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Naqvi SY, Shah MU, Renner M, Kouloumpinis A, Qamar MJU, Ali A, Goldberg S, Thackray S. Renal Artery Denervation for the Management of Hypertension: Current Trends and Future Direction. Am J Med 2024:S0002-9343(24)00418-2. [PMID: 38977147 DOI: 10.1016/j.amjmed.2024.06.029] [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: 06/01/2024] [Revised: 06/22/2024] [Accepted: 06/24/2024] [Indexed: 07/10/2024]
Abstract
Renal artery denervation has re-emerged as a potential therapeutic option for patients with hypertension, especially those resistant to conventional pharmacotherapy. This comprehensive review explores the importance of careful patient selection, procedural techniques, clinical efficacy, safety considerations, and future directions of renal artery denervation in hypertension management. Drawing upon a wide range of available evidence, this review aims to provide a thorough understanding of the procedure and its role in contemporary hypertension treatment paradigms.
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Affiliation(s)
- Syed Yaseen Naqvi
- Department of Cardiology, Castle Hill Hospital, Hull University Teaching Hospitals, Cottingham, United Kingdom
| | - Muhammad Usman Shah
- Department of Cardiology, Castle Hill Hospital, Hull University Teaching Hospitals, Cottingham, United Kingdom; School of Life Sciences, University of Lincoln, Lincoln, United Kingdom.
| | - Mandy Renner
- Department of Cardiology, Castle Hill Hospital, Hull University Teaching Hospitals, Cottingham, United Kingdom
| | - Alexandros Kouloumpinis
- Department of Cardiology, Castle Hill Hospital, Hull University Teaching Hospitals, Cottingham, United Kingdom
| | - Muhammad Jawad Ul Qamar
- Department of Cardiology, Castle Hill Hospital, Hull University Teaching Hospitals, Cottingham, United Kingdom
| | - Ali Ali
- Department of Cardiology, Castle Hill Hospital, Hull University Teaching Hospitals, Cottingham, United Kingdom
| | | | - Simon Thackray
- Department of Cardiology, Castle Hill Hospital, Hull University Teaching Hospitals, Cottingham, United Kingdom
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Wang J, Yin Y, Lu C, Lu Z, Hu J, Wang Y, Ge J, Jiang H, Yao C, Yan X, Ma W, Qi X, Dang Y, Chen S, Zhu J, Wang D, Ding C, Wang W, Liu J, Wang Y, Li H, Pan Z, Cui K, Li C, Liang X, Chen W, Sobotka PA, Zhang J, Esler M, Sun N, Chen M, Huo Y. Efficacy and safety of sympathetic mapping and ablation of renal nerves for the treatment of hypertension (SMART): 6-month follow-up of a randomised, controlled trial. EClinicalMedicine 2024; 72:102626. [PMID: 38756107 PMCID: PMC11096821 DOI: 10.1016/j.eclinm.2024.102626] [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] [Received: 02/18/2024] [Revised: 04/17/2024] [Accepted: 04/17/2024] [Indexed: 05/18/2024] Open
Abstract
Background Previous trials of renal denervation (RDN) have been designed to investigate reduction of blood pressure (BP) as the primary efficacy endpoint using non-selective RDN without intraoperatively verified RDN success. It is an unmet clinical need to map renal nerves, selectively denervate renal sympathetic nerves, provide readouts for the interventionalists and avoid futile RDN. We aimed to examine the safety and efficacy of renal nerve mapping/selective renal denervation (msRDN) in patients with uncontrolled hypertension (HTN) and determine whether antihypertensive drug burden is reduced while office systolic BP (OSBP) is controlled to target level (<140 mmHg). Methods We conducted a randomized, prospective, multicenter, single-blinded, sham-controlled trial. The study combined two efficacy endpoints at 6 months as primary outcomes: The control rate of patients with OSBP <140 mmHg (non-inferior outcome) and change in the composite index of antihypertensive drugs (Drug Index) in the treatment versus Sham group (superior outcome). This design avoids confounding from excess drug-taking in the Sham group. Antihypertensive drug burden was assessed by a composite index constructed as: Class N (number of classes of antihypertensive drugs) × (sum of doses). 15 hospitals in China participated in the study and 220 patients were enrolled in a 1:1 ratio (msRDN vs Sham). The key inclusion criteria included: age (18-65 years old), history of essential HTN (at least 6 months), heart rate (≥70 bpm), OSBP (≥150 mmHg and ≤180 mmHg), ambulatory BP monitoring (ABPM, 24-h SBP ≥130 mmHg or daytime SBP ≥135 mmHg or nighttime SBP ≥120 mmHg), renal artery stenosis (<50%) and renal function (eGFR >45 mL/min/1.73 m2). The catheter with both stimulation and ablation functions was inserted in the distal renal main artery. The RDN site (hot spot) was selected if SBP increased (≥5 mmHg) by intra-renal artery (RA) electrical stimulation; an adequate RDN was confirmed by repeated electronic stimulation if no increase in BP otherwise, a 2nd ablation was performed at the same site. At sites where there was decreased SBP (≥5 mmHg, cold spot) or no BP response (neutral spot) to stimulation, no ablation was performed. The mapping, ablation and confirmation procedure was repeated until the entire renal main artery had been tested then either treated or avoided. After msRDN, patients had to follow a predefined, vigorous drug titration regimen in order to achieve target OSBP (<140 mmHg). Drug adherence was monitored by liquid chromatography-tandem mass spectrometry analysis using urine. This study is registered with ClinicalTrials.gov (NCT02761811) and 5-year follow-up is ongoing. Findings Between July 8, 2016 and February 23, 2022, 611 patients were consented, 220 patients were enrolled in the study who received standardized antihypertensive drug treatments (at least two drugs) for at least 28 days, presented OSBP ≥150 mmHg and ≤180 mmHg and met all inclusion and exclusion criteria. In left RA and right RA, mapped sites were 8.2 (3.0) and 8.0 (2.7), hot/ablated sites were 3.7 (1.4) and 4.0 (1.6), cold spots were 2.4 (2.6) and 2.0 (2.2), neutral spots were 2.0 (2.1) and 2.0 (2.1), respectively. Hot, cold and neutral spots was 48.0%, 27.5% and 24.4% of total mapped sites, respectively. At 6 M, the Control Rate of OSBP was comparable between msRDN and Sham group (95.4% vs 92.8%, p = 0.429), achieved non-inferiority margin -10% (2.69%; 95% CI -4.11%, 9.83%, p < 0.001 for non-inferiority); the change in Drug Index was significantly lower in msRDN group compared to Sham group (4.37 (6.65) vs 7.61 (10.31), p = 0.010) and superior to Sham group (-3.25; 95% CI -5.56, -0.94, p = 0.003), indicating msRDN patients need significantly fewer drugs to control OSBP <140 mmHg. 24-hour ambulatory SBP decreased from 146.8 (13.9) mmHg by 10.8 (14.1) mmHg, and from 149.8 (12.8) mmHg by 10.0 (14.0) mmHg in msRDN and Sham groups, respectively (p < 0.001 from Baseline; p > 0.05 between groups). Safety profiles were comparable between msRDN and Sham groups, demonstrating the safety and efficacy of renal mapping/selective RDN to treat uncontrolled HTN. Interpretation The msRDN therapy achieved the goals of reducing the drug burden of HTN patients and controlling OSBP <140 mmHg, with only approximately four targeted ablations per renal main artery, much lower than in previous trials. Funding SyMap Medical (Suzhou), LTD, Suzhou, China.
