325:F235-F247. [PMID: 37348026 PMCID: PMC10396274 DOI: 10.1152/ajprenal.00064.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 06/13/2023] [Accepted: 06/21/2023] [Indexed: 06/24/2023] Open
Abstract
Renal nerves have been an attractive target for interventions aimed at lowering blood pressure; however, the specific roles of renal afferent (sensory) versus efferent sympathetic nerves in mediating hypertension are poorly characterized. A number of studies have suggested that a sympathoexcitatory signal conveyed by renal afferents elicits increases in blood pressure, whereas other studies identified sympathoinhibitory afferent pathways. These sympathoinhibitory pathways have been identified as protective against salt-sensitive increases in blood pressure through endothelin B (ETB) receptor activation. We hypothesized that ETB-deficient (ETB-def) rats, which are devoid of functional ETB receptors except in adrenergic tissues, lack appropriate sympathoinhibition and have lower renal afferent nerve activity following a high-salt diet compared with transgenic controls. We found that isolated renal pelvises from high salt-fed ETB-def animals lack a response to a physiological stimulus, prostaglandin E2, compared with transgenic controls but respond equally to a noxious stimulus, capsaicin. Surprisingly, we observed elevated renal afferent nerve activity in intact ETB-def rats compared with transgenic controls under both normal- and high-salt diets. ETB-def rats have been previously shown to have heightened global sympathetic tone, and we also observed higher total renal sympathetic nerve activity in ETB-def rats compared with transgenic controls under both normal- and high-salt diets. These data indicate that ETB receptors are integral mediators of the sympathoinhibitory renal afferent reflex (renorenal reflex), and, in a genetic rat model of ETB deficiency, the preponderance of sympathoexcitatory renal afferent nerve activity prevails and may contribute to hypertension.NEW & NOTEWORTHY Here, we found that endothelin B receptors are an important contributor to renal afferent nerve responsiveness to a high-salt diet. Rats lacking endothelin B receptors have increased afferent nerve activity that is not responsive to a high-salt diet.
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Affiliation(s)
- Bryan K Becker
- Cardio-Renal Physiology and Medicine, Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, United States
| | - Caroline M Grady
- Cardio-Renal Physiology and Medicine, Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, United States
| | - Alexa E Markl
- Cardio-Renal Physiology and Medicine, Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, United States
| | - Alfredo A Torres Rodriguez
- Cardio-Renal Physiology and Medicine, Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, United States
| | - David M Pollock
- Cardio-Renal Physiology and Medicine, Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, United States
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van Weperen VYH, Ripplinger CM, Vaseghi M. Autonomic control of ventricular function in health and disease: current state of the art. Clin Auton Res 2023; 33:491-517. [PMID: 37166736 PMCID: PMC10173946 DOI: 10.1007/s10286-023-00948-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Accepted: 04/20/2023] [Indexed: 05/12/2023]
Abstract
PURPOSE Cardiac autonomic dysfunction is one of the main pillars of cardiovascular pathophysiology. The purpose of this review is to provide an overview of the current state of the art on the pathological remodeling that occurs within the autonomic nervous system with cardiac injury and available neuromodulatory therapies for autonomic dysfunction in heart failure. METHODS Data from peer-reviewed publications on autonomic function in health and after cardiac injury are reviewed. The role of and evidence behind various neuromodulatory therapies both in preclinical investigation and in-use in clinical practice are summarized. RESULTS A harmonic interplay between the heart and the autonomic nervous system exists at multiple levels of the neuraxis. This interplay becomes disrupted in the setting of cardiovascular disease, resulting in pathological changes at multiple levels, from subcellular cardiac signaling of neurotransmitters to extra-cardiac, extra-thoracic remodeling. The subsequent detrimental cycle of sympathovagal imbalance, characterized by sympathoexcitation and parasympathetic withdrawal, predisposes to ventricular arrhythmias, progression of heart failure, and cardiac mortality. Knowledge on the etiology and pathophysiology of this condition has increased exponentially over the past few decades, resulting in a number of different neuromodulatory approaches. However, significant knowledge gaps in both sympathetic and parasympathetic interactions and causal factors that mediate progressive sympathoexcitation and parasympathetic dysfunction remain. CONCLUSIONS Although our understanding of autonomic imbalance in cardiovascular diseases has significantly increased, specific, pivotal mediators of this imbalance and the recognition and implementation of available autonomic parameters and neuromodulatory therapies are still lagging.
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Affiliation(s)
- Valerie Y H van Weperen
- Division of Cardiology, Department of Medicine, UCLA Cardiac Arrythmia Center, University of California, 100 Medical Plaza, Suite 660, Los Angeles, CA, 90095, USA
| | | | - Marmar Vaseghi
- Division of Cardiology, Department of Medicine, UCLA Cardiac Arrythmia Center, University of California, 100 Medical Plaza, Suite 660, Los Angeles, CA, 90095, USA.
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Dai S, Zhao L, Wang G, Chen C, Li C, Xiao B, Miao Y. Celiac ganglia neurolysis suppresses high blood pressure in rats. Hypertens Res 2023; 46:1771-1781. [PMID: 37173429 DOI: 10.1038/s41440-023-01305-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Revised: 04/13/2023] [Accepted: 04/17/2023] [Indexed: 05/15/2023]
Abstract
The efficacy of renal denervation in the treatment of resistant hypertension has been controversial, and new strategies for its therapy are urgently needed. We performed the celiac ganglia neurolysis (CGN) or sham surgery on both spontaneously hypertensive rat (SHR) and Dahl salt-sensitive rat models of hypertension. Following CGN surgery in both strains, systolic blood pressure, diastolic blood pressure and mean arterial pressure were all lower than the levels in the respective sham surgery rats, which were maintained until the end of the study, 18 weeks postoperatively in SHRs and 12 weeks postoperatively in Dahl rats. CGN therapy destroyed ganglion cell structure and significantly inhibited celiac ganglia nerve viability. Four and twelve weeks after CGN, the plasma renin, angiotensin II and aldosterone levels were markedly attenuated, and the nitric oxide content was significantly increased in the CGN group compared with the respective sham surgery rats. However, CGN did not result in statistical difference in malondialdehyde levels compared with sham surgery in both strains. The CGN has efficacy in reducing high blood pressure and may be an alternative for resistant hypertension. Minimally invasive endoscopic ultrasound-guided celiac ganglia neurolysis (EUS-CGN) and percutaneous CGN are safe and convenient treatment approaches. Moreover, for hypertensive patients who need surgery due to abdominal disease or pain relief from pancreatic cancer, intraoperative CGN or EUS-CGN will be a good choice for hypertension therapy. The graphical abstract of antihypertensive effect of CGN.
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Affiliation(s)
- Shangnan Dai
- Pancreas Center, First Affiliated Hospital of Nanjing Medical University, Nanjing, China
- Pancreas Institute, Nanjing Medical University, Nanjing, China
| | - Li Zhao
- Pancreas Center, First Affiliated Hospital of Nanjing Medical University, Nanjing, China
- Pancreas Institute, Nanjing Medical University, Nanjing, China
| | - Guangfu Wang
- Pancreas Center, First Affiliated Hospital of Nanjing Medical University, Nanjing, China
- Pancreas Institute, Nanjing Medical University, Nanjing, China
| | - Chongfa Chen
- Pancreas Center, First Affiliated Hospital of Nanjing Medical University, Nanjing, China
- Pancreas Institute, Nanjing Medical University, Nanjing, China
| | - Chenchen Li
- Pancreas Center, First Affiliated Hospital of Nanjing Medical University, Nanjing, China
- Pancreas Institute, Nanjing Medical University, Nanjing, China
| | - Bin Xiao
- Pancreas Center, First Affiliated Hospital of Nanjing Medical University, Nanjing, China.
- Pancreas Institute, Nanjing Medical University, Nanjing, China.
| | - Yi Miao
- Pancreas Center, First Affiliated Hospital of Nanjing Medical University, Nanjing, China.
- Pancreas Institute, Nanjing Medical University, Nanjing, China.
- Pancreas Center, The Affiliated BenQ Hospital of Nanjing Medical University, Nanjing, China.
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Kiuchi MG, Carnagarin R, Matthews VB, Schlaich MP. Multi-organ denervation: a novel approach to combat cardiometabolic disease. Hypertens Res 2023; 46:1747-1758. [PMID: 37088807 PMCID: PMC10319631 DOI: 10.1038/s41440-023-01287-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 02/17/2023] [Accepted: 04/02/2023] [Indexed: 04/25/2023]
Abstract
Cardiometabolic disorders are associated with a substantial loss in quality of life and pose a large burden on healthcare systems worldwide. Overactivation of the sympathetic nervous system has been shown to be a key player in several aspects relating to cardiometabolic disturbances. While diet- and exercise-induced approaches to help reduce weight remains the main strategy to combat metabolic disorders, this is often difficult to achieve. Current pharmacological approaches result in variable responses in different patient cohorts and long-term efficacy may be limited by medication side effects and non-adherence in the long term. There is a clear clinical need for complementary therapies to curb the burden of cardiometabolic disease. One such approach may include interventional sympathetic neuromodulation of organs relevant to cardiometabolic control. Data from sham-controlled clinical trials demonstrate the feasibility, safety and efficacy of catheter-based renal denervation. In analogy, denervation of the common hepatic artery is now feasible in humans and may prove to be similarly useful in modulating sympathetic overdrive directed towards the liver, pancreas and duodenum. Such a targeted multi-organ neuromodulation strategy may beneficially influence multiple aspects of the cardiometabolic disease continuum including blood pressure, glucose and lipid control.
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Affiliation(s)
- Márcio Galindo Kiuchi
- Dobney Hypertension Centre, Medical School-Royal Perth Hospital Unit and RPH Research Foundation, The University of Western Australia, Perth, WA, Australia
| | - Revathy Carnagarin
- Dobney Hypertension Centre, Medical School-Royal Perth Hospital Unit and RPH Research Foundation, The University of Western Australia, Perth, WA, Australia
| | - Vance B Matthews
- Dobney Hypertension Centre, Medical School-Royal Perth Hospital Unit and RPH Research Foundation, The University of Western Australia, Perth, WA, Australia
| | - Markus P Schlaich
- Dobney Hypertension Centre, Medical School-Royal Perth Hospital Unit and RPH Research Foundation, The University of Western Australia, Perth, WA, Australia.
- Departments of Cardiology and Nephrology, Royal Perth Hospital, Perth, WA, Australia.
- Neurovascular Hypertension & Kidney Disease Laboratory, Baker Heart and Diabetes Institute, Melbourne, VIC, Australia.
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Götzinger F, Kunz M, Lauder L, Mahfoud F, Böhm M. Radio frequency-based renal denervation: a story of simplicity? Future Cardiol 2023; 19:431-440. [PMID: 37791469 DOI: 10.2217/fca-2023-0059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/05/2023] Open
Abstract
Radio frequency-based renal denervation is a safe and effective way of lowering blood pressure, a common condition associated with high cardiovascular risk. Several catheters have been developed to administer energy to the renal arteries and their side branches, thereby modulating sympathetic renal activity. The Symplicity Flex™ and Symplicity Spyral™ are first- and second-generation devices, respectively, for radio frequency-based renal denervation. There is a continuous need to further improve and adjust interventional antihypertensive therapies. Several randomized controlled trials have been conducted to investigate the safety and efficacy of these catheters and most were able to show radio frequency-based renal denervation to be feasible, safe and effective in lowering blood pressure in hypertensive patients with and without concomitant antihypertensive medication. Herein, the authors discuss the pathophysiologic concepts of renal denervation and its procedural approaches, report catheter designs, summarize clinical trials outcomes and, finally, discuss real-world evidence.
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Affiliation(s)
- Felix Götzinger
- Department of Internal Medicine III, Cardiology, Angiology & Intensive Care Medicine, University Hospital Saarland, Saarland University, Homburg, 66421, Germany
| | - Michael Kunz
- Department of Internal Medicine III, Cardiology, Angiology & Intensive Care Medicine, University Hospital Saarland, Saarland University, Homburg, 66421, Germany
| | - Lucas Lauder
- Department of Internal Medicine III, Cardiology, Angiology & Intensive Care Medicine, University Hospital Saarland, Saarland University, Homburg, 66421, Germany
| | - Felix Mahfoud
- Department of Internal Medicine III, Cardiology, Angiology & Intensive Care Medicine, University Hospital Saarland, Saarland University, Homburg, 66421, Germany
| | - Michael Böhm
- Department of Internal Medicine III, Cardiology, Angiology & Intensive Care Medicine, University Hospital Saarland, Saarland University, Homburg, 66421, Germany
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Vogt A, Dutzmann J, Nußbaum M, Hoyer D, Tongers J, Schlitt A, Sedding D, Plehn A. Safety and efficacy of renal sympathetic denervation: a 9-year long-term follow-up of 24-hour ambulatory blood pressure measurements. Front Cardiovasc Med 2023; 10:1210801. [PMID: 37404730 PMCID: PMC10315532 DOI: 10.3389/fcvm.2023.1210801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Accepted: 05/26/2023] [Indexed: 07/06/2023] Open
Abstract
Background Renal sympathetic denervation (RDN) has been shown to lower arterial blood pressure both in the presence and in the absence of antihypertensive medication in an observation period of up to 3 years. However, long-term results beyond 3 years are scarcely reported. Methods We performed a long-term follow-up on patients who were previously enrolled in a local renal denervation registry and who underwent radiofrequency RDN with the Symplicity Flex® renal denervation system between 2011 and 2014. The patients were assessed to evaluate their renal function by performing 24-hour ambulatory blood pressure measurement (ABPM), recording their medical history, and conducting laboratory tests. Results Ambulatory blood pressure readings for 24 h were available for 72 patients at long-term follow-up (FU) [9.3 years (IQR: 8.5-10.1)]. We found a significant reduction of ABP from 150.1/86.1 ± 16.9/12.0 mmHg at baseline to 138.3/77.1 ± 16.5/11.1 mmHg at long-term FU (P < 0.001 for both systolic and diastolic ABP). The number of antihypertensive medications used by the patients significantly decreased from 5.4 ± 1.5 at baseline to 4.8 ± 1.6 at long-term FU (P < 0.01). Renal function showed a significant but expected age-associated decrease in the eGFR from 87.8 (IQR: 81.0-100.0) to 72.5 (IQR: 55.8-86.8) ml/min/1.73 m2 (P < 0.01) in patients with an initial eGFR > 60 ml/min/1.73 m2, while a non-significant decrease was observed in patients with an initial eGFR < 60 ml/min/1.73 m2 at long-term FU [56.0 (IQR: 40.9-58.4) vs. 39.0 (IQR: 13.5-56.3) ml/min/1.73 m2]. Conclusions RDN was accompanied by a long-lasting reduction in blood pressure with a concomitant reduction in antihypertensive medication. No negative effects could be detected, especially with regard to renal function.