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Affiliation(s)
- Jie Wang
- The First Affiliated Hospital with Nanjing Medical University, Nanjing, 210029, China
- Division of Cardiology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, NY, 10032, USA
| | - Yuehui Yin
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China
| | - Chengzhi Lu
- Department of Cardiology, Tianjin First Central Hospital, Tianjin, 300190, China
| | - Zhibing Lu
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, 430060, China
- Department of Cardiology, Zhongnan Hospital, Wuhan University, Wuhan, 430071, China
| | - Jialu Hu
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai, 200032, China
| | - Yue Wang
- The First Affiliated Hospital with Nanjing Medical University, Nanjing, 210029, 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
| | - Chen Yao
- Peking University Health Science Center, Beijing, 100034, China
| | - Xiaoyan Yan
- Peking University Health Science Center, Beijing, 100034, China
| | - Wei Ma
- Department of Cardiology, Peking University First Hospital, Beijing, 100034, China
| | - Xiaoyong Qi
- Department of Cardiology, Hebei General Hospital, Shijiazhuang, 050057, China
| | - Yi Dang
- Department of Cardiology, Hebei General Hospital, Shijiazhuang, 050057, China
| | - Shaoliang Chen
- Department of Cardiology, Nanjing First Hospital, Nanjing, 210012, China
| | - Jiancheng Zhu
- Department of Cardiology, Nanjing First Hospital, Nanjing, 210012, China
| | - Dongmei Wang
- Department of Cardiology, Norman Bethune International Peace Hospital, Shijiazhuang, 050082, China
| | - Chao Ding
- Department of Cardiology, Norman Bethune International Peace Hospital, Shijiazhuang, 050082, China
| | - Weimin Wang
- Department of Cardiology, Peking University People's Hospital, Beijing, 100044, China
| | - Jian Liu
- Department of Cardiology, Peking University People's Hospital, Beijing, 100044, China
| | - Yanbin Wang
- Department of Cardiology, Taiyuan Central Hospital, Taiyuan, 030009, China
| | - Hui Li
- Department of Cardiology, Daqing Oilfield General Hospital, Daqing, 163458, China
| | - Zhenhua Pan
- Department of Cardiology, Daqing Oilfield General Hospital, Daqing, 163458, China
| | - Kaijun Cui
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, 332001, China
| | - Chengzong Li
- Department of Cardiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, 221002, China
| | - Xinjian Liang
- Department of Cardiology, Shenzhen People's Hospital, Shenzhen, Guangdong, 430060, China
| | - Weijie Chen
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China
| | - Paul A. Sobotka
- Department of Cardiology, The Ohio State University College of Medicine, Columbus, OH, 43210, USA
| | | | - Murray Esler
- Baker IDI Heart and Diabetes Institute, Melbourne, Australia
| | - Ningling Sun
- Department of Hypertension, Heart Center, Peking University People's Hospital, Beijing, 100044, China
| | - Minglong Chen
- Department of Cardiology, The First Affiliated Hospital with Nanjing Medical University, Nanjing, 210029, China
| | - Yong Huo
- Department of Cardiology, Peking University First Hospital, Beijing, 100034, China
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Doiron JE, Li Z, Yu X, LaPenna KB, Quiriarte H, Allerton TD, Koul K, Malek A, Shah SJ, Sharp TE, Goodchild TT, Kapusta DR, Lefer DJ. Early Renal Denervation Attenuates Cardiac Dysfunction in Heart Failure With Preserved Ejection Fraction. J Am Heart Assoc 2024; 13:e032646. [PMID: 38353216 PMCID: PMC11010115 DOI: 10.1161/jaha.123.032646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 12/08/2023] [Indexed: 02/21/2024]
Abstract
BACKGROUND The renal sympathetic nervous system modulates systemic blood pressure, cardiac performance, and renal function. Pathological increases in renal sympathetic nerve activity contribute to the pathogenesis of heart failure with preserved ejection fraction (HFpEF). We investigated the effects of renal sympathetic denervation performed at early or late stages of HFpEF progression. METHODS AND RESULTS Male ZSF1 obese rats were subjected to radiofrequency renal denervation (RF-RDN) or sham procedure at either 8 weeks or 20 weeks of age and assessed for cardiovascular function, exercise capacity, and cardiorenal fibrosis. Renal norepinephrine and renal nerve tyrosine hydroxylase staining were performed to quantify denervation following RF-RDN. In addition, renal injury, oxidative stress, inflammation, and profibrotic biomarkers were evaluated to determine pathways associated with RDN. RF-RDN significantly reduced renal norepinephrine and tyrosine hydroxylase content in both study cohorts. RF-RDN therapy performed at 8 weeks of age attenuated cardiac dysfunction, reduced cardiorenal fibrosis, and improved endothelial-dependent vascular reactivity. These improvements were associated with reductions in renal injury markers, expression of renal NLR family pyrin domain containing 3/interleukin 1β, and expression of profibrotic mediators. RF-RDN failed to exert beneficial effects when administered in the 20-week-old HFpEF cohort. CONCLUSIONS Our data demonstrate that early RF-RDN therapy protects against HFpEF disease progression in part due to the attenuation of renal fibrosis and inflammation. In contrast, the renoprotective and left ventricular functional improvements were lost when RF-RDN was performed in later HFpEF progression. These results suggest that RDN may be a viable treatment option for HFpEF during the early stages of this systemic inflammatory disease.
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Affiliation(s)
- Jake E. Doiron
- Department of Pharmacology and Experimental TherapeuticsLouisiana State University Health Sciences CenterNew OrleansLAUSA
| | - Zhen Li
- Department of Cardiac SurgerySmidt Heart Institute, Cedars‐Sinai Medical CenterLos AngelesCAUSA
| | - Xiaoman Yu
- Department of Cardiac SurgerySmidt Heart Institute, Cedars‐Sinai Medical CenterLos AngelesCAUSA
| | - Kyle B. LaPenna
- Department of Pharmacology and Experimental TherapeuticsLouisiana State University Health Sciences CenterNew OrleansLAUSA
| | - Heather Quiriarte
- Department of Vascular MetabolismPennington Biomedical Research CenterBaton RougeLAUSA
| | - Timothy D. Allerton
- Department of Vascular MetabolismPennington Biomedical Research CenterBaton RougeLAUSA
| | - Kashyap Koul
- School of MedicineLouisiana State University Health Sciences Center New OrleansNew OrleansLAUSA
| | - Andrew Malek
- School of MedicineLouisiana State University Health Sciences Center New OrleansNew OrleansLAUSA
| | - Sanjiv J. Shah
- Division of Cardiology, Department of Medicine and Bluhm Cardiovascular InstituteNorthwestern University Feinberg School of MedicineChicagoILUSA
| | - Thomas E. Sharp
- Department of Molecular Pharmacology and Physiology, Morsani College of MedicineUniversity of South FloridaTampaFLUSA
- USF Health Heart InstituteTampaFLUSA
| | - Traci T. Goodchild
- Department of Cardiac SurgerySmidt Heart Institute, Cedars‐Sinai Medical CenterLos AngelesCAUSA
| | - Daniel R. Kapusta
- Department of Pharmacology and Experimental TherapeuticsLouisiana State University Health Sciences CenterNew OrleansLAUSA
| | - David J. Lefer
- Department of Cardiac SurgerySmidt Heart Institute, Cedars‐Sinai Medical CenterLos AngelesCAUSA
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Jelaković B, Perkov D, Barišić K, Bukal N, Gellineo L, Jelaković A, Josipović J, Prkačin I, Željković Vrkić T, Živko M. Renal Denervation in the Treatment of Resistant Hypertension and Difficult-to-Control Hypertension - Consensus Document of the Croatian Hypertension League - Croatian Society of Hypertension, Croatian Cardiac Society, Croatian Endovascular Initiative, Croatian Society for Diabetes and Metabolic Diseases, Croatian Renal Association, and Croatian Society of Family Physicians of the Croatian Medical Association. Vasc Health Risk Manag 2023; 19:805-826. [PMID: 38108022 PMCID: PMC10724019 DOI: 10.2147/vhrm.s422773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 11/21/2023] [Indexed: 12/19/2023] Open
Abstract
Renal denervation (RDN) as a method of treating arterial hypertension (AH) was introduced in Croatia in 2012. A multidisciplinary team and a network of hospitals that diagnose and treat patients with severe forms of AH were established, and a very strict diagnostic-treatment algorithm was prepared. At monthly meetings patients with truly resistant hypertension who were candidates for RDN were discussed. According to the 2021 ESH position statement and 2023 ESH guidelines, RDN is considered an alternative and additional, not a competitive method of treating patients with various forms of AH which must be performed by following a structured procedure and the patient's preference should be considered. In view of the changes in the global scientific community, the Croatian Hypertension League brings this consensus document on RDN conducted with radiofrequency-based catheter, the only currently available method in Croatia. In this document, exclusion and inclusion criteria are shown, as well as three groups of patients in whom RDN could be considered. The new diagnostic-treatment algorithm is prepared and follow-up procedure is explained. In Croatia, RDN is reimbursed by the national insurance company, thus pharmacoeconomic analyses is also shown. Criteria required by an individual centre to be approved of RDN are listed, and plans for prospective research on RDN in Croatia, including the Croatian registry for RDN, are discussed.