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Affiliation(s)
- Alexander Vogt
- Department of Internal Medicine III, University Hospital Halle (Saale), Halle (Saale), Germany
| | - Jochen Dutzmann
- Department of Internal Medicine III, University Hospital Halle (Saale), Halle (Saale), Germany
| | - Michael Nußbaum
- Department of Internal Medicine III, University Hospital Halle (Saale), Halle (Saale), Germany
| | - Daniel Hoyer
- Department of Internal Medicine III, University Hospital Halle (Saale), Halle (Saale), Germany
| | - Jörn Tongers
- Department of Internal Medicine III, University Hospital Halle (Saale), Halle (Saale), Germany
| | - Axel Schlitt
- Department of Cardiology and Diabetes, Paracelsus-Harz-Clinic Bad Suderode, Quedlinburg, Germany
| | - Daniel Sedding
- Department of Internal Medicine III, University Hospital Halle (Saale), Halle (Saale), Germany
| | - Alexander Plehn
- Department of Internal Medicine III, University Hospital Halle (Saale), Halle (Saale), Germany
- Praxisklinik Salzatal, Salzatal, Germany
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Hohl M, Lauder L, Sevimli Ö, Tokcan M, Wagmann L, Götzinger F, Schneider C, Hübner U, Lehnert U, Meyer MR, Böhm M, Mahfoud F. Efficacy of Antihypertensive Drugs of Different Classes After Renal Denervation in Spontaneously Hypertensive Rats. Hypertension 2023; 80:e90-e100. [PMID: 36999443 DOI: 10.1161/hypertensionaha.122.20756] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 03/17/2023] [Indexed: 04/01/2023]
Abstract
BACKGROUND Renal denervation (RDN) lowers blood pressure (BP) in patients with uncontrolled hypertension. Limited data exist on the effectiveness of different antihypertensive medications following RDN on BP and maladaptive cardiac phenotypes. METHODS Eighty-nine male spontaneously hypertensive rats with continuous BP recording underwent RDN or sham operation. Ten days postsurgery, spontaneously hypertensive rats were randomized to receive no antihypertensive medication, amlodipine, olmesartan, hydrochlorothiazide, bisoprolol, doxazosin, or moxonidine for 28 days. Cardiac remodeling was determined histologically, and activation of the renin-angiotensin-aldosterone system was explored. RESULTS Before initiation of antihypertensive drugs, RDN reduced mean arterial pressure (-12.6 mm Hg [95% CI, -14.4 to -10.8]; P<0.001). At study end, mean arterial pressure was lower in RDN compared with sham operation in drug-naïve controls (P=0.006), olmesartan (P=0.002), amlodipine (P=0.0004), hydrochlorothiazide (P=0.006), doxazosin (P=0.001), and bisoprolol (P=0.039) but not in animals receiving moxonidine (P=0.122). Compared with pooled BP change of all other drug classes, mean arterial pressure change was largest for olmesartan (-15.9 mm Hg [95% CI, -18.6 to -13.2]; P<0.001) and amlodipine (-12.0 mm Hg [95% CI, -14.7 to -9.3]; P<0.001). In drug-naïve controls, RDN reduced plasma renin activity (-5.6%¸ P=0.03) and aldosterone concentration (-53.0%; P=0.005). In the presence of antihypertensive medication, plasma renin activity and aldosterone remained unchanged after RDN. Cardiac remodeling was not affected by RDN alone. In animals receiving olmesartan after RDN, cardiac perivascular fibrosis was attenuated. Amlodipine and bisoprolol following RDN reduced cardiomyocyte diameter. CONCLUSIONS Following RDN, treatment with amlodipine and olmesartan resulted in the largest BP reduction. Antihypertensive medications mediated heterogeneous effects on renin-angiotensin-aldosterone system activity and cardiac remodeling.
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Affiliation(s)
- Mathias Hohl
- Klinik für Innere Medizin III (M.H., L.L., O.S., M.T., F.G., C.S., U.L., M.B., F.M.), Universität des Saarlandes, Homburg/Saar, Germany
| | - Lucas Lauder
- Klinik für Innere Medizin III (M.H., L.L., O.S., M.T., F.G., C.S., U.L., M.B., F.M.), Universität des Saarlandes, Homburg/Saar, Germany
| | - Özlem Sevimli
- Klinik für Innere Medizin III (M.H., L.L., O.S., M.T., F.G., C.S., U.L., M.B., F.M.), Universität des Saarlandes, Homburg/Saar, Germany
| | - Mert Tokcan
- Klinik für Innere Medizin III (M.H., L.L., O.S., M.T., F.G., C.S., U.L., M.B., F.M.), Universität des Saarlandes, Homburg/Saar, Germany
| | - Lea Wagmann
- Department of Experimental and Clinical Toxicology, Institute of Experimental and Clinical Pharmacology and Toxicology, Center for Molecular Signaling (PZMS), Saarland University, Homburg/Saar, Germany (L.W., M.R.M.)
| | - Felix Götzinger
- Klinik für Innere Medizin III (M.H., L.L., O.S., M.T., F.G., C.S., U.L., M.B., F.M.), Universität des Saarlandes, Homburg/Saar, Germany
| | - Clara Schneider
- Klinik für Innere Medizin III (M.H., L.L., O.S., M.T., F.G., C.S., U.L., M.B., F.M.), Universität des Saarlandes, Homburg/Saar, Germany
| | - Ulrich Hübner
- Klinische Chemie und Laboratoriumsmedizin (U.H.), Universität des Saarlandes, Homburg/Saar, Germany
| | - Ulrike Lehnert
- Klinik für Innere Medizin III (M.H., L.L., O.S., M.T., F.G., C.S., U.L., M.B., F.M.), Universität des Saarlandes, Homburg/Saar, Germany
| | - Markus R Meyer
- Department of Experimental and Clinical Toxicology, Institute of Experimental and Clinical Pharmacology and Toxicology, Center for Molecular Signaling (PZMS), Saarland University, Homburg/Saar, Germany (L.W., M.R.M.)
| | - Michael Böhm
- Klinik für Innere Medizin III (M.H., L.L., O.S., M.T., F.G., C.S., U.L., M.B., F.M.), Universität des Saarlandes, Homburg/Saar, Germany
| | - Felix Mahfoud
- Klinik für Innere Medizin III (M.H., L.L., O.S., M.T., F.G., C.S., U.L., M.B., F.M.), Universität des Saarlandes, Homburg/Saar, Germany
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Wang C, Wang P, Qi G. A new use of transcutaneous electrical nerve stimulation: Role of bioelectric technology in resistant hypertension (Review). Biomed Rep 2023; 18:38. [PMID: 37168651 PMCID: PMC10165504 DOI: 10.3892/br.2023.1621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 02/21/2023] [Indexed: 05/13/2023] Open
Abstract
Hypertension is an important risk factor for cardiovascular and cerebrovascular disease-associated death. Hypertension and its complications are the main problems that have an impact on public health at present. A portion of adults with hypertension fail to meet the recommended blood pressure (BP) treatment goals, despite strict clinical management. Those individuals requiring at least three types of antihypertensive drugs to achieve their BP goal may be classified as patients with resistant hypertension (RH). Bioelectric technology is an emerging method that functions with the help of the human body's own bioelectric system. It is widely used in auxiliary examination, pain relief and organ function rehabilitation. Bioelectrical technology, as an effective treatment for RH, has developed rapidly in recent years and mainly includes renal sympathetic denervation, carotid baroreflex activation therapy, Traditional Chinese Medicine electroacupuncture and transcutaneous electrical nerve stimulation (TENS). The present review describes the pathogenesis of hypertension and provides an understanding of bioelectrical technology as a treatment. In particular, the development of the application of TENS in RH is introduced. The aim is to provide a basis for the clinical treatment of RH and a new idea for further clinical trials in this field.
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Affiliation(s)
- Chenghua Wang
- The Third Department of Cardiology, The First Hospital of Hebei Medical University, Shijiazhuang, Hebei 050030, P.R. China
| | - Pu Wang
- The Third Department of Cardiology, The First Hospital of Hebei Medical University, Shijiazhuang, Hebei 050030, P.R. China
| | - Guoqing Qi
- The Third Department of Cardiology, The First Hospital of Hebei Medical University, Shijiazhuang, Hebei 050030, P.R. China
- Correspondence to: Dr Guoqing Qi, The Third Department of Cardiology, The First Hospital of Hebei Medical University, 89 Donggang Road, Shijiazhuang, Hebei 050030, P.R. China
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Huang TC, Lo LW, Chou YH, Lin WL, Chang SL, Lin YJ, Liu SH, Cheng WH, Liu PY, Chen SA. Renal denervation reverses ventricular structural and functional remodeling in failing rabbit hearts. Sci Rep 2023; 13:8664. [PMID: 37248400 DOI: 10.1038/s41598-023-35954-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 05/26/2023] [Indexed: 05/31/2023] Open
Abstract
Renal denervation (RDN) suppresses the activity of the renin-angiotensin-aldosterone system and inflammatory cytokines, leading to the prevention of cardiac remodeling. Limited studies have reported the effects of renal denervation on ventricular electrophysiology. We aimed to use optical mapping to evaluate the effect of RDN on ventricular structural and electrical remodeling in a tachycardia-induced cardiomyopathy rabbit model. Eighteen rabbits were randomized into 4 groups: sham control group (n = 5), renal denervation group receiving RDN (n = 5), heart failure group receiving rapid ventricular pacing for 1 month (n = 4), and RDN-heart failure group (n = 4). Rabbit hearts were harvested for optical mapping. Different cycle lengths were paced (400, 300, 250, 200, and 150 ms), and the results were analyzed. In optical mapping, the heart failure group had a significantly slower epicardial ventricular conduction velocity than the other three groups. The RDN-heart failure, sham control, and RDN groups had similar velocities. We then analyzed the 80% action potential duration at different pacing cycle lengths, which showed a shorter action potential duration as cycle length decreased (P for trend < 0.01), which was consistent across all groups. The heart failure group had a significantly longer action potential duration than the sham control and RDN groups. Action potential duration was shorter in the RDN-heart failure group than the heart failure group (P < 0.05). Reduction of conduction velocity and prolongation of action potential duration are significant hallmarks of heart failure, and RDN reverses these remodeling processes.
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Affiliation(s)
- Ting-Chun Huang
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Division of Cardiology, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Li-Wei Lo
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, No. 201, Sec. 2, Shi-Pai Road, 11217, Taipei, Taiwan.
- Institute of Clinical Medicine, and Cardiovascular Research Institute, National Yang-Ming Chiao-Tung University, Taipei, Taiwan.
| | - Yu-Hui Chou
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, No. 201, Sec. 2, Shi-Pai Road, 11217, Taipei, Taiwan
| | - Wei-Lun Lin
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, No. 201, Sec. 2, Shi-Pai Road, 11217, Taipei, Taiwan
- Institute of Clinical Medicine, and Cardiovascular Research Institute, National Yang-Ming Chiao-Tung University, Taipei, Taiwan
| | - Shih-Lin Chang
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, No. 201, Sec. 2, Shi-Pai Road, 11217, Taipei, Taiwan
- Institute of Clinical Medicine, and Cardiovascular Research Institute, National Yang-Ming Chiao-Tung University, Taipei, Taiwan
| | - Yenn-Jiang Lin
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, No. 201, Sec. 2, Shi-Pai Road, 11217, Taipei, Taiwan
- Institute of Clinical Medicine, and Cardiovascular Research Institute, National Yang-Ming Chiao-Tung University, Taipei, Taiwan
| | - Shin-Huei Liu
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, No. 201, Sec. 2, Shi-Pai Road, 11217, Taipei, Taiwan
- Institute of Clinical Medicine, and Cardiovascular Research Institute, National Yang-Ming Chiao-Tung University, Taipei, Taiwan
| | - Wen-Han Cheng
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, No. 201, Sec. 2, Shi-Pai Road, 11217, Taipei, Taiwan
- Institute of Clinical Medicine, and Cardiovascular Research Institute, National Yang-Ming Chiao-Tung University, Taipei, Taiwan
| | - Ping-Yen Liu
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Division of Cardiology, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Shih-Ann Chen
- Institute of Clinical Medicine, and Cardiovascular Research Institute, National Yang-Ming Chiao-Tung University, Taipei, Taiwan
- Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan
- National Chung Hsing University, Taichung, Taiwan
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72
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Wang J, Sun N, Ge J, Jiang H, Yin Y, Chen M, Wang Y, Yao C, Yan X, Sobotka PA, Huo Y. Rationale and Design of Sympathetic Mapping/Ablation of Renal Nerves Trial (SMART) for the Treatment of Hypertension: a Prospective, Multicenter, Single-Blind, Randomized and Sham Procedure-Controlled Study. J Cardiovasc Transl Res 2023; 16:358-370. [PMID: 36042146 DOI: 10.1007/s12265-022-10307-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 08/18/2022] [Indexed: 10/14/2022]
Abstract
Renal denervation (RDN) is proposed as a durable and patient compliance independent treatment for hypertension. However, 20-30% non-responder after RDN treatment weakened the therapeutic effect, which may be due to blind ablation. The renal nerve mapping/selective ablation system developed by SyMap Medical Ltd (Suzhou), China, has the function of mapping renal sympathetic/parasympathetic nerve sites and selectively removing renal sympathetic nerves and is expected to meet the urgent unmet clinical need of targeted RDN. The "Sympathetic Mapping/Ablation of Renal Nerves Trial" (SMART) is a prospective, multicenter, randomized, single-blinded, sham procedure-controlled trial, to evaluate the safety and efficacy of targeted renal sympathetic denervation in patients with essential and uncontrolled hypertension. The study is the first clinical registry trial using a targeted RDN for the treatment of uncontrolled hypertension; the dual-endpoint design can answer the question of how many antihypertensive drugs can be reduced in patients after RDN. The trial is registered on clinicaltrials.gov NCT02761811.
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Affiliation(s)
- Jie Wang
- Division of Cardiology, Department of Medicine, College of Physician and Surgeons, Columbia University, New York, NY, 10032, USA.
- Academy of Clinical and Translational Research Jiangsu Province, The First Affiliated Hospital With Nanjing Medical University, Nanjing, 210029, China.
| | - Ningling Sun
- Department of Hypertension, Heart Center, Peking University People's Hospital, Beijing, 100044, China
| | - Junbo Ge
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai, 200032, China
| | - Hong Jiang
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, 430060, China
| | - Yuehui Yin
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China
| | - Minglong Chen
- Department of Cardiology, The First Affiliated Hospital With Nanjing Medical University, Nanjing, 210029, China
| | - Yue Wang
- Academy of Clinical and Translational Research Jiangsu Province, The First Affiliated Hospital With Nanjing Medical University, Nanjing, 210029, China
| | - Chen Yao
- Peking University Clinical Research Institute, Beijing, 100191, China
- Department of Biostatistics, Peking University First Hospital, Beijing, 100034, China
| | - Xiaoyan Yan
- Peking University Clinical Research Institute, Beijing, 100191, China
| | | | - Yong Huo
- Division of Cardiology, Peking University First Hospital, Beijing, 100034, China.
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73
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Xiong B, Chen S, Chen W, Yin Y, Ling Z. Advances in Renal Denervation in the Treatment of Hypertension. CARDIOVASCULAR INNOVATIONS AND APPLICATIONS 2023. [DOI: 10.15212/cvia.2023.0014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/03/2023] Open
Abstract
Hypertension significantly increases the risk of cardiovascular events and it is associated with high rates of disability and mortality. Hypertension is a common cause of cardiovascular and cerebrovascular accidents, which severely affect patients’ quality of life and lifespan. Current treatment strategies for hypertension are based primarily on medication and lifestyle interventions. The renal sympathetic nervous system plays an important role in the pathogenesis of hypertension, and catheter-based renal denervation (RDN) has provided a new concept for the treatment of hypertension. In recent years, studies on RDN have been performed worldwide. This article reviews the latest preclinical research and clinical evidence for RDN.
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Liu H, Li Y, Zhou H, Chen W, Xu Y, Du H, Zhang B, Xia T, Li D, Ou Z, Tang R, Chen Q, Zhao B, Yin Y. Renal nerve stimulation identifies renal innervation and optimizes the strategy for renal denervation in canine. J Transl Med 2023; 21:100. [PMID: 36759871 PMCID: PMC9912587 DOI: 10.1186/s12967-023-03919-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 01/25/2023] [Indexed: 02/11/2023] Open
Abstract
BACKGROUND Renal denervation (RDN) was still performed without any intra-procedural method for nerve mapping. Whether renal nerve stimulation (RNS) is an efficient way to identify renal autonomic innervation and optimize the strategy for RDN remain to be worthy for further exploration. METHODS The characteristics of renal autonomic innervation at the sites with different blood pressure (BP) responses to RNS were explored. Then, dogs anatomically eligible for RDN were randomly assigned into elevated BP response ablation group, reduced BP response ablation group, and RNS-control group. The postoperative outcomes were measured at baseline and after 4 weeks follow-up. RESULTS The proportion of afferent sensory nerve was higher at elevated BP response sites (ERS) than reduced BP response sites (RRS) and non-response sites (NRS) (P = 0.012 and P = 0.004). Conversely, the proportion of parasympathetic nerve at RRS was the highest (RRS vs. ERS, P = 0.017; RRS vs. NRS, P = 0.023). More importantly, there was a significant correlation between systolic blood pressure changes and the area ratios of afferent sensory and parasympathetic nerve (R = 0.859; P < 0.001). In addition, ablation at BP-elevation sites can result in a significant decrease in BP and plasma norepinephrine (NE) after 4 weeks (P = 0.002; P = 0.008), while ablation at BP-reduction sites can lead to significant increases in BP and plasma NE (P = 0.016; P = 0.033). CONCLUSIONS RNS is an effective method to identify renal autonomic innervation. It could not only help to identify optimal target sites, but also avoid ablation of sympathetic-inhibitory areas during RDN.
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Affiliation(s)
- Hang Liu
- grid.412461.40000 0004 9334 6536Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China ,Chongqing Cardiac Arrhythmias Therapeutic Service Center, Chongqing, China
| | - Yidan Li
- grid.412461.40000 0004 9334 6536Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China ,Chongqing Cardiac Arrhythmias Therapeutic Service Center, Chongqing, China
| | - Hao Zhou
- grid.412461.40000 0004 9334 6536Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China ,Chongqing Cardiac Arrhythmias Therapeutic Service Center, Chongqing, China
| | - Weijie Chen
- grid.412461.40000 0004 9334 6536Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China ,Chongqing Cardiac Arrhythmias Therapeutic Service Center, Chongqing, China
| | - Yanping Xu
- grid.412461.40000 0004 9334 6536Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China ,Chongqing Cardiac Arrhythmias Therapeutic Service Center, Chongqing, China
| | - Huaan Du
- grid.412461.40000 0004 9334 6536Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China ,Chongqing Cardiac Arrhythmias Therapeutic Service Center, Chongqing, China
| | - Bo Zhang
- grid.412461.40000 0004 9334 6536Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China ,Chongqing Cardiac Arrhythmias Therapeutic Service Center, Chongqing, China
| | - Tianli Xia
- grid.412461.40000 0004 9334 6536Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China ,Chongqing Cardiac Arrhythmias Therapeutic Service Center, Chongqing, China
| | - Dan Li
- grid.412461.40000 0004 9334 6536Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China ,Chongqing Cardiac Arrhythmias Therapeutic Service Center, Chongqing, China
| | - Zhenhong Ou
- grid.412461.40000 0004 9334 6536Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China ,Chongqing Cardiac Arrhythmias Therapeutic Service Center, Chongqing, China
| | - Ruotian Tang
- grid.412461.40000 0004 9334 6536Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China ,Chongqing Cardiac Arrhythmias Therapeutic Service Center, Chongqing, China
| | - Qingsong Chen
- grid.412461.40000 0004 9334 6536Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China ,Chongqing Cardiac Arrhythmias Therapeutic Service Center, Chongqing, China
| | - Binyi Zhao
- grid.412461.40000 0004 9334 6536Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China ,Chongqing Cardiac Arrhythmias Therapeutic Service Center, Chongqing, China
| | - Yuehui Yin
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China. .,Chongqing Cardiac Arrhythmias Therapeutic Service Center, Chongqing, China. .,Chongqing Key Laboratory of Arrhythmia, Chongqing, China.
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Roubsanthisuk W, Kunanon S, Chattranukulchai P, Panchavinnin P, Wongpraparut N, Chaipromprasit J, Pienvichitr P, Ayudhya RKN, Sukonthasarn A. 2022 Renal denervation therapy for the treatment of hypertension: a statement from the Thai Hypertension Society. Hypertens Res 2023; 46:898-912. [PMID: 36759658 PMCID: PMC10073020 DOI: 10.1038/s41440-022-01133-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Revised: 11/18/2022] [Accepted: 11/25/2022] [Indexed: 02/11/2023]
Abstract
Hypertension remains a significant risk factor for major cardiovascular events worldwide. Poor adherence to treatment is extremely common in clinical practice, leading to uncontrolled hypertension. However, some patients with resistant hypertension still have uncontrolled blood pressure despite good medical compliance. A specific group of patients also develop adverse reactions to many blood pressure-lowering medications. These scenarios indicate that innovative strategies to lower blood pressure in challenging cases of hypertension are needed. The blood pressure-lowering efficacy of catheter-based renal denervation therapy to decrease sympathetic tone has been confirmed in many publications in recent years. Apart from both the invasiveness and the expensiveness of this technology, appropriate case selection to undergo this procedure is still developing. The utilization of renal denervation therapy for hypertension treatment in Thailand has lasted for 10 years with a good response in most cases. Currently, only certain interventionists at a few medical schools in Thailand can perform this procedure. However, more physicians are now interested in applying this technology to their patients. The Thai Hypertension Society Committee has reviewed updated information to provide principles for the appropriate utilization of renal denervation therapy. The blood pressure-lowering mechanism, efficacy, suitable patient selection, pre- and postprocedural assessment and procedural safety of renal denervation are included in this statement.
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Affiliation(s)
- Weranuj Roubsanthisuk
- Division of Hypertension, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Sirisawat Kunanon
- Division of Hypertension, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Pairoj Chattranukulchai
- Division of Cardiovascular Medicine, Department of Medicine, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Pariya Panchavinnin
- Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Nattawut Wongpraparut
- Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Jarkarpun Chaipromprasit
- Division of Cardiovascular Medicine, Department of Medicine, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Pavit Pienvichitr
- Division of Cardiology, Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | | | - Apichard Sukonthasarn
- Cardiology Division, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand.
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Lai Y, Zhou H, Chen W, Liu H, Liu G, Xu Y, Du H, Zhang B, Li Y, Woo K, Yin Y. The intrarenal blood pressure modulation system is differentially altered after renal denervation guided by different intensities of blood pressure responses. Hypertens Res 2023; 46:456-467. [PMID: 36202981 DOI: 10.1038/s41440-022-01047-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 08/16/2022] [Accepted: 08/17/2022] [Indexed: 02/07/2023]
Abstract
The aim of this study was to investigate alterations in the intrarenal blood pressure (BP) regulation system after renal denervation (RDN) guided by renal nerve stimulation (RNS). Twenty-one dogs were randomized to receive RDN at strong (SRA group, n = 7) or weak (WRA group, n = 7) BP-elevation response sites identified by RNS or underwent RNS only (RNS-control, RSC, n = 7). After 4 weeks of follow-up, renal sympathetic components, the main components of renin-angiotensin system (RAS) and the major transporters involved in sodium and water reabsorption were assessed by immunohistochemical analysis. Compared with RSC treatment, RDN therapy significantly reduced renal norepinephrine and tyrosine hydroxylase levels, decreased the renin content and inhibited the onsite generation of angiotensinogen. Moreover, the expression of exciting axis components, including angiotensin-converting enzyme (ACE), angiotensin II and angiotensin II type-1 receptor, was downregulated, while protective axis components for the cardiovascular system, including ACE2 and Mas receptors, were upregulated in both WRA and SRA groups. Moreover, RDN reduced the abundance of aquaporin-1 and aquaporin-2 in kidneys. Although RDN had a minimal effect on overall NKCC2 expression, its activation (p-NKCC2) and directional enrichment in the apical membrane (mNKCC2) were dramatically blunted. All these changes were more obvious in the SRA group than WRA group. Selective RDN guided by RNS effectively reduced systemic BP by affecting the renal neurohormone system, as well as the sodium and water transporter system, and these effects at sites with a strong BP response were more superior.