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Affiliation(s)
- Bojan Jelaković
- School of Medicine University of Zagreb, Zagreb, Croatia
- Department of Nephrology, Hypertension, Dialysis and Transplantation, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Dražen Perkov
- Department of Diagnostic and Interventional Radiology, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Klara Barišić
- Department of Nephrology, Hypertension, Dialysis and Transplantation, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Nikolina Bukal
- Department of Internal Medicine, Nephrology and Pulmonology, General Hospital “Dr. J. Benčević”, Slavonski Brod, Croatia
| | - Lana Gellineo
- Department of Nephrology, Hypertension, Dialysis and Transplantation, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Ana Jelaković
- Department of Nephrology, Hypertension, Dialysis and Transplantation, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Josipa Josipović
- Croatian Catholic University, Zagreb, Croatia
- Department of Nephrology and Dialysis, University Hospital Centre Sestre Milosrdnice, Zagreb, Croatia
| | - Ingrid Prkačin
- Department for Emergency Medicine, Clinical Hospital Merkur, Zagreb, Croatia
| | | | - Marijana Živko
- Department of Nephrology, Hypertension, Dialysis and Transplantation, University Hospital Centre Zagreb, Zagreb, Croatia
| | - On the behalf of Task force for the Resistant Hypertension and Renal Denervation of the Croatian Hypertension League
- School of Medicine University of Zagreb, Zagreb, Croatia
- Department of Nephrology, Hypertension, Dialysis and Transplantation, University Hospital Centre Zagreb, Zagreb, Croatia
- Department of Diagnostic and Interventional Radiology, University Hospital Centre Zagreb, Zagreb, Croatia
- Department of Internal Medicine, Nephrology and Pulmonology, General Hospital “Dr. J. Benčević”, Slavonski Brod, Croatia
- Croatian Catholic University, Zagreb, Croatia
- Department of Nephrology and Dialysis, University Hospital Centre Sestre Milosrdnice, Zagreb, Croatia
- Department for Emergency Medicine, Clinical Hospital Merkur, Zagreb, Croatia
- Institute for Cardiovascular Prevention and Rehabilitation, Zagreb, Croatia
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Dickert NW, Devireddy CM. Honest Deception: The Importance of Sham-Controlled Trials. JACC Cardiovasc Interv 2023; 16:2558-2560. [PMID: 37879809 DOI: 10.1016/j.jcin.2023.08.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 08/08/2023] [Indexed: 10/27/2023]
Affiliation(s)
- Neal W Dickert
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia, USA; Emory Health Services Research Center, Atlanta, Georgia, USA.
| | - Chandan M Devireddy
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia, USA
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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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Obi MF, Sharma M, Reinberg MA, N'Dandu Z, Hyun Joon C, Vega M. The Implementation of Renal Denervation in the Management of Resistant Hypertension Despite Use of Multitherapy Antihypertensives at Maximally Tolerated Doses: A Contemporary Literature Review. Cureus 2023; 15:e41598. [PMID: 37559838 PMCID: PMC10409301 DOI: 10.7759/cureus.41598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/09/2023] [Indexed: 08/11/2023] Open
Abstract
Refractory hypertension is highly prevalent among the hypertensive population, and current clinical management has failed to provide optimal control for these individuals. This subtype of arterial hypertension is defined as a persistently elevated systolic blood pressure reading of 140 mmHg, or higher, despite multiple antihypertensive use at maximally tolerated dosing. These patients have an elevated risk of cardiovascular and renal complications, urging for the need of more effective therapeutic management. Renal sympathetic efferent nerves have been noted to play an important role in volume and blood pressure homeostasis. Before the implementation of oral antihypertensives, the use of surgical lumbar sympathectomy for the reduction of persistent hypertension was considered a life-saving approach. However, individuals were left with debilitating side effects, such as postural hypotension, syncope, and impotence. A new and minimally invasive technique has been proposed, where the kidneys undergo selective denervation in hopes of providing decreased cardiovascular morbidity and mortality for patients with resistant hypertension. Some studies demonstrated promising outcomes with a reduction in blood pressure, a decrease in medication reliance, and a potential long-lasting effect of the procedure with an overall improvement in cardiovascular health. Unfortunately, most of the available data was obtained from observational, uncontrolled studies with short-term follow-up, small sample sizes, and high variability in blood pressure measurement. Therefore, further evidence is needed to determine whether renal denervation provides long-term benefits for blood pressure control and improves outcomes for mortality and cardiovascular events in this patient population.
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Affiliation(s)
- Mukosolu F Obi
- Internal Medicine, Wyckoff Heights Medical Center, Brooklyn, USA
| | - Manjari Sharma
- Internal Medicine, Wyckoff Heights Medical Center, Brooklyn, USA
| | | | - Zola N'Dandu
- Interventional Cardiology, Ochsner Medical Center, New Orleans, USA
| | - Cho Hyun Joon
- Internal Medicine, Wyckoff Heights Medical Center, Brooklyn, USA
| | - Melissa Vega
- Internal Medicine, Wyckoff Heights Medical Center, Brooklyn, USA
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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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Sridharan A, Bradfield JS, Shivkumar K, Ajijola OA. Autonomic nervous system and arrhythmias in structural heart disease. Auton Neurosci 2022; 243:103037. [DOI: 10.1016/j.autneu.2022.103037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 09/21/2022] [Accepted: 09/21/2022] [Indexed: 11/28/2022]
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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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11
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Ameer OZ. Hypertension in chronic kidney disease: What lies behind the scene. Front Pharmacol 2022; 13:949260. [PMID: 36304157 PMCID: PMC9592701 DOI: 10.3389/fphar.2022.949260] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 09/26/2022] [Indexed: 12/04/2022] Open
Abstract
Hypertension is a frequent condition encountered during kidney disease development and a leading cause in its progression. Hallmark factors contributing to hypertension constitute a complexity of events that progress chronic kidney disease (CKD) into end-stage renal disease (ESRD). Multiple crosstalk mechanisms are involved in sustaining the inevitable high blood pressure (BP) state in CKD, and these play an important role in the pathogenesis of increased cardiovascular (CV) events associated with CKD. The present review discusses relevant contributory mechanisms underpinning the promotion of hypertension and their consequent eventuation to renal damage and CV disease. In particular, salt and volume expansion, sympathetic nervous system (SNS) hyperactivity, upregulated renin–angiotensin–aldosterone system (RAAS), oxidative stress, vascular remodeling, endothelial dysfunction, and a range of mediators and signaling molecules which are thought to play a role in this concert of events are emphasized. As the control of high BP via therapeutic interventions can represent the key strategy to not only reduce BP but also the CV burden in kidney disease, evidence for major strategic pathways that can alleviate the progression of hypertensive kidney disease are highlighted. This review provides a particular focus on the impact of RAAS antagonists, renal nerve denervation, baroreflex stimulation, and other modalities affecting BP in the context of CKD, to provide interesting perspectives on the management of hypertensive nephropathy and associated CV comorbidities.
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Affiliation(s)
- Omar Z. Ameer
- Department of Pharmaceutical Sciences, College of Pharmacy, Alfaisal University, Riyadh, Saudi Arabia
- Department of Biomedical Sciences, Faculty of Medicine, Macquarie University, Sydney, NSW, Australia
- *Correspondence: Omar Z. Ameer,
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12
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Rey-García J, Townsend RR. Renal Denervation: A Review. Am J Kidney Dis 2022; 80:527-535. [PMID: 35598810 DOI: 10.1053/j.ajkd.2022.03.015] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 03/14/2022] [Indexed: 02/02/2023]
Abstract
Uncontrolled hypertension persists as an important health issue despite the availability of many medications and nondrug therapies that lower blood pressure. Increasingly, nonadherence to medication is found in approximately 2 of every 5 patients with uncontrolled hypertension. In the search for interventions that lower blood pressure that do not rely on adherence to a regimen requiring daily ingestion of medication or repeated physical activity, device-based methods that denervate the renal arteries have emerged as a potential complement to standard antihypertensive treatments. At least 3 different approaches to renal artery denervation are under active investigation, including the use of radiofrequency energy, ultrasound, or the injection of neurolytic agents into the renal perivascular tissue. In this review, we cover what is currently known about the mechanisms of antihypertensive effects of renal denervation, summarize the efficacy and safety of renal denervation using recent controlled trial publications in a number of hypertensive populations, and conclude with some thoughts about challenges in the field, including the optimization of patient selection for the procedure and what the reader can expect in the near future in this rapidly developing field.