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Affiliation(s)
- Yinchuan Lai
- Department of Cardiology, the Second Affiliated Hospital of Chongqing Medical University, Chongqing Cardiac Arrhythmia Therapeutic Service Center, Chongqing Key Laboratory of Arrhythmia, Chongqing, China
- Department of Cardiology, the Second People's Hospital of Yibin & West China Hospital, Sichuan University Yibin Hospital, Yibin City, Sichuan, China
| | - Hao Zhou
- Department of Cardiology, the Second Affiliated Hospital of Chongqing Medical University, Chongqing Cardiac Arrhythmia Therapeutic Service Center, Chongqing Key Laboratory of Arrhythmia, Chongqing, China
| | - Weijie Chen
- Department of Cardiology, the Second Affiliated Hospital of Chongqing Medical University, Chongqing Cardiac Arrhythmia Therapeutic Service Center, Chongqing Key Laboratory of Arrhythmia, Chongqing, China
| | - Hang Liu
- Department of Cardiology, the Second Affiliated Hospital of Chongqing Medical University, Chongqing Cardiac Arrhythmia Therapeutic Service Center, Chongqing Key Laboratory of Arrhythmia, Chongqing, China
| | - Guangliang Liu
- Department of Cardiology, the Second Affiliated Hospital of Chongqing Medical University, Chongqing Cardiac Arrhythmia Therapeutic Service Center, Chongqing Key Laboratory of Arrhythmia, Chongqing, China
| | - Yanping Xu
- Department of Cardiology, the Second Affiliated Hospital of Chongqing Medical University, Chongqing Cardiac Arrhythmia Therapeutic Service Center, Chongqing Key Laboratory of Arrhythmia, Chongqing, China
| | - Huaan Du
- Department of Cardiology, the Second Affiliated Hospital of Chongqing Medical University, Chongqing Cardiac Arrhythmia Therapeutic Service Center, Chongqing Key Laboratory of Arrhythmia, Chongqing, China
| | - Bo Zhang
- Department of Cardiology, the Second Affiliated Hospital of Chongqing Medical University, Chongqing Cardiac Arrhythmia Therapeutic Service Center, Chongqing Key Laboratory of Arrhythmia, Chongqing, China
| | - Yidan Li
- Department of Cardiology, the Second Affiliated Hospital of Chongqing Medical University, Chongqing Cardiac Arrhythmia Therapeutic Service Center, Chongqing Key Laboratory of Arrhythmia, Chongqing, China
| | - Kamsang Woo
- Institute of Future Cities, the Chinese University of Hong Kong, Hong Kong, China
| | - Yuehui Yin
- Department of Cardiology, the Second Affiliated Hospital of Chongqing Medical University, Chongqing Cardiac Arrhythmia Therapeutic Service Center, Chongqing Key Laboratory of Arrhythmia, Chongqing, China.
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Kandzari DE, Weber MA, Poulos C, Coulter J, Cohen SA, DeBruin V, Jones D, Pathak A. Patient Preferences for Pharmaceutical and Device-Based Treatments for Uncontrolled Hypertension: Discrete Choice Experiment. Circ Cardiovasc Qual Outcomes 2023; 16:e008997. [PMID: 36484251 PMCID: PMC9848220 DOI: 10.1161/circoutcomes.122.008997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Discrete choice experiment is a survey method used to understand how individuals make decisions and to quantify the relative importance of features. Using discrete choice experiment methods, we quantified patient benefit-risk preferences for hypertension treatments, including pharmaceutical and interventional treatments, like renal denervation. METHODS Respondents from the United States with physician-confirmed uncontrolled hypertension selected between treatments involving a procedure or pills, using a structured survey. Treatment features included interventional, noninterventional, or no hypertension treatment; number of daily blood pressure (BP) pills; expected reduction in office systolic BP; duration of effect; and risks of drug side effects, access site pain, or vascular injury. The results of a random-parameters logit model were used to estimate the importance of each treatment attribute. RESULTS Among 400 patients completing the survey between 2020 and 2021, demographics included: 52% women, mean age 59.2±13.0 years, systolic BP 155.1±12.3 mm Hg, and 1.8±0.9 prescribed antihypertensive medications. Reduction in office systolic BP was the most important treatment attribute. The remaining attributes, in decreasing order, were duration of effect, whether treatment was interventional, number of daily pills, risk of vascular injury, and risk of drug side effects. Risk of access site pain did not influence choice. In general, respondents preferred noninterventional over interventional treatments, yet only a 2.3 mm Hg reduction in office systolic BP was required to offset this preference. Small reductions in office systolic BP would offset risks of vascular injury or drug side effects. At least a 20% risk of vascular injury or drug side effects would be tolerated in exchange for improved BP. CONCLUSIONS Reduction in systolic BP was identified as the most important driver of patient treatment preference, while treatment-related risks had less influence. The results indicate that respondents would accept interventional treatments in exchange for modest reductions in systolic BP compared with those observed in renal denervation trials.
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Affiliation(s)
| | | | | | - Joshua Coulter
- RTI Health Solutions, Research Triangle Park, NC, (J.C.)
| | | | | | - Denise Jones
- Medtronic, Santa Rosa, CA (S.A.C., V.D.B., D.J.)
| | - Atul Pathak
- Department of Cardiovascular Medicine, Centre Hospitalier Princese Grace, Monaco (A.P.).,UMR UT CNRS 88 Hypertension and Heart Failure: molecular and clinical investigations. Toulouse, France, INI-CRCT F-CRIN, GREAT Networks (A.P.)
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Kirstein B, Tomala J, Mayer J, Ulbrich S, Wagner M, Pu L, Piorkowski J, Hankel A, Huo Y, Gaspar T, Richter U, Hindricks G, Piorkowski C. Effect of concomitant Renal DeNervation and cardiac ablation on Atrial Fibrillation recurrence - RDN+AF study. J Cardiovasc Electrophysiol 2023; 34:44-53. [PMID: 36259713 DOI: 10.1111/jce.15714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 10/09/2022] [Indexed: 01/18/2023]
Abstract
BACKGROUND Renal denervation (RDN) can reduce cardiac sympathetic activity maintained by arterial hypertension (aHT). Its potential antiarrhythmic effect on rhythm outcome in patients with multi-drug resistant aHT undergoing catheter ablation for atrial fibrillation (AF) is unclear. METHODS The RDN+AF study was a prospective, randomized, two-center trial. Patients with paroxysmal or persistent AF and uncontrolled aHT (mean systolic 24-h ambulatory BP > 135 mmHg) despite taking at least three antihypertensive drugs were enrolled. Patients were 1:2 randomized to either RDN+AF ablation or AF-only ablation. Primary endpoint was freedom from any AF episode > 2 min at 12 months assessed by implantable loop recorder (ILR) or 7d-holter electrocardiogram. Secondary endpoints included rhythm outcome at 24 months, blood pressure control, periprocedural complications, and renovascular safety. RESULTS The study randomized 61 patients (mean age 65 ± 9 years, 53% men). At 12 months, RDN+AF patients tended to have a greater decrease in ambulatory BPs but did not reach statistical significance. No differences in rhythm outcome were observed. Freedom from AF recurrence in the RDN+AF and AF-only group measured 61% versus 53% p = .622 at 12 months and 39% versus 47% p = .927 at 24 months, respectively. Periprocedural complications occurred in 9/61 patients (15%). No patient died. CONCLUSION Among patients with multidrug-resistant aHT and paroxysmal or persistent AF, concomitant RDN+AF ablation was not associated with better blood pressure control or rhythm outcome in comparison to AF-only ablation and medical therapy.
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Affiliation(s)
- Bettina Kirstein
- Department of Rhythmology, University Heart Center Lübeck, University Hospital Schleswig-Holstein, Lübeck, Germany.,Department of Electrophysiology, Heart Center Dresden, TU Dresden, Faculty of Medicine Carl Gustav Carus, Dresden, Germany
| | - Jakub Tomala
- Department of Electrophysiology, Heart Center Dresden, TU Dresden, Faculty of Medicine Carl Gustav Carus, Dresden, Germany
| | - Julia Mayer
- Department of Electrophysiology, Heart Center Dresden, TU Dresden, Faculty of Medicine Carl Gustav Carus, Dresden, Germany
| | - Stefan Ulbrich
- Department of Electrophysiology, Heart Center Dresden, TU Dresden, Faculty of Medicine Carl Gustav Carus, Dresden, Germany
| | - Michael Wagner
- Department of Electrophysiology, Heart Center Dresden, TU Dresden, Faculty of Medicine Carl Gustav Carus, Dresden, Germany
| | - Liying Pu
- Department of Electrophysiology, Heart Center Dresden, TU Dresden, Faculty of Medicine Carl Gustav Carus, Dresden, Germany
| | - Judith Piorkowski
- Department of Electrophysiology, Heart Center Dresden, TU Dresden, Faculty of Medicine Carl Gustav Carus, Dresden, Germany.,Steinbeis Research Center, "Rhythm & Heart", Dresden, Germany
| | | | - Yan Huo
- Department of Electrophysiology, Heart Center Dresden, TU Dresden, Faculty of Medicine Carl Gustav Carus, Dresden, Germany
| | - Thomas Gaspar
- Department of Electrophysiology, Heart Center Dresden, TU Dresden, Faculty of Medicine Carl Gustav Carus, Dresden, Germany
| | - Utz Richter
- Department of Electrophysiology, Heart Center Dresden, TU Dresden, Faculty of Medicine Carl Gustav Carus, Dresden, Germany
| | - Gerhard Hindricks
- Department of Electrophysiology, Heart Center, Leipzig University, Leipzig, Germany
| | - Christopher Piorkowski
- Department of Electrophysiology, Heart Center Dresden, TU Dresden, Faculty of Medicine Carl Gustav Carus, Dresden, Germany.,Steinbeis Research Center, "Rhythm & Heart", Dresden, Germany
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79
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Zeijen VJM, Kroon AA, van den Born BH, Blankestijn PJ, Meijvis SCA, Nap A, Lipsic E, Elvan A, Versmissen J, van Geuns RJ, Voskuil M, Tonino PAL, Spiering W, Deinum J, Daemen J. The position of renal denervation in treatment of hypertension: an expert consensus statement. Neth Heart J 2023; 31:3-11. [PMID: 36001280 PMCID: PMC9807711 DOI: 10.1007/s12471-022-01717-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/01/2022] [Indexed: 01/07/2023] Open
Abstract
Hypertension is an important risk factor for cardiovascular disease. In the Netherlands, there are approximately 2.8 million people with hypertension. Despite treatment recommendations including lifestyle changes and antihypertensive drugs, most patients do not meet guideline-recommended blood pressure (BP) targets. In order to improve BP control and lower the risk of subsequent cardiovascular events, renal sympathetic denervation (RDN) has been introduced and studied as a non-pharmacological approach. While early data on the efficacy of RDN showed conflicting results, improvements in treatment protocols and study design resulted in robust new evidence supporting the potential of the technology to improve patient care in hypertensive subjects. Recently, 5 randomised sham-controlled trials demonstrated the safety and efficacy of the technology. Modelling studies have further shown that RDN is cost-effective in the Dutch healthcare setting. Given the undisputable disease burden along with the shortcomings of current therapeutic options, we postulate a new, clearly framed indication for RDN as an adjunct in the treatment of hypertension. The present consensus statement summarises current guideline-recommended BP targets, proposed workup and treatment for hypertension, and position of RDN for those patients with primary hypertension who do not meet guideline-recommended BP targets (see central illustration).
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Affiliation(s)
- V J M Zeijen
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - A A Kroon
- Department of Internal Medicine, Maastricht University Medical Center & Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
| | - B H van den Born
- Department of Vascular Medicine, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - P J Blankestijn
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, The Netherlands
| | - S C A Meijvis
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, The Netherlands
| | - A Nap
- Department of Cardiology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - E Lipsic
- Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands
| | - A Elvan
- Department of Cardiology, Isala Heart Center, Zwolle, The Netherlands
| | - J Versmissen
- Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - R J van Geuns
- Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - M Voskuil
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - P A L Tonino
- Department of Cardiology, Catharina Hospital, Eindhoven, The Netherlands
| | - W Spiering
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - J Deinum
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - J Daemen
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands.
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80
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Tsioufis PA, Theofilis P, Vlachakis PK, Dimitriadis K, Tousoulis D, Tsioufis K. Novel Invasive Methods as the Third Pillar for the Treatment of Essential Uncontrolled Hypertension. Curr Pharm Des 2023; 29:2780-2786. [PMID: 37641987 DOI: 10.2174/1381612829666230828142346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 07/16/2023] [Accepted: 07/27/2023] [Indexed: 08/31/2023]
Abstract
Pharmacologic therapies remain the treatment of choice for patients with essential hypertension, as endorsed by international guidelines. However, several cases warrant additional modalities, such as invasive antihypertensive therapeutics. The major target of these interventions is the modulation of the sympathetic nervous system, which is a common pathophysiologic mechanism in essential hypertension. In this narrative review, we elaborate on the role of invasive antihypertensive treatments with a focus on renal denervation, stressing their potential as well as the drawbacks that prevent their widespread implementation in everyday clinical practice. In the field of renal denervation, several trials have shown significant and sustained reductions in the level of office and ambulatory blood pressure, regardless of the type of energy that was used (radiofrequency or ultrasound). Critically, renal denervation is considered a safe intervention, as evidenced by follow-up data from large clinical trials. Baroreflex activation therapy may result in enhanced parasympathetic nervous system activation, thus lowering blood pressure levels. Along the same lines, carotid body ablation could also produce a significant antihypertensive effect, which has not been tested in appropriately designed randomized trials. Moreover, cardiac neuromodulation therapy could prove efficacious by altering the duration of the atrioventricular interval in order to regulate the preload of the left ventricle and, therefore, lower blood pressure.