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Affiliation(s)
- Jimena Rey-García
- Department of Preventive Medicine and Public Health, Universidad Autónoma de Madrid, Madrid, Spain; Internal Medicine Department, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria, Madrid, Spain
| | - Raymond R Townsend
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
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13
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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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14
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Zhang H, Huang T, Shen J, Zou Y, Deng Y, Hou M, Huang X. Clinical Effect of Renal Arterial Sympathetic Radiofrequency Ablation on Secondary Hypertension. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2022; 2022:9948057. [PMID: 35959345 PMCID: PMC9359839 DOI: 10.1155/2022/9948057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 07/07/2022] [Accepted: 07/09/2022] [Indexed: 11/30/2022]
Abstract
Sympathetic hyperactivity is one of the main mechanisms of secondary hypertension. Reducing renal sympathetic activity through surgery can effectively reduce blood pressure. Many cases have shown that renal denervation (RDN) can selectively block renal artery sympathetic nerve activity to control refractory hypertension. This surgery is a minimally invasive surgery, and the risk of surgery-related adverse events is significantly reduced compared with surgery. Therefore, the purpose of this study is to explore the efficacy of radiofrequency ablation of renal artery sympathetic nerve in the treatment of secondary hypertension. Eight patients with secondary hypertension diagnosed by the cardiovascular department of our hospital and treated with RDN were followed up for 3-18 months, of which 5 cases were followed up for more than 12 months and 8 cases were followed up for more than 3 months. Eight patients were treated with radiofrequency ablation of renal artery catheter. The parameters such as preoperative blood pressure, antihypertensive drugs, organ function, intraoperative ablation resistance, power, time, and temperature were determined. The related changes of blood pressure, antihypertensive drugs, and visceral function and the occurrence of side effects at 1 week and 1, 3, 6, and 12 months after operation were related to the operation. In conclusion, RDN has a significant clinical effect in the treatment of refractory hypertension, with stable postoperative blood pressure drop, reduced drug dosage, and less side effects.
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Affiliation(s)
- Hui Zhang
- Department of Cardiology, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430000, China
| | - Ting Huang
- Department of Cardiology, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430000, China
| | - Jie Shen
- Department of Cardiology, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430000, China
| | - Yuanlin Zou
- Department of Cardiology, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430000, China
| | - Yunchao Deng
- Department of Cardiology, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430000, China
| | - Min Hou
- Department of Internal Medicine, Daji Street Health Center, Caidian District, Wuhan 430113, China
| | - Xiang Huang
- Department of Surgery, Affiliated Huangjiahu Hospital, Hubei University of Chinese Medicine, 430065, China
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15
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Siontis GC, Nikolakopoulou A, Sweda R, Mavridis D, Salanti G. Estimating the sample size of sham-controlled randomized controlled trials using existing evidence. F1000Res 2022; 11:85. [PMID: 36451658 PMCID: PMC9669514 DOI: 10.12688/f1000research.108554.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/03/2022] [Indexed: 09/08/2024] Open
Abstract
Background: In randomized controlled trials (RCTs), the power is often 'reverse engineered' based on the number of participants that can realistically be achieved. An attractive alternative is planning a new trial conditional on the available evidence; a design of particular interest in RCTs that use a sham control arm (sham-RCTs). Methods: We explore the design of sham-RCTs, the role of sequential meta-analysis and conditional planning in a systematic review of renal sympathetic denervation for patients with arterial hypertension. The main efficacy endpoint was mean change in 24-hour systolic blood pressure. We performed sequential meta-analysis to identify the time point where the null hypothesis would be rejected in a prospective scenario. Evidence-based conditional sample size calculations were performed based on fixed-effect meta-analysis. Results: In total, six sham-RCTs (981 participants) were identified. The first RCT was considerably larger (535 participants) than those subsequently published (median sample size of 80). All trial sample sizes were calculated assuming an unrealistically large intervention effect which resulted in low power when each study is considered as a stand-alone experiment. Sequential meta-analysis provided firm evidence against the null hypothesis with the synthesis of the first four trials (755 patients, cumulative mean difference -2.75 (95%CI -4.93 to -0.58) favoring the active intervention)). Conditional planning resulted in much larger sample sizes compared to those in the original trials, due to overoptimistic expected effects made by the investigators in individual trials, and potentially a time-effect association. Conclusions: Sequential meta-analysis of sham-RCTs can reach conclusive findings earlier and hence avoid exposing patients to sham-related risks. Conditional planning of new sham-RCTs poses important challenges as many surgical/minimally invasive procedures improve over time, the intervention effect is expected to increase in new studies and this violates the underlying assumptions. Unless this is accounted for, conditional planning will not improve the design of sham-RCTs.
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Affiliation(s)
| | | | - Romy Sweda
- Department of Cardiology, University Hospital of Bern, Bern, Switzerland
| | - Dimitris Mavridis
- Department of Primary Education, University of Ioannina, Ioannina, Greece
| | - Georgia Salanti
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland
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16
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Siontis GC, Nikolakopoulou A, Sweda R, Mavridis D, Salanti G. Estimating the sample size of sham-controlled randomized controlled trials using existing evidence. F1000Res 2022; 11:85. [PMID: 36451658 PMCID: PMC9669514 DOI: 10.12688/f1000research.108554.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/18/2022] [Indexed: 09/08/2024] Open
Abstract
Background: In randomized controlled trials (RCTs), the power is often 'reverse engineered' based on the number of participants that can realistically be achieved. An attractive alternative is planning a new trial conditional on the available evidence; a design of particular interest in RCTs that use a sham control arm (sham-RCTs). Methods: We explore the design of sham-RCTs, the role of sequential meta-analysis and conditional planning in a systematic review of renal sympathetic denervation for patients with arterial hypertension. The main efficacy endpoint was mean change in 24-hour systolic blood pressure. We performed sequential meta-analysis to identify the time point where the null hypothesis would be rejected in a prospective scenario. Evidence-based conditional sample size calculations were performed based on fixed-effect meta-analysis. Results: In total, six sham-RCTs (981 participants) were identified. The first RCT was considerably larger (535 participants) than those subsequently published (median sample size of 80). All trial sample sizes were calculated assuming an unrealistically large intervention effect which resulted in low power when each study is considered as a stand-alone experiment. Sequential meta-analysis provided firm evidence against the null hypothesis with the synthesis of the first four trials (755 patients, cumulative mean difference -2.75 (95%CI -4.93 to -0.58) favoring the active intervention)). Conditional planning resulted in much larger sample sizes compared to those in the original trials, due to overoptimistic expected effects made by the investigators in individual trials, and potentially a time-effect association. Conclusions: Sequential meta-analysis of sham-RCTs can reach conclusive findings earlier and hence avoid exposing patients to sham-related risks. Conditional planning of new sham-RCTs poses important challenges as many surgical/minimally invasive procedures improve over time, the intervention effect is expected to increase in new studies and this violates the underlying assumptions. Unless this is accounted for, conditional planning will not improve the design of sham-RCTs.
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Affiliation(s)
| | | | - Romy Sweda
- Department of Cardiology, University Hospital of Bern, Bern, Switzerland
| | - Dimitris Mavridis
- Department of Primary Education, University of Ioannina, Ioannina, Greece
| | - Georgia Salanti
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland
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17
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Pisano A, Iannone LF, Leo A, Russo E, Coppolino G, Bolignano D. Renal denervation for resistant hypertension. Cochrane Database Syst Rev 2021; 11:CD011499. [PMID: 34806762 PMCID: PMC8607757 DOI: 10.1002/14651858.cd011499.pub3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Resistant hypertension is highly prevalent among the general hypertensive population and the clinical management of this condition remains problematic. Different approaches, including a more intensified antihypertensive therapy, lifestyle modifications or both, have largely failed to improve patients' outcomes and to reduce cardiovascular and renal risk. As renal sympathetic hyperactivity is a major driver of resistant hypertension, in the last decade renal sympathetic ablation (renal denervation) has been proposed as a possible therapeutic alternative to treat this condition. OBJECTIVES We sought to evaluate the short- and long-term effects of renal denervation in individuals with resistant hypertension on clinical end points, including fatal and non-fatal cardiovascular events, all-cause mortality, hospital admissions, quality of life, blood pressure control, left ventricular hypertrophy, cardiovascular and metabolic profile and kidney function, as well as the potential adverse events related to the procedure. SEARCH METHODS For this updated review, the Cochrane Hypertension Information Specialist searched the following databases for randomised controlled trials up to 3 November 2020: Cochrane Hypertension's Specialised Register, CENTRAL (2020, Issue 11), Ovid MEDLINE, and Ovid Embase. The World Health Organization International Clinical Trials Registry Platform (via CENTRAL) and the US National Institutes of Health Ongoing Trials Register ClinicalTrials.gov were searched for ongoing trials. We also contacted authors of relevant papers regarding further published and unpublished work. The searches had no language restrictions. SELECTION CRITERIA We considered randomised controlled trials (RCTs) that compared renal denervation to standard therapy or sham procedure to treat resistant hypertension, without language restriction. DATA COLLECTION AND ANALYSIS Two authors independently extracted data and assessed study risk of bias. We summarised treatment effects on available clinical outcomes and adverse events using random-effects meta-analyses. We assessed heterogeneity in estimated treatment effects using Chi² and I² statistics. We calculated summary treatment estimates as a mean difference (MD) or standardised mean difference (SMD) for continuous outcomes, and a risk ratio (RR) for dichotomous outcomes, together with their 95% confidence intervals (CI). Certainty of evidence has been assessed using the GRADE approach. MAIN RESULTS We found 15 eligible studies (1416 participants). In four studies, renal denervation was compared to sham procedure; in the remaining studies, renal denervation was tested against standard or intensified antihypertensive therapy. Most studies had unclear or high risk of bias for allocation concealment and blinding. When compared to control, there was low-certainty evidence that renal denervation had little or no effect on the risk of myocardial infarction (4 studies, 742 participants; RR 1.31, 95% CI 0.45 to 3.84), ischaemic stroke (5 studies, 892 participants; RR 0.98, 95% CI 0.33 to 2.95), unstable angina (3 studies, 270 participants; RR 0.51, 95% CI 0.09 to 2.89) or hospitalisation (3 studies, 743 participants; RR 1.24, 95% CI 0.50 to 3.11). Based on moderate-certainty evidence, renal denervation may reduce 24-hour ambulatory blood pressure monitoring (ABPM) systolic BP (9 studies, 1045 participants; MD -5.29 mmHg, 95% CI -10.46 to -0.13), ABPM diastolic BP (8 studies, 1004 participants; MD -3.75 mmHg, 95% CI -7.10 to -0.39) and office diastolic BP (8 studies, 1049 participants; MD -4.61 mmHg, 95% CI -8.23 to -0.99). Conversely, this procedure had little or no effect on office systolic BP (10 studies, 1090 participants; MD -5.92 mmHg, 95% CI -12.94 to 1.10). Moderate-certainty evidence suggested that renal denervation may not reduce serum creatinine (5 studies, 721 participants, MD 0.03 mg/dL, 95% CI -0.06 to 0.13) and may not increase the estimated glomerular filtration rate (eGFR) or creatinine clearance (6 studies, 822 participants; MD -2.56 mL/min, 95% CI -7.53 to 2.42). AUTHORS' CONCLUSIONS: In patients with resistant hypertension, there is low-certainty evidence that renal denervation does not improve major cardiovascular outomes and renal function. Conversely, moderate-certainty evidence exists that it may improve 24h ABPM and diastolic office-measured BP. Future trials measuring patient-centred instead of surrogate outcomes, with longer follow-up periods, larger sample size and more standardised procedural methods are necessary to clarify the utility of this procedure in this population.
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Affiliation(s)
- Anna Pisano
- Institute of Clinical Physiology, CNR - Italian National Council of Research, Reggio Calabria, Italy
| | | | - Antonio Leo
- Department of Health Sciences, Magna Graecia University of Catanzaro, Catanzaro, Italy
| | - Emilio Russo
- Department of Health Sciences, Magna Graecia University of Catanzaro, Catanzaro, Italy
| | - Giuseppe Coppolino
- Department of Health Sciences, Magna Graecia University of Catanzaro, Catanzaro, Italy
| | - Davide Bolignano
- Department of Medical and Surgical Sciences, Magna Graecia University of Catanzaro, Catanzaro, Italy
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18
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Cheng Y, Liu H, Tian Z, Zhang M, Liu Y, Nan Q. Evaluating the thermal performance of a balloon-based renal sympathetic denervation system with array electrodes: a finite element study. Electromagn Biol Med 2021; 40:488-501. [PMID: 34352188 DOI: 10.1080/15368378.2021.1961266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Renal denervation transmits radiofrequency (RF) energy through an electrode to treat resistant hypertension (RH), applying ablation in the renal artery. Several experimental studies have shown that this treatment has been used effectively to treat RH. The aim of this paper is to investigate the effect of ablation parameters (i.e., electrode length, applied voltage, ablation time, and blood flow) on the temperature distribution using a balloon-based array electrodes system. A simplified three-dimensional model including four electrodes and a balloon was established. The balloon diameter was 3 mm and placed in a 5 mm diameter renal artery for forming intra-arterial occlusion. Four electrodes were mounted on the balloon and distributed in the same plane to mimic circumferential RF ablation. Computer simulations were conducted to investigate the thermal performances of the device by setting different electrode configurations, treatment protocols, and physiological factors. The thermal performances including the thermal distribution, maximum lesion depth, length, and area were analyzed. The lesion shape of the array RF electrodes was approximately a sphere with a 100% circumference coverage rate of the renal artery. The lesion depth and length increase with each factor except for blood velocity. Increasing the electrode length from 2 to 4 mm or 2 to 6 mm, the lesion depth increases by 1.15 mm and 0.54 mm at 60 s. The corresponding lesion length increases by 2.65 mm and 2.34 mm, respectively. The range of effective lesion depth is 1.90-4.90 mm, at a voltage of 15-30 V. But the peak temperature at the arterial outer wall exceeded 100 °C when the voltage is above 25 V. In tissue, the degree of thermal injury in the 2 mm area reached 100%, but in blood was not more than 5%. There was no significant difference at different flow conditions because the difference value in lesion depth was not exceeded 0.5 mm. The results showed that the balloon-based four electrodes system is expected to overcome the difficulty of incomplete ablation. In clinical application, 2 mm-electrode is recommended to avoid long wall damage as much as possible and control the voltage below 25 V. This treatment has little thermal injury on the blood, which means it may avoid coagulation formation. Moreover, the application of this device does not need to consider the difference in individual blood velocity.