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Affiliation(s)
| | - Panagiotis Theofilis
- First Department of Cardiology, "Hippocration" General Hospital, University of Athens Medical School, Athens, Greece
| | - Panayotis K Vlachakis
- First Department of Cardiology, "Hippocration" General Hospital, University of Athens Medical School, Athens, Greece
| | - Kyriakos Dimitriadis
- First Department of Cardiology, "Hippocration" General Hospital, University of Athens Medical School, Athens, Greece
| | - Dimitris Tousoulis
- First Department of Cardiology, "Hippocration" General Hospital, University of Athens Medical School, Athens, Greece
| | - Konstantinos Tsioufis
- First Department of Cardiology, "Hippocration" General Hospital, University of Athens Medical School, Athens, Greece
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81
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Wang X, Zhao X, Ji C, Liu G, Li X, Guo H. Effect of extensive artery isolation during robotic-assisted partial nephrectomy on blood pressure of patients with poorly controlled hypertension: a preliminary study. Int Urol Nephrol 2023; 55:29-36. [PMID: 36309925 PMCID: PMC9807541 DOI: 10.1007/s11255-022-03384-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 09/29/2022] [Indexed: 01/24/2023]
Abstract
PURPOSE To investigate whether extensive renal artery isolation during robotic-assisted partial nephrectomy (RAPN) for renal cell carcinoma (RCC) affects blood pressure (BP) of patients with poorly controlled hypertension. METHODS We included 60 patients diagnosed with poorly controlled hypertension who underwent RAPN by an experienced surgeon. The renal artery of the treated kidney was sufficiently isolated. Systolic BP (SBP), diastolic BP (DBP) and antihypertensive medication information were obtained at baseline and 3- and 6-month follow-up after surgery. Primary endpoints were changes in BP, and medications. Predictors of SBP reduction at 3 months were assessed by multivariable logistic regression. RESULTS All 60 RAPN procedures were successful, with no major intra- or postoperative complications. Mean SBP and DBP decreased significantly at 3 months after surgery (SBP, -7.8 ± 6.3 mmHg, P < 0.001; DBP, -4.2 ± 6.4 mmHg, P = 0.01). SBP and DBP did not differ between 3- and 6-month follow-up. The mean number of BP medications prescribed was lower at 3 months than baseline (1.7 ± 1.0 vs 2.1 ± 1.0, P = 0.016). The only significant predictor of SBP reduction at 3 months was baseline SBP. CONCLUSIONS Renal denervation with extensive renal artery isolation during RAPN may improve BP control among patients with poorly controlled hypertension in short term.
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Affiliation(s)
- Xin Wang
- grid.41156.370000 0001 2314 964XDepartment of Urology, Drum Tower Hospital, Institute of Urology, Medical School of Nanjing University, Nanjing University, 321 Zhongshan Rd., Nanjing, 210008 Jiangsu People’s Republic of China
| | - Xiaozhi Zhao
- grid.41156.370000 0001 2314 964XDepartment of Urology, Drum Tower Hospital, Institute of Urology, Medical School of Nanjing University, Nanjing University, 321 Zhongshan Rd., Nanjing, 210008 Jiangsu People’s Republic of China
| | - ChangWei Ji
- grid.41156.370000 0001 2314 964XDepartment of Urology, Drum Tower Hospital, Institute of Urology, Medical School of Nanjing University, Nanjing University, 321 Zhongshan Rd., Nanjing, 210008 Jiangsu People’s Republic of China
| | - Guangxiang Liu
- grid.41156.370000 0001 2314 964XDepartment of Urology, Drum Tower Hospital, Institute of Urology, Medical School of Nanjing University, Nanjing University, 321 Zhongshan Rd., Nanjing, 210008 Jiangsu People’s Republic of China
| | - Xiaogong Li
- grid.41156.370000 0001 2314 964XDepartment of Urology, Drum Tower Hospital, Institute of Urology, Medical School of Nanjing University, Nanjing University, 321 Zhongshan Rd., Nanjing, 210008 Jiangsu People’s Republic of China
| | - Hongqian Guo
- grid.41156.370000 0001 2314 964XDepartment of Urology, Drum Tower Hospital, Institute of Urology, Medical School of Nanjing University, Nanjing University, 321 Zhongshan Rd., Nanjing, 210008 Jiangsu People’s Republic of China
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82
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Long-term reduction in morning and nighttime blood pressure after renal denervation: 36-month results from SPYRAL HTN-ON MED trial. Hypertens Res 2023; 46:280-288. [PMID: 36241705 PMCID: PMC9747613 DOI: 10.1038/s41440-022-01042-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 09/06/2022] [Accepted: 09/07/2022] [Indexed: 02/03/2023]
Abstract
Elevated morning and nighttime blood pressures (BP) are associated with increased risk of cardiovascular events such as stroke and myocardial infarction. We compared the long-term changes in morning and nighttime BP in patients with uncontrolled hypertension (office systolic BP between 150 and <180 mmHg/diastolic BP ≥ 90 mmHg; mean ambulatory systolic BP (SBP) between 140 and <170 mmHg; 1-3 prescribed antihypertensive medications). Eighty patients were randomized to RDN or sham control. In patients taking at least 3 antihypertensive medications at 36 months (N = 23 RDN group; N = 23 sham group), the 24 h ambulatory SBP as well as morning (7:00-9:00AM) and nighttime (1:00-6:00AM) ambulatory SBP were significantly lower for the RDN group compared to sham control (24 h SBP: -20.2 vs. -10.2, p = 0.0087; morning SBP: -23.9 vs. -8.0 mmHg, p = 0.029; nighttime SBP: -20.8 vs. -7.2 mmHg, p = 0.0011). At 36 months, 24 h SBP was controlled to <130 mmHg in 40% of RDN patients in the morning compared to 6% for the sham group; P = 0.021 and in 80% of the RDN patients at night compared to 39% in the sham group; P = 0.019. Major adverse events through 36 months were rare in both groups, and there were no renal artery re-interventions or vascular complications. Morning and nighttime SBP were significantly lower in patients prescribed at least 3 antihypertensive medications at 36 months in the SPYRAL HTN-ON MED trial for RDN compared with sham control. The results suggest RDN has significant benefit when the risk of cardiovascular events is highest.
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83
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Wang TD. Consensus and inconsistency between different consensus documents on renal denervation worldwide: the way forward. Chin Med J (Engl) 2022; 135:2926-2937. [PMID: 36103983 PMCID: PMC10106155 DOI: 10.1097/cm9.0000000000002109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Indexed: 01/11/2023] Open
Abstract
ABSTRACT Given the unsatisfactory hypertension control rates and high rates of non-adherence to antihypertensive medications worldwide, device therapy which can safely provide durable blood pressure-lowering effects can fulfill the unmet need. A series of second-generation randomized sham-controlled renal denervation (RDN) trials have demonstrated the efficacy and safety of RDN in a wide range of hypertensive patients. The four representative consensus documents on RDN (from the Chinese Taiwan Hypertension Society and Taiwan Society of Cardiology [THS/TSOC 2019], Asia Renal Denervation Consortium 2019, European Society of Hypertension [ESH 2021], and Society for Cardiovascular Angiography & Intervention and National Kidney Foundation [SCAI/NKF 2021]) consistently recommend RDN as an alternative or complementary treatment strategy for patients with uncontrolled hypertension. In addition, both documents from Asia further recommend that RDN can be considered as an initial treatment strategy for drug-naïve hypertensive patients. There is still inconsistency regarding whether ambulatory blood pressure monitoring should be used routinely both before and after RDN, and whether patients with a secondary cause of hypertension could be treated with RDN if their blood pressure remains uncontrolled after definitive treatment (treatment-resistant secondary hypertension). The THS/TSOC consensus provides acronyms to summarize key aspects of patient selection (RDNi2) and pre-RDN assessments (RAS). The ESH and SCAI/NKF documents recommend establishing structured pathways for clinical practice and issues regarding reimbursement. All documents identify knowledge gaps in RDN, from identifying predictors of super-responders to demonstrating effects on cardiovascular events. These gaps should be urgently filled to facilitate the wider application of this device therapy for patients with hypertension.
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Affiliation(s)
- Tzung-Dau Wang
- Department of Internal Medicine, Cardiovascular Center and Divisions of Cardiology and Hospital Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan 100225, China
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84
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Manukyan M, Falkovskaya A, Mordovin V, Pekarskiy S, Zyubanova I, Solonskaya E, Ryabova T, Khunkhinova S, Vtorushina A, Popov S. Favorable effect of renal denervation on elevated renal vascular resistance in patients with resistant hypertension and type 2 diabetes mellitus. Front Cardiovasc Med 2022; 9:1010546. [PMID: 36601066 PMCID: PMC9806766 DOI: 10.3389/fcvm.2022.1010546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 11/22/2022] [Indexed: 12/15/2022] Open
Abstract
Objective To assess the effect of renal denervation (RDN) on renal vascular resistance and renal function in patients with drug-resistant hypertension (HTN) and type 2 diabetes mellitus (T2DM). Materials and methods Fifty-nine patients (mean age 60.3 ± 7.9 years, 25 men) with resistant HTN [mean 24-h ambulatory blood pressure (BP) 158.0 ± 16.3/82.5 ± 12.7 mmHg, systolic/diastolic] and T2DM (mean HbA1c 7.5 ± 1.5%) were included in the single-arm prospective study and underwent RDN. Renal resistive index (RRI) derived from ultrasound Doppler; estimated glomerular filtration rate (Chronic Kidney Disease Epidemiology Collaboration formula), office and 24-h ambulatory BP were measured at baseline, 6, and 12 months after RDN to evaluate the respective changes in renal vascular resistance, renal function, and BP during treatment. Results Forty-three patients completed 12 months follow-up. The RRI changed depending on the baseline value. Specifically, the RRI decreased significantly in patients with elevated baseline RRI values ≥ 0.7 {n = 23; -0.024 [95% confidence interval (CI): -0.046, -0.002], p = 0.035} and did not change in those with baseline RRI < 0.7 [n = 36; 0.024 (95% CI: -0.002, 0.050), p = 0.069]. No significant change was observed in eGFR whereas BP was significantly reduced at 12 months after RDN by -10.9 (95% CI: -16.7, -5.0)/-5.5 (95% CI: -8.7, -2.4) mmHg, systolic/diastolic. No relationship was found between the changes in RRI and BP. Conclusion Our study shows that RDN can decrease elevated renal vascular resistance (RRI > 0.7) and stabilize kidney function in patients with RHTN and T2DM independently of its BP-lowering effect.
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85
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Hanssen TA, Subbotina A, Miroslawska A, Solbu MD, Steigen TK. Quality of life following renal sympathetic denervation in treatment-resistant hypertensive patients: a two-year follow-up study. SCAND CARDIOVASC J 2022; 56:174-179. [PMID: 35686551 DOI: 10.1080/14017431.2022.2084562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Objective. Hypertension is a significant health burden. In the last 10 years, renal sympathetic denervation has been tested as a potential treatment option for a select group of patients with treatment-resistant hypertension. The aim of this study was to broadly assess the quality of life in patients undergoing renal sympathetic denervation with two years' follow-up. Materials and methods. Patients with treatment-resistant hypertension being treated by hypertension specialists were eligible for inclusion in this study. Bilateral renal sympathetic denervation was performed with the Symplicity Catheter System. Quality of life was measured using standardised questionnaires (Short Form 36, 15 D and a single-item question) and an open question before denervation, after six months and after two years. Results. A total of 23 patients were included. The typical participant was male, 53 years, had a mean office blood pressure of 162/108 mmHg, body mass index of 32 kg/m2, and was prescribed 4.8 blood pressure lowering drug classes. At baseline, both physical and mental aspects of quality of life were affected negatively by the treatment-resistant hypertension. Over time, there were modest improvements in quality of life. The largest improvements were seen at six months. Simultaneously, the mean number of blood pressure lowering drug classes was reduced to 4.2. Conclusion. Following renal sympathetic denervation treatment, some aspects of health related quality of life showed an improved trend during follow-up. The observed improvement may reflect the impact of a reduced number of blood pressure lowering drug classes. Clinical Trial Number registered: NCT01630928.
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Affiliation(s)
- Tove Aminda Hanssen
- Department of Cardiology, University Hospital of North Norway, Tromsø, Norway.,Department of Health and Care Sciences, UiT The Arctic University of Norway, Tromsø, Norway
| | - Anna Subbotina
- Clinical Cardiovascular Research Group, UiT The Arctic University of Norway, Tromsø, Norway
| | - Atena Miroslawska
- Department of Cardiology, University Hospital of North Norway, Tromsø, Norway.,Clinical Cardiovascular Research Group, UiT The Arctic University of Norway, Tromsø, Norway
| | - Marit Dahl Solbu
- Section of Nephrology, University Hospital of North Norway, Tromsø, Norway.,Metabolic and Renal Research Group, UiT The Arctic University of Norway, Tromsø, Norway
| | - Terje Kristian Steigen
- Department of Cardiology, University Hospital of North Norway, Tromsø, Norway.,Clinical Cardiovascular Research Group, UiT The Arctic University of Norway, Tromsø, Norway
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Yang X, Lin L, Zhang Z, Chen X. Effects of catheter-based renal denervation on renin-aldosterone system, catecholamines, and electrolytes: A systematic review and meta-analysis. J Clin Hypertens (Greenwich) 2022; 24:1537-1546. [PMID: 36321724 PMCID: PMC9731592 DOI: 10.1111/jch.14590] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 08/26/2022] [Accepted: 10/03/2022] [Indexed: 11/07/2022]
Abstract
In recent years, catheter-based renal denervation (RDN) has emerged as a promising instrumental therapy for hypertension. The interruption of sympathetic nervous system was regarded as a possible mechanism for RDN regulating blood pressure. While the results reflected by renin-angiotensin-aldosterone system (RAAS), catecholamines and electrolytes remained inconsistent and was never systematically assessed. Pubmed, Embase, and Web of Science were comprehensively searched from inception to September 5, 2021. Studies that evaluated the effects of RDN on RAAS, catecholamines, and electrolytes were identified. Primary outcomes were changes in RAAS hormones after RDN, and secondary outcomes involved changes in plasma norepinephrine, serum, and urinary sodium and potassium. Out of 6391 retrieved studies, 20 studies (two randomized controlled studies and 18 observational studies) involving 771 persons were eventually included. Plasma renin activity had a statistically significant reduction after RDN (0.24 ng/mL/h, 95% CI 0.04 to 0.44, P = .02). While no significant change was found regarding plasma aldosterone (1.53 ng/dL, 95% CI -0.61 to 3.67, P = .16), norepinephrine (0.42 nmol/L, 95% -0.51 to 1.35, P = 0.38), serum sodium and potassium (0.16 mmol/L, 95% CI -0.17 to 0.49, P = .34; -0.02 mmol/L, 95% CI -0.09 to 0.04, P = .48, respectively), and urinary sodium and potassium (3.95 mmol/24 h, 95% CI -29.36 to 37.26, P = .82; 10.22 mmol/24 h, 95% CI -12.11 to 32.54, P = .37, respectively). In conclusion, plasma renin activity significantly decreased after RDN, while no significant change was observed in plasma aldosterone, plasma norepinephrine, and serum and urinary electrolytes.