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Affiliation(s)
- Yanyan Cheng
- College of Life Science and Chemistry, The Faculty of Environment and Life ScienceBeijing University of Technology, Beijing, China
| | - Hongxing Liu
- College of Life Science and Chemistry, The Faculty of Environment and Life ScienceBeijing University of Technology, Beijing, China
| | - Zhen Tian
- College of Life Science and Chemistry, The Faculty of Environment and Life ScienceBeijing University of Technology, Beijing, China
| | - Meng Zhang
- College of Life Science and Chemistry, The Faculty of Environment and Life ScienceBeijing University of Technology, Beijing, China
| | - Youjun Liu
- College of Life Science and Chemistry, The Faculty of Environment and Life ScienceBeijing University of Technology, Beijing, China
| | - Qun Nan
- College of Life Science and Chemistry, The Faculty of Environment and Life ScienceBeijing University of Technology, Beijing, China
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Juknevičius V, Berūkštis A, Juknevičienė R, Jasiūnas E, Šerpytis P, Laucevičius A. Long-Term Effects of Renal Artery Denervation. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:662. [PMID: 34199107 PMCID: PMC8305318 DOI: 10.3390/medicina57070662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Revised: 06/22/2021] [Accepted: 06/23/2021] [Indexed: 11/16/2022]
Abstract
Background and Objectives: Renal artery denervation (RDN) procedure is a broadly discussed method in the treatment of resistant hypertension. Many studies report short-term (3-12 months) results for blood pressure and arterial stiffness. The primary endpoints were changes in 24 h mean systolic blood pressure (BP) and office systolic BP 48 months after RDN. The secondary endpoints were changes in aortic pulse wave velocity and impact of polypharmacy on these variables. Materials and Methods: Renal artery denervation was performed in 73 patients treated for resistant hypertension; 49 patients remained in final analysis. Patient examination was carried out before the procedure, and subsequently at 3, 6, 12, 24, and 48 months later. Patients' antihypertensive and overall medication regimens were carefully analysed. Results: Mean 24 h arterial blood pressure lowered and was sustained at lower levels for up to 48 months; median (interequartile range-IQR) from 158(23.5)/100(14.2) to 140(26.5)/86(16.2) mmHg. Mean reduction in 24 h ambulatory systolic BP was -11 ± 25 mmHg (95% CI, -20 to -2; p < 0.001), while office systolic BP reduced by -7 ± 23 mmHg (95%CI, -24 to -1; p < 0.02). A significant reduction in median aortic pulse wave velocity 12 months after the procedure (drop from baseline 11.2 [3.15] m/s (95%CI 6.1 to 16.2) to 9.8 [2.1] m/s (95%CI 6.1 to 13.7; p = 0.002)). After 48 months, there was no worsening compared to the baseline level of 10.3 [4.0] m/s (95% CI 6.9 to 17.8) (p > 0.05). The total mean number of antihypertensive drugs remained unchanged: 5.97(±1.1) vs. 5.24 (±1.45). A higher number of pills after 48 months was associated with higher aortic pulse wave velocity (1-5 pill group: 8.1 ± 1.6 m/s; 6-10 pill group: 10.9 ± 1.8 m/s; >11 pill group: 15.1 ± 2.6 m/s) (p = 0.003). Conclusions: Antihypertensive effect after renal denervation lasts up to 48 months with no worsening of arterial stiffness compared to baseline. In our study, polypharmacy was associated with increased arterial stiffness 48 months after the procedure.
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Affiliation(s)
- Vytautas Juknevičius
- Clinic of Heart and Vessel Diseases, Institute of Clinical Medicine at the Faculty of Medicine, Vilnius University, LT-03101 Vilnius, Lithuania; (A.B.); (R.J.); (P.Š.); (A.L.)
| | - Andrius Berūkštis
- Clinic of Heart and Vessel Diseases, Institute of Clinical Medicine at the Faculty of Medicine, Vilnius University, LT-03101 Vilnius, Lithuania; (A.B.); (R.J.); (P.Š.); (A.L.)
| | - Renata Juknevičienė
- Clinic of Heart and Vessel Diseases, Institute of Clinical Medicine at the Faculty of Medicine, Vilnius University, LT-03101 Vilnius, Lithuania; (A.B.); (R.J.); (P.Š.); (A.L.)
| | - Eugenijus Jasiūnas
- Center of Informatics and Development, Vilnius University Hospital Santaros Clinics, LT-08661 Vilnius, Lithuania;
| | - Pranas Šerpytis
- Clinic of Heart and Vessel Diseases, Institute of Clinical Medicine at the Faculty of Medicine, Vilnius University, LT-03101 Vilnius, Lithuania; (A.B.); (R.J.); (P.Š.); (A.L.)
| | - Aleksandras Laucevičius
- Clinic of Heart and Vessel Diseases, Institute of Clinical Medicine at the Faculty of Medicine, Vilnius University, LT-03101 Vilnius, Lithuania; (A.B.); (R.J.); (P.Š.); (A.L.)
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Chong T, Nguyen M. Renal Denervation: A Revival or The Same Old Story. Heart Lung Circ 2021; 30:843-847. [PMID: 33612429 DOI: 10.1016/j.hlc.2020.12.020] [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: 07/21/2020] [Revised: 11/10/2020] [Accepted: 12/30/2020] [Indexed: 10/22/2022]
Abstract
Despite well-established pharmacological treatment, hypertension has remained a large contributor to noncommunicable deaths. Given the well-known association of hypertension with adverse cardiovascular disease the importance of blood pressure control has never been more crucial. Traditionally, pharmacological management has been the mainstay of care, however, with a growing burden of disease alternative and innovative approaches are now being considered. Minimally invasive catheter-based ablation systems, targeting renal sympathetic nerves, has been proposed as a more permanent way to control blood pressure. However, the clinical data supporting renal denervation has had many rises and falls throughout the years. With the promising results of the recent second-generation clinical trials there has been a renewed area of interest for renal denervation in the treatment of hypertension.
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Affiliation(s)
- Travis Chong
- Department of Cardiology, Fiona Stanley Hospital, Perth, WA, Australia.
| | - Michael Nguyen
- Department of Population Health, University of Western Australia, Perth, WA, Australia
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21
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Zhang H, Li LY, Xiao RX, Zhang TC, Liu ZJ, Gao JQ. Effects of different ablation points of renal denervation on the efficacy of resistant hypertension. PeerJ 2020; 8:e9842. [PMID: 32983640 PMCID: PMC7500320 DOI: 10.7717/peerj.9842] [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: 06/17/2020] [Accepted: 08/10/2020] [Indexed: 11/20/2022] Open
Abstract
Objective To explore the blood pressure response to different ablation points of renal denervation (RDN) in patients with resistant hypertension Methods A total of 42 cases with resistant hypertension treated by RDN in our center from 2013 to 2015 were retrospectively analyzed. The patients were divided into two groups according to the different ablation points of RDN: the standard treatment group (spiral ablation from near to proximal, with less than 8 points per artery) and the intensive treatment group (from near to far by spiral ablation, with at least 8 points per artery), with 21 patients in each group. The ablation parameters, including points, impedance, actual wattage, and actual temperature, were recorded intraoperatively. Renal angiography was performed again after RDN. Ambulatory blood pressure (ABP) images were taken for all patients at the baseline and 6 months after operation. Results The mean 24-h blood pressure of the standard treatment group was lower than that of the baseline (24-h systolic blood pressure decreased by 7.4 ± 10.6 mmHg and 24-h diastolic blood pressure decreased by 4.6 ± 6.1 mmHg), and the mean 24-h blood pressure decreased significantly from baseline to 6 months in the intensive treatment group (24–h systolic blood pressure decreased by 27.4 ± 11.4 mmHg, P < 0.0001; 24–h diastolic blood pressure decreased by 10.9 ± 9.6 mmHg, P = 0.005). There was a positive correlation between the decrease of systolic/diastolic 24-hour mean and the number of ablation points used in the procedure. The mean value of systolic and diastolic blood pressure was positively correlated with ablation points at 24-hour (R2 = 0.777 and 0.633 respectively, P < 0.01). There were no adverse events in either group after the operation and during the follow-up. Conclusions RDN could significantly reduce BP in patients with resistant hypertension. Our study showed that the antihypertensive effect appeared to be positively correlated with the number of ablation points.
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Affiliation(s)
- Hua Zhang
- Department of Cardiology, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Ling-Yan Li
- Department of Cardiology, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Rong-Xue Xiao
- Shanghai Putuo Center Clinical College, Anhui Medical University, Shanghai, China
| | - Ting-Chuan Zhang
- Department of Cardiology, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Zong-Jun Liu
- Shanghai Putuo Center Clinical College, Anhui Medical University, Shanghai, China
| | - Jun-Qing Gao
- Department of Cardiology, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
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Mensa Sorato M, Davari M, Kebriaeezadeh A, Naderi N, Sarrafzadegan N, Shibru T, Nikfar S, Arero AG. Cost-effectiveness of Interventional therapies for management of Treatment-resistant hypertension: systematic review of pharmacoeconomic studies. JOURNAL OF PHARMACEUTICAL HEALTH SERVICES RESEARCH 2020. [DOI: 10.1111/jphs.12384] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Abstract
Background
Treatment resistant hypertension (TRH) is defined as uncontrolled blood pressure (>140/90 mm Hg) after treatment with the intensified dose of three standard antihypertensive drugs. Management of TRH involves addition of fourth line drugs on standard care or interventional therapies (Renal denervation, Baroreceptor activation, Central venous anastomosis). However, evidence concerning cost-effectiveness of interventional therapies is inconclusive. Objective: This systematic review was conducted to extract the level of evidence on cost-effectiveness of interventional therapies for TRH.
Method
We systematically searched articles written in English language since January 2000 to January 2020 from the following databases: PubMed/Medline, Ovid/Medline, Embase, Scopus, Web of Science, Google scholar and other relevant sources.
Key findings
Twelve pharmacoeconomic studies were included in this systematic review. Renal denervation (RDN) is the most commonly studied intervention therapy for treatment of TRH. Participants included in the study vary from age 18-99 years. The incremental cost-effectiveness ratio (ICER) of RDN ranged from $1,709.84 per QALY gained in Netherlands to 66,380.3 per QALY gained in Australia. RDN was cost-effective in high-risk patients in UK, Australia, Canada, Netherlands, USA, Germany, Russia and Korea. The cost-effectiveness was influenced by the magnitude of effect of RDN on systolic blood pressure, the rate of RDN nonresponders, and the procedure costs of RDN and assumption of long-term time horizon. However, the ICER of RDN in Mexico was above MXN$ 139,000 GDP/capita of the country. The ICER of implantable carotid body stimulator was $64,400 per QALYs gained. The cost-effectiveness of baroreceptor activation didn’t improve with age.
Conclusion
Overall cost-effectiveness of interventional therapies for treatment of TRH was inconclusive based on the current available evidence. Therefore, strong clinical trials and pharmacoeconomic evaluations from different perspectives in various candidate populations are needed to generate adequate clinical and cost-effectiveness evidence for using interventional therapies in treatment of treatment resistant hypertension.
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Affiliation(s)
- Mende Mensa Sorato
- Department of Pharmacy, Arba Minch University College of Medicine and Health Sciences, Tehran, Iran
| | - Majid Davari
- Department of Pharmacoeconomics and Pharmaceutical Administration, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Abbas Kebriaeezadeh
- Department of Pharmacoeconomics and Pharmaceutical Administration, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Nasim Naderi
- Rajaie Cardiovascular Medical and Research Center, Tehran, Iran
| | | | - Tamiru Shibru
- College of Medicine and Health Sciences, Arba Minch University, Arba Minch, Ethiopia
| | - Shekoufeh Nikfar
- Department of Pharmacoeconomics and Pharmaceutical Administration, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Amanuel Godana Arero
- Students' Scientific Research Center, Tehran University of Medical sciences, Tehran, Iran
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Akinseye OA, Ralston WF, Johnson KC, Ketron LL, Womack CR, Ibebuogu UN. Renal Sympathetic Denervation: A Comprehensive Review. Curr Probl Cardiol 2020; 46:100598. [PMID: 32448758 DOI: 10.1016/j.cpcardiol.2020.100598] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 04/06/2020] [Indexed: 12/28/2022]
Abstract
In 2017, the American College of Cardiology and American Heart Association released its updated blood pressure guidelines, redefining hypertension to be any systolic blood pressure ≥130 mm Hg or diastolic blood pressure ≥80 mm Hg. Among United States adults, these new parameters increased the prevalence of hypertension from 72.2 million (31.9%) to 103.3 million (45.6%) adults and decreased the rate of medication-controlled hypertension from 53.4% to 39% with the prevalence of resistant hypertension ranging from 12% to 18%. Results of the pivotal SPRINT trial showed that more intensive blood pressure control in diabetic patients decreased both cardiovascular events and all-cause mortality. However, even with ideal goals in mind, compliance remains an issue due to multiple causes, and approximately half of study participants had stopped taking their antihypertensive drug within a year. Renal sympathetic denervation is a process in which catheter-based techniques are used to ablate specific portions of the renal artery nerves with the goal of decreasing sympathetic nerve activity and reducing blood pressure. Several studies using renal artery denervation have already shown benefit in patients with resistant hypertension, and now newer trials are beginning to focus on those with stage II hypertension as an additional potential treatment population. This review will seek to summarize the current evidence surrounding renal artery denervation and discuss some of its future trials, current issues, and potential roles both in hypertension and other comorbidities.
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24
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Sigmund CD, Carey RM, Appel L, Arnett D, Bosworth HB, Cushman WC, Galis ZS, Parker MG, Hall JE, Harrison DG, McDonough AA, Nicastro HL, Oparil S, Osborn JW, Raizada MK, Wright JD, Oh YS. Report of the National Heart, Lung, and Blood Institute Working Group on Hypertension: Barriers to Translation. Hypertension 2020; 75:902-917. [PMID: 32063061 PMCID: PMC7067675 DOI: 10.1161/hypertensionaha.119.13887] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The National Heart, Lung, and Blood Institute convened a multidisciplinary working group of hypertension researchers on December 6 to 7, 2018, in Bethesda, MD, to share current scientific knowledge in hypertension and to identify barriers to translation of basic into clinical science/trials and implementation of clinical science into clinical care of patients with hypertension. The goals of the working group were (1) to provide an overview of recent discoveries that may be ready for testing in preclinical and clinical studies; (2) to identify gaps in knowledge that impede translation; (3) to highlight the most promising scientific areas in which to pursue translation; (4) to identify key challenges and barriers for moving basic science discoveries into translation, clinical studies, and trials; and (5) to identify roadblocks for effective dissemination and implementation of basic and clinical science in real-world settings. The working group addressed issues that were responsive to many of the objectives of the National Heart, Lung, and Blood Institute Strategic Vision. The working group identified major barriers and opportunities for translating research to improved control of hypertension. This review summarizes the discussion and recommendations of the working group.
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Affiliation(s)
| | | | | | | | | | | | | | | | - John E. Hall
- University of Mississippi Medical Center, Jackson, MS
| | | | | | | | | | | | | | | | - Young S. Oh
- Vascular Biology & Hypertension Branch, DCVS, NHLBI
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25
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Bergman RN, Piccinini F, Kabir M, Ader M. Novel aspects of the role of the liver in carbohydrate metabolism. Metabolism 2019; 99:119-125. [PMID: 31158368 PMCID: PMC7216693 DOI: 10.1016/j.metabol.2019.05.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 05/23/2019] [Accepted: 05/25/2019] [Indexed: 01/21/2023]
Abstract
Malfunction of the liver is a central factor in metabolic disease. Glucose production by liver is complex and controlled via indirect mechanisms; insulin regulates adipose tissue lipolysis, and free fatty acids in turn regulate liver glucose output. This latter concept is confirmed by studies in L-Akt-Foxo1 knockout mice. The adipocyte is a likely locus of hepatic insulin resistance. Also, kidneys play a role in regulating glucose production; denervated kidneys abrogate the effect of fat feeding to cause insulin resistance. Glucose itself is an important regulator of liver metabolism ("glucose effectiveness"); after entering liver, glucose is phosphorylated and can be exported as lactate. Using the dynamic glucose/lactate relationship, we have been able to estimate glucose effectiveness in intact animals and human subjects. Families have been identified with a glucokinase regulatory protein defect; modeling demonstrates elevated glucokinase activity. Insulin clearance by liver is highly variable among normal individuals, and is under environmental control: high fat diet reduces clearance by 30%. Liver insulin clearance is significantly lower in African American (AA) adults and children compared to European American participants, accounting for fasting hyperinsulinemia in AA. We hypothesize that reduced hepatic insulin clearance causes peripheral insulin resistance and increased Type 2 diabetes in AA.
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Affiliation(s)
- Richard N Bergman
- Diabetes and Obesity Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States of America.
| | - Francesca Piccinini
- Diabetes and Obesity Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
| | - Morvarid Kabir
- Diabetes and Obesity Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
| | - Marilyn Ader
- Diabetes and Obesity Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
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26
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Townsend RR. Revisiting Renal Denervation. Mayo Clin Proc 2019; 94:1665-1667. [PMID: 31402055 DOI: 10.1016/j.mayocp.2019.07.006] [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: 07/03/2019] [Accepted: 07/03/2019] [Indexed: 10/26/2022]
Affiliation(s)
- Raymond R Townsend
- Perelman School of Medicine, University of Pennsylvania Health System, Philadelphia.