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Affiliation(s)
- Xiangyu Yang
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Lede Lin
- Department of Urology, West China Hospital, Sichuan University, Chengdu, China
| | - Zhipeng Zhang
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Xiaoping Chen
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
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87
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Rea F, Morabito G, Savaré L, Corrao G, Mancia G. The impact of renal denervation procedure on use of antihypertensive drugs in the real-life setting. Blood Press 2022; 31:245-253. [PMID: 36146925 DOI: 10.1080/08037051.2022.2126345] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Purpose. Randomised controlled trials have shown that renal denervation lowers office and ambulatory blood pressure. The aim of the present study was to evaluate whether patients undergoing renal denervation procedure in a real-life setting have a reduction in antihypertensive drug prescription over the subsequent years.Material and methods. Using the healthcare utilisation database of the Lombardy Region (Italy), the 136 patients who, during the period 2011-2016, were prescribed four or more antihypertensive drugs and underwent renal denervation were included in the study cohort. The number and type of antihypertensive drugs were assessed over the year before and during the three-year period after renal denervation.Results. The median age of the patients was 67 years and 68% of them were men. Based on a multisource comorbidity score, about 40% of patients showed a poor or very poor clinical status. Before renal denervation, the majority of the patients were prescribed four or five antihypertensive drugs. The number of drugs decreased after the denervation and reached 55% after three years. Over the same period, patients prescribed six drugs decreased from 18% to 2%. All antihypertensive drugs were less prescribed throughout the post denervation period. Compared to the year before the denervation, after three years prescription of diuretics was reduced by 15%, calcium channel blockers by 21%, ACE-inhibitors by 32%, angiotensin receptor blockers by 22%, beta-blockers by 20%, and alfa-blockers by 30%. Use of antihypertensive drugs exhibited a reduction also in an age, sex, and clinically matched control group with no renal denervation to an extent, however, much lower than in denervated patients (p-value = 0.013).Conclusion. In the real-life setting, patients who underwent renal denervation had a clearcut reduction in antihypertensive drug prescription over the following years.Plain Language SummaryPatients exhibited a reduction in the prescription of antihypertensive drugs during the three years that followed the denervation procedureThe decrease in the number of antihypertensive drugs was marked, started after a relatively short time (six months), and involved all drugs prescribed before the denervationThe number of hospitalisations for a cardiovascular event was similar before and after renal denervationAlbeit blood pressure values were not recorded in our database, all these findings taken together suggest the renal denervation procedure has a favourable influence on blood pressure control and is not associated with an increase in the risk of major cardiovascular complications.
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Affiliation(s)
- Federico Rea
- National Centre for Healthcare Research and Pharmacoepidemiology, University of Milano-Bicocca, Milan, Italy.,Laboratory of Healthcare Research and Pharmacoepidemiology, Unit of Biostatistics, Epidemiology and Public Health, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy
| | - Gabriella Morabito
- National Centre for Healthcare Research and Pharmacoepidemiology, University of Milano-Bicocca, Milan, Italy.,Laboratory of Healthcare Research and Pharmacoepidemiology, Unit of Biostatistics, Epidemiology and Public Health, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy
| | - Laura Savaré
- National Centre for Healthcare Research and Pharmacoepidemiology, University of Milano-Bicocca, Milan, Italy.,MOX - Laboratory for Modeling and Scientific Computing, Department of Mathematics, Politecnico di Milano, Milan, Italy.,CHDS - Center for Health data Science, Human Technopole, Milan, Italy
| | - Giovanni Corrao
- National Centre for Healthcare Research and Pharmacoepidemiology, University of Milano-Bicocca, Milan, Italy.,Laboratory of Healthcare Research and Pharmacoepidemiology, Unit of Biostatistics, Epidemiology and Public Health, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy
| | - Giuseppe Mancia
- University of Milano-Bicocca (Emeritus Professor), Milan, Italy
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88
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Jami O, Tijani Y, Et-Tahir A. Device-Based Therapy for Resistant Hypertension: An Up-to-Date Review. High Blood Press Cardiovasc Prev 2022; 29:537-546. [PMID: 36178479 PMCID: PMC9523625 DOI: 10.1007/s40292-022-00539-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Accepted: 08/23/2022] [Indexed: 11/29/2022] Open
Abstract
Hypertension is the major risk factor for cardiovascular morbidity and mortality. Matter of fact, untreated hypertension can worsen the overall health, whereas pharmacotherapy can play an important role in lowering the risk of high blood pressure in hypertensive patients. However, persistent uncontrolled hypertension remains an unsolved condition characterized by non-adherence to medication and increased sympathetic activity. This paper will review the non-pharmacological treatments for resistant hypertension (RH) that have emerged in recent years. In addition, the technologies developed in device-based RH therapy, as well as the clinical trials that support their use, will be discussed. Indeed, the novel device-based approaches that target RH present a promising therapy which has been supported by several studies and clinical trials, whereas drug non-adherence and high sympathetic activity are known to be the main causes of RH. Nevertheless, some additional aspects of these RH systems need to be tested in the near future, with a particular focus on the device's design and availability of randomized controlled trials.
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Affiliation(s)
- Oussama Jami
- High School of Technology in Salé, Materials, Energy and Acoustics Team Rabat, Mohammed V University in Rabat, Rabat, Morocco.
- Biomedical Engineering Department, Mohammed VI University of Health Sciences, Casablanca, Morocco.
| | - Youssef Tijani
- Faculty of Medicine, Mohammed VI University of Health Sciences, Casablanca, Morocco
| | - Aziz Et-Tahir
- High School of Technology in Salé, Materials, Energy and Acoustics Team Rabat, Mohammed V University in Rabat, Rabat, Morocco
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Heradien M, Mahfoud F, Greyling C, Lauder L, van der Bijl P, Hettrick DA, Stilwaney W, Sibeko S, Jansen van Rensburg R, Peterson D, Khwinani B, Goosen A, Saaiman JA, Ukena C, Böhm M, Brink PA. Renal denervation prevents subclinical atrial fibrillation in patients with hypertensive heart disease: Randomized, sham-controlled trial. Heart Rhythm 2022; 19:1765-1773. [PMID: 35781044 DOI: 10.1016/j.hrthm.2022.06.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 06/09/2022] [Accepted: 06/26/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND Catheter-based renal denervation (RD), in addition to pulmonary vein isolation (PVI), reduces atrial fibrillation (AF) recurrence in hypertensive patients. Whether RD, without additional PVI, can prevent subclinical atrial fibrillation (SAF) in patients with hypertensive heart disease (HHD) is unknown. OBJECTIVE The purpose of this study was to assess the efficacy of RD in preventing SAF in patients with HHD. METHODS A single-center, randomized, sham-controlled pilot trial, including patients >55 years in sinus rhythm, but with a high risk of developing SAF was conducted. Patients had uncontrolled hypertension despite taking 3 antihypertensive drugs, including a diuretic. The primary endpoint was the first SAF episode lasting ≥6 minutes recorded via an implantable cardiac monitor scanned every 6 months for 24 months. A blinded independent monitoring committee assessed electrocardiographic rhythm recordings. Change in SAF burden (SAFB), and office and 24-hour ambulatory blood pressure (BP) at 6-month follow-up were secondary endpoints. RESULTS Eighty patients were randomly assigned to RD (n = 42) or sham groups (n = 38). After 24 months of follow-up, SAF occurred in 8 RD patients (19%) and 15 sham patients (39.5%) (hazard ratio 0.40; 95% confidence interval 0.17-0.96; P = .031). Median [interquartile range] SAFB was low in both groups but was significantly lower in the RD vs sham group (0% [0-0] vs 0% [0-0.3]; P = .043). Fast AF (>100 bpm) occurred less frequently in the RD than sham group (2% vs 26%; P = .002). After adjusting for baseline values, there were no significant differences in office or 24-hour BP changes between treatment groups. CONCLUSION RD reduced incident SAF events, SAFB, and fast AF in patients with HHD. The observed effects may occur independent of BP lowering.
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Affiliation(s)
- Marshall Heradien
- Department of Medicine, Stellenbosch University, Tygerberg, South Africa; SA Endovascular, Netcare Kuils River Hospital, Cape Town, South Africa.
| | - Felix Mahfoud
- Department of Internal Medicine III, Cardiology, Angiology, Intensive Care Medicine, Saarland University Hospital, Homburg/Saar, Germany
| | | | - Lucas Lauder
- Department of Internal Medicine III, Cardiology, Angiology, Intensive Care Medicine, Saarland University Hospital, Homburg/Saar, Germany
| | | | | | - Warren Stilwaney
- Department of Medicine, Stellenbosch University, Tygerberg, South Africa
| | - Siyolise Sibeko
- Department of Medicine, Stellenbosch University, Tygerberg, South Africa
| | | | - Dale Peterson
- Department of Medicine, Stellenbosch University, Tygerberg, South Africa
| | - Bonke Khwinani
- SA Endovascular, Netcare Kuils River Hospital, Cape Town, South Africa
| | - Althea Goosen
- Department of Medicine, Stellenbosch University, Tygerberg, South Africa; SA Endovascular, Netcare Kuils River Hospital, Cape Town, South Africa
| | - Jan A Saaiman
- SA Endovascular, Netcare Kuils River Hospital, Cape Town, South Africa
| | - Christian Ukena
- Department of Internal Medicine III, Cardiology, Angiology, Intensive Care Medicine, Saarland University Hospital, Homburg/Saar, Germany
| | - Michael Böhm
- Department of Internal Medicine III, Cardiology, Angiology, Intensive Care Medicine, Saarland University Hospital, Homburg/Saar, Germany
| | - Paul A Brink
- Department of Medicine, Stellenbosch University, Tygerberg, South Africa; SA Endovascular, Netcare Kuils River Hospital, Cape Town, South Africa
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Mahfoud F, Mancia G, Schmieder RE, Ruilope L, Narkiewicz K, Schlaich M, Williams B, Ribichini F, Weil J, Kao HL, Rodriguez-Leor O, Noory E, Ong TK, Unterseeh T, de Araújo Gonçalves P, Zirlik A, Almerri K, Sharif F, Lauder L, Wanten M, Fahy M, Böhm M. Cardiovascular Risk Reduction After Renal Denervation According to Time in Therapeutic Systolic Blood Pressure Range. J Am Coll Cardiol 2022; 80:1871-1880. [DOI: 10.1016/j.jacc.2022.08.802] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 08/12/2022] [Accepted: 08/29/2022] [Indexed: 11/09/2022]
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91
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Bhatt DL, Vaduganathan M, Kandzari DE, Leon MB, Rocha-Singh K, Townsend RR, Katzen BT, Oparil S, Brar S, DeBruin V, Fahy M, Bakris GL. Long-term outcomes after catheter-based renal artery denervation for resistant hypertension: final follow-up of the randomised SYMPLICITY HTN-3 Trial. Lancet 2022; 400:1405-1416. [PMID: 36130612 DOI: 10.1016/s0140-6736(22)01787-1] [Citation(s) in RCA: 72] [Impact Index Per Article: 36.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 09/02/2022] [Accepted: 09/06/2022] [Indexed: 01/02/2023]
Abstract
BACKGROUND The SYMPLICITY HTN-3 (Renal Denervation in Patients With Uncontrolled Hypertension) trial showed the safety but not efficacy of the Symplicity system (Medtronic, Santa Rosa, CA, USA) at 6 months follow-up in patients with treatment-resistant hypertension. This final report presents the 36-month follow-up results. METHODS SYMPLICITY HTN-3 was a single-blind, multicentre, sham-controlled, randomised clinical trial, done in 88 centres in the USA. Adults aged 18-80 years, with treatment-resistant hypertension on stable, maximally tolerated doses of three or more drugs including a diuretic, who had a seated office systolic blood pressure of 160 mm Hg or more and 24 h ambulatory systolic blood pressure of 135 mm Hg or more were randomly assigned (2:1) to receive renal artery denervation using the single electrode (Flex) catheter or a sham control. The original primary endpoint was the change in office systolic blood pressure from baseline to 6 months for the renal artery denervation group compared with the sham control group. Patients were unmasked after the primary endpoint assessment at 6 months, at which point eligible patients in the sham control group who met the inclusion criteria (office blood pressure ≥160 mm Hg, 24 h ambulatory systolic blood pressure ≥135 mm Hg, and still prescribed three or more antihypertensive medications) could cross over to receive renal artery denervation. Changes in blood pressure up to 36 months were analysed in patients in the original renal artery denervation group and sham control group, including those who underwent renal artery denervation after 6 months (crossover group) and those who did not (non-crossover group). For comparisons between the renal artery denervation and sham control groups, follow-up blood pressure values were imputed for patients in the crossover group using their most recent pre-crossover masked blood pressure value. We report long-term blood pressure changes in renal artery denervation and sham control groups, and investigate blood pressure control in both groups using time in therapeutic blood pressure range analysis. The primary safety endpoint was the incidence of all-cause mortality, end stage renal disease, significant embolic event, renal artery perforation or dissection requiring intervention, vascular complications, hospitalisation for hypertensive crisis unrelated to non-adherence to medications, or new renal artery stenosis of more than 70% within 6 months. The trial is registered with ClinicalTrials.gov, NCT01418261. FINDINGS From Sep 29, 2011, to May 6, 2013, 1442 patients were screened, of whom 535 (37%; 210 [39%] women and 325 [61%] men; mean age 57·9 years [SD 10·7]) were randomly assigned: 364 (68%) patients received renal artery denervation (mean age 57·9 years [10·4]) and 171 (32%) received the sham control (mean age 56·2 years [11·2]). 36-month follow-up data were available for 219 patients (original renal artery denervation group), 63 patients (crossover group), and 33 patients (non-crossover group). At 36 months, the change in office systolic blood pressure was -26·4 mm Hg (SD 25·9) in the renal artery denervation group and -5·7 mm Hg (24·4) in the sham control group (adjusted treatment difference -22·1 mm Hg [95% CI -27·2 to -17·0]; p≤0·0001). The change in 24 h ambulatory systolic blood pressure at 36 months was -15·6 mm Hg (SD 20·8) in the renal artery denervation group and -0·3 mm Hg (15·1) in the sham control group (adjusted treatment difference -16·5 mm Hg [95% CI -20·5 to -12·5]; p≤0·0001). Without imputation, the renal artery denervation group spent a significantly longer time in therapeutic blood pressure range (ie, better blood pressure control) than patients in the sham control group (18% [SD 25·0] for the renal artery denervation group vs 9% [SD 18·8] for the sham control group; p≤0·0001) despite a similar medication burden, with consistent and significant results with imputation. Rates of adverse events were similar across treatment groups, with no evidence of late-emerging complications from renal artery denervation. The rate of the composite safety endpoint to 48 months, including all-cause death, new-onset end-stage renal disease, significant embolic event resulting in end-organ damage, vascular complication, renal artery re-intervention, and hypertensive emergency was 15% (54 of 352 patients) for the renal artery denervation group, 14% (13 of 96 patients) for the crossover group, and 14% (10 of 69 patients) for the non-crossover group. INTERPRETATION This final report of the SYMPLICITY HTN-3 trial adds to the totality of evidence supporting the safety of renal artery denervation to 36 months after the procedure. From 12 months to 36 months after the procedure, patients who were originally randomly assigned to receive renal artery denervation had larger reductions in blood pressure and better blood pressure control compared with patients who received sham control. FUNDING Medtronic.
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Affiliation(s)
- Deepak L Bhatt
- Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, MA, USA.
| | - Muthiah Vaduganathan
- Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, MA, USA
| | | | - Martin B Leon
- New York Presbyterian Hospital, Columbia University Medical Center, and Cardiovascular Research Foundation, New York, NY, USA
| | | | - Raymond R Townsend
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Suzanne Oparil
- University of Alabama at Birmingham, Birmingham, AL, USA
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Rader F, Kirtane AJ, Wang Y, Daemen J, Lurz P, Sayer J, Saxena M, Levy T, Scicli AP, Thackeray L, Azizi M, Weber MA. Durability of blood pressure reduction after ultrasound renal denervation: three-year follow-up of the treatment arm of the randomised RADIANCE-HTN SOLO trial. EUROINTERVENTION 2022; 18:e677-e685. [PMID: 35913759 PMCID: PMC10241283 DOI: 10.4244/eij-d-22-00305] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 06/28/2022] [Indexed: 08/16/2023]
Abstract
BACKGROUND While the blood pressure (BP)-lowering effect of renal denervation (RDN) has been established, long-term durability is a key prerequisite for a broader clinical implementation. AIMS Our aims were to assess the long-term durability of the office BP (OBP)-lowering efficacy, antihypertensive medication (AHM) use, and safety of ultrasound RDN (uRDN). METHODS Four weeks after withdrawal of AHM, patients with untreated daytime ambulatory BP ≥135/85 mmHg and <170/105 mmHg were randomised to uRDN (n=74) or sham (n=72) in the RADIANCE-HTN SOLO trial. Initiation of AHM was encouraged for home BP >135/85 mmHg following primary endpoint ascertainment at 2 months. Patients and physicians were unblinded at 6 months. Results: Fifty-one of 74 patients (age: 53.9±11 years; 67% men) originally randomised to uRDN completed the 36-month follow-up. Initial screening OBP upon study entry was 145/92±14/10 mmHg on a mean of 1.2 AHM (range: 0-2.0). Baseline OBP after AHM washout was 154/99±13/8 mmHg. At 36 months, patients were on an average of 1.3 AHM (range: 0-3.0) with 8 patients on no AHM. OBP decreased by 18/11±15/9 mmHg from baseline to 36 months (p<0.001 for both). Overall, OBP control (<140/90 mmHg) improved from 29.4% at screening to 45.1% at 36 months (p=0.059). For patients uncontrolled at screening (n=36), systolic OBP decreased by 10.8 mmHg (p<0.001) at 36 months on similar AHM (p=0.158). CONCLUSIONS The safety and effectiveness of uRDN was durable to 36 months, with reduced OBP and improved OBP control despite a similar starting medication burden. No new uRDN-related long-term safety concerns were identified.
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Affiliation(s)
- Florian Rader
- Cedars-Sinai Smidt Heart Institute, Los Angeles, CA, USA
| | - Ajay J Kirtane
- Columbia University Medical Center/New York-Presbyterian Hospital and the Cardiovascular Research Foundation, New York, NY, USA
| | - Yale Wang
- Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Joost Daemen
- Erasmus MC, University Medical Center Rotterdam, Department of Cardiology, Rotterdam, the Netherlands
| | - Philipp Lurz
- Department of Internal Medicine/Cardiology, Heart Center Leipzig, University of Leipzig, Leipzig, Germany
| | | | - Manish Saxena
- Barts NIHR Biomedical Research Centre, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Terry Levy
- Royal Bournemouth Hospital, Bournemouth, UK
| | | | | | - Michel Azizi
- Université de Paris, Paris, France; AP-HP, Hôpital Européen Georges-Pompidou, Hypertension Department and DMU CARTE, Paris, France; INSERM, CIC1418, Paris, France
| | - Michael A Weber
- Division of Cardiovascular Medicine, State University of New York, Downstate Medical Center, New York, NY, USA
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Fengler K, Rommel KP, Kriese W, Kresoja KP, Blazek S, Obradovic D, Feistritzer HJ, Lücke C, Gutberlet M, Desch S, Thiele H, Lurz P. Assessment of arterial stiffness to predict blood pressure response to renal sympathetic denervation. EUROINTERVENTION 2022; 18:e686-e694. [PMID: 35244604 PMCID: PMC10241279 DOI: 10.4244/eij-d-21-01036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 02/02/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND Recent trials support the efficacy of renal sympathetic denervation (RDN) to reduce blood pressure (BP). Nevertheless, about one third of patients are considered non-responders to RDN. Previous retrospective analyses suggest arterial stiffness could predict BP response to RDN. AIMS We prospectively assessed the potential of invasive pulse wave velocity (iPWV) to predict BP response to RDN. Additionally, we aimed to establish non-invasive models based on arterial stiffness to predict BP response to RDN. METHODS iPWV, magnetic resonance imaging-based markers of arterial stiffness and the carotid-femoral pulse wave velocity were recorded prior to RDN in patients with treatment resistant hypertension. Changes in daytime BP after 3 months were analysed according to the prespecified iPWV cut-off (14.4 m/s). Regression analyses were used to establish models for non-invasive prediction of BP response. Results were compared to iPWV as reference and were then validated in an external patient cohort. RESULTS Eighty patients underwent stiffness assessment before RDN. After 3 months, systolic 24h and daytime BP were reduced by 13.6±9.8 mmHg and 14.7±10.6 mmHg in patients with low iPWV, versus 6.2±13.3 mmHg and 6.3±12.8 mmHg in those with high iPWV (p<0.001 for both). Upon regression analysis, logarithmic ascending aortic distensibility and systolic baseline BP independently predicted BP change at follow-up. Both were confirmed in the validation cohort. CONCLUSIONS iPWV is an independent predictor for BP response after RDN. In addition, BP change prediction following RDN using non-invasive measures is feasible. This could facilitate patient selection for RDN treatment.
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Affiliation(s)
- Karl Fengler
- Department of Cardiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
- Leipzig Heart Institute, Leipzig, Germany
| | - Karl-Philipp Rommel
- Department of Cardiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
- Leipzig Heart Institute, Leipzig, Germany
| | - Wenzel Kriese
- Department of Cardiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
- Leipzig Heart Institute, Leipzig, Germany
| | - Karl-Patrik Kresoja
- Department of Cardiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
- Leipzig Heart Institute, Leipzig, Germany
| | - Stephan Blazek
- Department of Cardiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
- Leipzig Heart Institute, Leipzig, Germany
| | - Danilo Obradovic
- Department of Cardiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
- Leipzig Heart Institute, Leipzig, Germany
| | - Hans-Josef Feistritzer
- Department of Cardiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
- Leipzig Heart Institute, Leipzig, Germany
| | - Christian Lücke
- Leipzig Heart Institute, Leipzig, Germany
- Department of Interventional and Diagnostic Radiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Matthias Gutberlet
- Leipzig Heart Institute, Leipzig, Germany
- Department of Interventional and Diagnostic Radiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Steffen Desch
- Department of Cardiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
- Leipzig Heart Institute, Leipzig, Germany
| | - Holger Thiele
- Department of Cardiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
- Leipzig Heart Institute, Leipzig, Germany
| | - Philipp Lurz
- Department of Cardiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
- Leipzig Heart Institute, Leipzig, Germany
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Messerli FH, Bavishi C, Brguljan J, Burnier M, Dobner S, Elijovich F, Ferdinand KC, Kjeldsen S, Laffer CL, S Ram CV, Rexhaj E, Ruilope LM, Shalaeva EV, Siontis GC, Staessen JA, Textor SC, Vongpatanasin W, Vogt L, Volpe M, Wang J, Williams B. Renal denervation in the antihypertensive arsenal - knowns and known unknowns. J Hypertens 2022; 40:1859-1875. [PMID: 36052518 PMCID: PMC10010701 DOI: 10.1097/hjh.0000000000003171] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Revised: 03/26/2022] [Accepted: 03/26/2022] [Indexed: 01/21/2023]
Abstract
Even though it has been more than a decade since renal denervation (RDN) was first used to treat hypertension and an intense effort on researching this therapy has been made, it is still not clear how RDN fits into the antihypertensive arsenal. There is no question that RDN lowers blood pressure (BP), it does so to an extent at best corresponding to one antihypertensive drug. The procedure has an excellent safety record. However, it remains clinically impossible to predict whose BP responds to RDN and whose does not. Long-term efficacy data on BP reduction are still unconvincing despite the recent results in the SPYRAL HTN-ON MED trial; experimental studies indicate that reinnervation is occurring after RDN. Although BP is an acceptable surrogate endpoint, there is complete lack of outcome data with RDN. Clear indications for RDN are lacking although patients with resistant hypertension, those with documented increase in activity of the sympathetic system and perhaps those who desire to take fewest medication may be considered.
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Affiliation(s)
- Franz H. Messerli
- Department of BioMedical Research, University of Bern, Bern, Switzerland
- Jagiellonian University Krakow, Krakow, Poland
| | - Chirag Bavishi
- Department of Cardiology, University of Missouri, Columbia, Missouri, USA
| | - Jana Brguljan
- University Medical Centre Ljubljana, Department of Hypertension, Medical University Ljubljana, Slovenia
| | - Michel Burnier
- University of Lausanne. Faculty of Biology and Medicine, Lausanne, Switzerland
| | - Stephan Dobner
- Department of Cardiology, Bern University Hospital University of Bern, Bern, Switzerland
| | - Fernando Elijovich
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University, USA
| | | | - Sverre Kjeldsen
- Department of Cardiology, University of Oslo Hospital, Oslo, Norway
| | - Cheryl L. Laffer
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - C. Venkata S Ram
- Apollo Hospitals and Medical College, Hyderabad, Telangana, India
| | - Emrush Rexhaj
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland
- Department of BioMedical Research, University of Bern, Bern, Switzerland
| | - Luis M. Ruilope
- Cardiorenal Translational Laboratory and Hypertension Unit, Institute of Research i+12, CIBER-CV, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Evgeniya V. Shalaeva
- Division of Public Health Science, Westminster International University in Tashkent, Tashkent, Uzbekistan
- Department of Cardiology, Tashkent Medical Academy, Tashkent, Uzbekistan
| | - George C.M. Siontis
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jan A. Staessen
- NPO Research Institute Alliance for the Promotion of Preventive Medicine, Mechelen, Belgium
- Biomedical Science Group, Faculty of Medicine, Leuven, Belgium
| | - Stephen C. Textor
- Division of Hypertension and Nephrology, Mayo Clinic, Rochester, Minnesota, USA
| | - Wanpen Vongpatanasin
- Hypertension Section, Cardiology Division, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Liffert Vogt
- Department of Internal Medicine, section Nephrology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Massimo Volpe
- Department of Clinical and Molecular Medicine, University of Rome Sapienza, Rome, Italy
| | - Jiguang Wang
- The Shanghai Institute of Hypertension, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Bryan Williams
- Institute of Cardiovascular Science, University College London, London, United Kingdom
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Narita K, Hoshide S, Kario K. The role of blood pressure management in stroke prevention: current status and future prospects. Expert Rev Cardiovasc Ther 2022; 20:829-838. [PMID: 36245101 DOI: 10.1080/14779072.2022.2137490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 10/14/2022] [Indexed: 10/31/2022]
Abstract
INTRODUCTION Stroke is the second-leading cause of death worldwide and the second-leading cause of disability-adjusted life-years. It is well known that hypertension is a significant risk factor for cardiovascular events, including stroke. AREAS COVERED Recent interventional trials have demonstrated the superiority of intensive blood pressure (BP) control for prevention of cardiovascular events compared to standard BP control. Notably, in the Strategy of Blood Pressure Intervention in Elderly Hypertensive Patients (STEP) trial, intensive BP control showed superiority in the prevention of stroke events in elderly hypertensive patients. Novel medications such as angiotensin receptor-neprilysin inhibitors and sodium glucose cotransporter 2 inhibitors have the potential to suppress various CVD events including stroke. Non-pharmacological antihypertensive therapies such as renal denervation have demonstrated BP-lowering effects and may be useful for stroke prevention. Additionally, new methods and systems of BP monitoring including various kinds of nighttime BP measurement devices, wearable devices, and methods using information and communication technology can be used to assess the pathophysiology of BP variability as a risk factor and an event trigger of stroke incidence. EXPERT OPINION Novel therapies and new technologies for BP evaluation strongly support the development of individualized anticipatory medicine, which should be useful for the prevention of stroke.
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Affiliation(s)
- Keisuke Narita
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Tochigi, Japan
| | - Satoshi Hoshide
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Tochigi, Japan
| | - Kazuomi Kario
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Tochigi, Japan
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96
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Guber K, Kirtane AJ. Renal Sympathetic Denervation for Hypertension. Kidney Int Rep 2022; 7:2129-2140. [PMID: 36217529 PMCID: PMC9546727 DOI: 10.1016/j.ekir.2022.06.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 05/16/2022] [Accepted: 06/27/2022] [Indexed: 12/01/2022] Open
Abstract
Arterial hypertension is the most prevalent global modifiable risk factor for cardiovascular morbidity and mortality. Despite the availability of numerous pharmacologic treatments, many patients do not achieve guideline-recommended blood pressure targets. Therefore, renal sympathetic denervation (RDN), a process in which catheter-directed techniques are used to ablate portions of the renal artery to reduce sympathetic activity, has been extensively investigated as a complementary and nonpharmacologic approach for the treatment of arterial hypertension. This review seeks to discuss the pathophysiological rationale of this strategy, to survey its history and development, and to highlight the current clinical evidence and possible future directions of its employment. In sum, RDN has demonstrated itself to be a safe and well-tolerated endovascular intervention that can reliably contribute to improved blood pressure control and, perhaps ultimately, significant cardiovascular prognosis.
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Affiliation(s)
- Kenneth Guber
- Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Ajay J. Kirtane
- Division of Cardiology, Columbia University Irving Medical Center/NewYork-Presbyterian Hospital, New York, New York, USA
- Cardiovascular Research Foundation, New York, New York, USA
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97
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Nawar K, Mohammad A, Johns EJ, Abdulla MH. Renal denervation for atrial fibrillation: a comprehensive updated systematic review and meta-analysis. J Hum Hypertens 2022; 36:887-897. [PMID: 35094013 PMCID: PMC9553644 DOI: 10.1038/s41371-022-00658-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 01/17/2022] [Indexed: 01/31/2023]
Abstract
The study aims to compare clinical outcomes following renal denervation (RDN) in hypertensive patients with atrial fibrillation (AF). Three online databases were searched (MEDLINE, EMBASE and PubMed) for literature related to outcomes of RDN on hypertension and AF, between January 1, 2010, and June 1, 2021. Where possible, risk ratios (RR) and mean differences (MD) were combined using a random effects model. Significance was set at p ≤ 0.05. Seven trials were included that assessed the effect of adding RDN to pulmonary vein isolation (PVI) in patients with hypertension and AF. A total of 711 patients (329 undergoing PVI + RDN and 382 undergoing PVI alone), with an age range of 56 ± 6 to 68 ± 9 years, were included. Pooled analysis showed a significant lowering of AF recurrence in the PVI + RDN (31.3%) group compared to the PVI-only (52.9%) group (p < 0.00001). Pooled analysis of patients with resistant hypertension showed a significant mean reduction of systolic blood pressure (SBP) (-9.42 mm Hg, p = 0.05), but not diastolic blood pressure (DBP) (-4.11 mm Hg, p = 0.16) in favor of PVI + RDN. Additionally, the pooled analysis showed that PVI + RDN significantly improved estimated glomerular filtration rate (eGFR) (+10.2 mL/min per 1.73 m2, p < 0.001) compared to PVI alone. RDN procedures in these trials have proven to be both safe and efficacious with an overall complication rate of 6.32%. Combined PVI and RDN is beneficial for patients with hypertension and AF. Combined therapy showed improvement in SBP and eGFR, reducing the risk of AF recurrence. RDN may serve as an innovative intervention in the treatment of AF.
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Affiliation(s)
- Khaled Nawar
- School of Medicine, University College Cork, Cork, Ireland
| | - Ahmed Mohammad
- School of Medicine, University College Cork, Cork, Ireland
| | - Edward J Johns
- Department of Physiology, University College Cork, Cork, Ireland
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Insight on Efficacy of Renal Artery Denervation for Refractory Hypertension with Chronic Kidney Diseases: A Long-Term Follow-Up of 24-Hour Ambulatory Blood Pressure. J Interv Cardiol 2022; 2022:6895993. [PMID: 36212674 PMCID: PMC9519348 DOI: 10.1155/2022/6895993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Accepted: 08/05/2022] [Indexed: 11/21/2022] Open
Abstract
Aims To explore the long-term efficacy and safety of renal denervation in patients with RHT and CKD, a post hoc analysis of eGFR subgroups was completed. Methods Fifty-four patients with refractory hypertension with chronic kidney disease were treated with RDN and enrolled in the study. Patients were divided into three groups according to eGFR: eGFR 46–90 ml/min group, eGFR 15–45 ml/min group, and eGFR <15 ml/min group. The planned follow-up period was 48 months to assess 24 h ambulatory blood pressure, renal function, type of antihypertensive medication, and RDN complications. Results The ablation sites of the GFR 46–90 ml/min group and GFR 15–45 ml/min group were 32.57 ± 2.99 and 29.53 ± 5.47, respectively. No complications occurred in the GFR 46–90 ml/min group. The GFR<15 ml/min group was treated with 27.07 ± 5.59 ablation. Renal artery dissection occurred in each group of GFR 15–45 ml/min and GFR <15 ml/min. And renal stent implantation artery was performed on these two patients. No severe renal artery stenosis occurred. There were no significant differences in Scr and eGFR between the three groups at each follow-up point. Compared with baseline, SBP was significantly of each group decreased to varying degrees at each follow-up time point. SBP decreased most in the GFR 46–90 ml/min group. Compared with baseline, the type of antihypertensive drugs used in the GFR46-90 ml/min group decreased significantly except for 36 and 48 months. At 48 months' postadmission, there was a significant decrease in the type of antihypertensive medication used in the GFR15-45 ml/min group, and there was no significant decrease in the type of antihypertensive medication used in the GFR<15 ml/min group. Conclusions RDN can safely reduce SBP in CKD patients combined with RHT for 48 months, with the most pronounced reduction in the GFR15-45 ml/min group. The variety of antihypertensive drugs was significantly reduced after RDN. This was particularly evident in patients with GFR 15–45 ml/min.
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Huang H, Cheng H, Chia Y, Li Y, Van Minh H, Siddique S, Sukonthasarn A, Tay JC, Turana Y, Verma N, Kario K, Wang T. The role of renal nerve stimulation in percutaneous renal denervation for hypertension: A mini-review. J Clin Hypertens (Greenwich) 2022; 24:1187-1193. [PMID: 36196464 PMCID: PMC9532907 DOI: 10.1111/jch.14554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Revised: 07/11/2022] [Accepted: 07/18/2022] [Indexed: 11/19/2022]
Abstract
Recent trials have demonstrated the efficacy and safety of percutaneous renal sympathetic denervation (RDN) for blood pressure (BP)-lowering in patients with uncontrolled hypertension. Nevertheless, major challenges exist, such as the wide variation of BP-lowering responses following RDN (from strong response to no response) and lack of feasible and reproducible peri-procedural predictors for patient response. Both animal and human studies have demonstrated different patterns of BP responses following renal nerve stimulation (RNS), possibly related to varied regional proportions of sympathetic and parasympathetic nerve tissues along the renal arteries. Animal studies of RNS have shown that rapid electrical stimulation of the renal arteries caused renal artery vasoconstriction and increased norepinephrine secretion with a concomitant increase in BP, and the responses were attenuated after RDN. Moreover, selective RDN at sites with strong RNS-induced BP increases led to a more efficient BP-lowering effect. In human, when RNS was performed before and after RDN, blunted changes in RNS-induced BP responses were noted after RDN. The systolic BP response induced by RNS before RDN and blunted systolic BP response to RNS after RDN, at the site with maximal RNS-induced systolic BP response before RDN, both correlated with the 24-h ambulatory BP reductions 3-12 months following RDN. In summary, RNS-induced BP changes, before and after RDN, could be used to assess the immediate effect of RDN and predict BP reductions months following RDN. More comprehensive, large-scale and long term trials are needed to verify these findings.
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Affiliation(s)
- Hui‐Chun Huang
- Cardiovascular Center and Division of CardiologyDepartment of Internal MedicineNational Taiwan University HospitalNational Taiwan University College of MedicineTaipeiTaiwan
- Graduate Institute of Epidemiology and Preventive MedicineCollege of Public HealthNational Taiwan UniversityTaipeiTaiwan
| | - Hao‐min Cheng
- Department of MedicineTaipei Veterans General HospitalMedical Education and ResearchNational Yang‐Ming UniversityTaipeiTaiwan
| | - Yook‐Chin Chia
- Department of Medical SciencesSchool of Healthcare and Medical SciencesSunway UniversityBandar SunwayMalaysia
- Department of Primary Care MedicineFaculty of MedicineUniversity of MalayaKuala LumpurMalaysia
| | - Yan Li
- Department of Cardiovascular MedicineShanghai Institute of HypertensionShanghai Key Laboratory of HypertensionState Key Laboratory of Medical GenomicsNational Research Centre for Translational MedicineRuijin HospitalShanghai Jiaotong University School of MedicineShanghaiChina
| | - Huynh Van Minh
- Department of CardiologyUniversity of Medicine and PharmacyHue UniversityHue CityThua Thien‐HueVietnam
| | - Saulat Siddique
- Department of CardiologyFatima Memorial HospitalLahorePakistan
| | - Apichard Sukonthasarn
- Cardiology DivisionDepartment of Internal MedicineFaculty of MedicineChiang Mai UniversityChiang MaiThailand
| | - Jam Chin Tay
- Department of General MedicineTan Tock Seng HospitalSingaporeSingapore
| | - Yuda Turana
- Faculty of Medicine and Health SciencesAtma Jaya Catholic University of IndonesiaJakartaIndonesia
| | - Narsingh Verma
- Division of Cardiovascular MedicineDepartment of MedicineJichi Medical University School of MedicineShimotsukeTochigiJapan
| | - Kazuomi Kario
- Department of PhysiologyKing George's Medical UniversityLucknowIndia
| | - Tzung‐Dau Wang
- Cardiovascular Center and Division of CardiologyDepartment of Internal MedicineNational Taiwan University HospitalNational Taiwan University College of MedicineTaipeiTaiwan
- Division of Hospital MedicineDepartment of Internal MedicineNational Taiwan University HospitalNational Taiwan University College of MedicineTaipeiTaiwan
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Mompeó-Corredera B, Hernández-Morera P, Castaño-González I, Quintana-Montesdeoca MDP, Mederos-Real N. Regions of the human renal artery: histomorphometric analysis. Anat Cell Biol 2022; 55:330-340. [PMID: 36038250 PMCID: PMC9519757 DOI: 10.5115/acb.22.072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 05/14/2022] [Accepted: 05/24/2022] [Indexed: 11/27/2022] Open
Abstract
The renal artery is frequently involved in the pathogenesis of vasculorenal diseases, and it is a target in kidney surgery and therapeutic techniques for refractory hypertension. However, few detailed structural studies on the human renal artery have been conducted. Using histocytochemistry, immunohistochemistry, and quantitative image analysis, the wall thickness, structure, smooth muscle cells, extracellular matrix, and proportion of elastic tissue in the tunica media of main human renal arteries were used estimated. Ninety-six tissue samples were collected from sections of the right and left main renal arteries. The results showed that the renal artery changed from an elastic vessel in its proximal segment to a muscular artery in its distal part. A critical characteristic of the renal artery was the presence of longitudinal smooth muscle cell formations in the tunica adventitia of middle and distal segments but not in the proximal part of the artery. In addition, the tunica adventitia of the renal artery showed a rich vascularization and the presence of numerous nerves profiles. The artery's regional structural and morphometric features explain that a particular arterial pathology is more frequent in a specific vessel sector than in others. In addition, those characteristics could determine a different therapeutic response attending to the arterial sector.
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Affiliation(s)
- Blanca Mompeó-Corredera
- Department of Morphology, University of Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Spain
| | - Pablo Hernández-Morera
- IUMA Information and Communication Systems, University of Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Spain
| | - Irene Castaño-González
- Department of Dermatology, Doctor Negrin University Hospital of Gran Canaria, Las Palmas de Gran Canaria, Spain
| | | | - Natalia Mederos-Real
- Department of Forensic Pathology, Institute of Legal Medicine of Las Palmas, Las Palmas de Gran Canaria, Spain
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