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27
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Choe WS, Song WH, Jeong CW, Choi EK, Oh S. Anatomic Conformation of Renal Sympathetic Nerve Fibers in Living Human Tissues. Sci Rep 2019; 9:4831. [PMID: 30886195 PMCID: PMC6423056 DOI: 10.1038/s41598-019-41159-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Accepted: 02/25/2019] [Indexed: 01/07/2023] Open
Abstract
Renal denervation using radiofrequency catheter ablation is known to eliminate the renal sympathetic nerve and to lower blood pressure in patients with resistant hypertension. We sought to investigate the detailed anatomic conformation of the peri-renal arterial sympathetic nerve fibers with living human specimens. Peri-renal arterial tissue was harvested from patients undergoing elective radical or simple nephrectomy. Digital images of each section from the distal arterial bifurcation to the proximal margin were obtained and analyzed after immunohistochemical staining with anti-tyrosine hydroxylase antibodies. A total of 3,075 nerve fibers were identified from 84 sections of peri-renal arterial tissue from 28 patients (mean age 62.5 ± 10.2 years, male 68%). Overall, 16% of nerve fibers were located at distances greater than 3 mm from the endoluminal surface of the renal artery. The median distance from the arterial lumen to the nerve fibers of the proximal, middle, and distal renal arterial segments was 1.51 mm, 1.48 mm, and 1.52 mm, respectively. The median diameter of the nerve fibers was 65 μm, and there was no significant difference between the segments. A substantial proportion of the sympathetic nerve fibers were located deeper in the peri-arterial soft tissue than in the lesion depth created by the conventional catheter-based renal sympathetic denervation system.
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Affiliation(s)
- Won-Seok Choe
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Won Hoon Song
- Department of Urology, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea.,Department of Urology, Seoul National University Hospital, Seoul, Republic of Korea
| | - Chang Wook Jeong
- Department of Urology, Seoul National University Hospital, Seoul, Republic of Korea.
| | - Eue-Keun Choi
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea.
| | - Seil Oh
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
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Wilson AL, Gandhi J, Suh Y, Joshi G, Smith NL, Khan SA. Renal Innervation in Resistant Hypertension: A Review of Pathophysiology and Renal Denervation as Potential Treatment. Curr Hypertens Rev 2019; 16:115-127. [PMID: 30827252 PMCID: PMC7527543 DOI: 10.2174/1573402115666190301154100] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Revised: 02/21/2019] [Accepted: 02/21/2019] [Indexed: 12/30/2022]
Abstract
Background Advances in treatment and increased awareness have improved the prognosis for many patients with hypertension (HTN). Resistant hypertension (RH) refers to a subset of hypertensive individuals who fail to achieve a desired blood pressure (BP) despite concurrent use of 3 different classes antihypertensive agents, one being a diuretic, and proper lifestyle changes. The prevalence and prognosis of RH are unclear owing to its heterogeneous etiologies, risk factors, and secondary comorbidities. Previous research has provided evidence that increased renal sympathetic nerve activity (RSNA) within the renal artery contributes to RH development. Renal denervation (RDN) is a procedure that attempts to ameliorate the effects of heightened RSNA via ablation renal sympathetic fibers. BP reductions associated with RDN may be attributed to decreased norepinephrine spillover, restoration of natriuresis, increasing renal blood flow, and lowering plasma renin activity. Early clinical trials perpetuated positive results, and enthusiasm grew exponentially. However, recent clinical trials have called into question RDN's efficacy. Numerous limitations must be addressed to discern the true effectiveness of RDN as a therapeutic option for RH. Objective We aimed to review the current understanding of RH, the anatomy of renal arteries, physiology of RH on renal arteries, anatomical pathways of the sympathetic involved in RH, RDN as a treatment option, and all relevant clinical trials treating RH with RDN. Methods We piloted a MEDLINE® database search of literature extending from 1980 to 2017, with emphasis on the previous five years, combining keywords such as “resistant hypertension” and
“renal denervation.” Conclusion A plethora of information is available regarding heightened RSNA leading to RH. RDN as a possible treatment option has shown a range of results. Reconciling RDN's true efficacy requires future trials to increased sites of nerve ablation, standardized protocol, increased anatomical understanding per individual basis, stricter guidelines regarding study design, increased operator experience, and integrating the use of a multielectrode catheter.
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Affiliation(s)
- Anthony L Wilson
- Department of Physiology and Biophysics, Renaissance School of Medicine at Stony Brook University, Stony Brook, NY 11794, United States
| | - Jason Gandhi
- Department of Physiology and Biophysics, Renaissance School of Medicine at Stony Brook University, Stony Brook, NY 11794, United States
| | - Yiji Suh
- Department of Physiology and Biophysics, Renaissance School of Medicine at Stony Brook University, Stony Brook, NY 11794, United States
| | - Gunjan Joshi
- Department of Internal Medicine, Stony Brook Southampton Hospital, Southampton, NY 11968, United States
| | - Noel L Smith
- Foley Plaza Medical, New York, NY 10007, United States
| | - Sardar Ali Khan
- Department of Physiology and Biophysics, Renaissance School of Medicine at Stony Brook University, Stony Brook, NY 11794, United States
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Townsend RR. Treating Hypertension Using Renal Artery Denervation: Problems and Progress. Adv Chronic Kidney Dis 2019; 26:117-121. [PMID: 31023445 DOI: 10.1053/j.ackd.2019.02.004] [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: 10/22/2018] [Revised: 02/21/2019] [Accepted: 02/21/2019] [Indexed: 11/11/2022]
Abstract
Early reports of renal denervation as a therapy for hypertension generated intense interest in this approach to management of elevated blood pressures despite ongoing treatment. The publication of the large, sham-controlled randomized clinical trial of renal denervation, Symplicity HTN-3, failed to show superiority of renal denervation by radiofrequency energy ablation compared with a sham procedure similar to the procedure used for denervation but without the application of energy to the renal artery. This prompted consideration of confounding factors and rethinking about the protocol and the procedure itself. This review describes these confounders and the progress made to improve trial design in the field of renal artery denervation.
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Mahfoud F, Bakris G, Bhatt DL, Esler M, Ewen S, Fahy M, Kandzari D, Kario K, Mancia G, Weber M, Böhm M. Reduced blood pressure-lowering effect of catheter-based renal denervation in patients with isolated systolic hypertension: data from SYMPLICITY HTN-3 and the Global SYMPLICITY Registry. Eur Heart J 2018; 38:93-100. [PMID: 28158510 PMCID: PMC5381589 DOI: 10.1093/eurheartj/ehw325] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2016] [Revised: 04/27/2016] [Accepted: 06/29/2016] [Indexed: 12/26/2022] Open
Abstract
Aims Catheter-based renal artery denervation (RDN) has been shown to lower blood pressure (BP) in certain patients with uncontrolled hypertension. Isolated systolic hypertension (ISH) (systolic BP [SBP] ≥140 mmHg and diastolic BP <90 mmHg), characterized by increased vascular stiffness, is the predominant hypertensive phenotype in elderly patients. This study compared baseline characteristics and SBP change at 6 months between patients with ISH and combined systolic–diastolic hypertension (CH). Methods and results This study pooled data from 1103 patients from SYMPLICITY HTN-3 and the Global SYMPLICITY Registry. A total of 429 patients had ISH, and 674 had CH. Patients with ISH were significantly older than those with CH (66 vs. 55 years), had more type 2 diabetes mellitus (52.9 vs. 34.6%), and a lower estimated glomerular filtration rate (71.8 vs. 78.6 mL/min/1.73 m2); all P < 0.001. At 6 months, the SBP drop for CH patients was −18.7 ± 23.7 mmHg compared with a reduction of −10.9 ± 21.7 mmHg for ISH patients −7.8 mmHg, 95% confidence interval, CI, −10.5, −5.1, P < 0.001). The change in 24-h SBP at 6 months was −8.8 ± 16.2 mmHg in patients with CH vs. −5.8 ± 15.4 mmHg in ISH (−3.0 mmHg, 95% CI −5.4, −0.6, P = 0.015). Presence of ISH at baseline but not age was associated with less pronounced BP changes following the procedure. The strongest predictor of office SBP reduction at 6 months was CH, followed by aldosterone antagonist use and non-use of vasodilators. Conclusion The reduction in BP among patients with ISH following RDN was less pronounced than the reduction in patients with CH. Clinical.Trials.gov identifiers NCT01534299 and NCT01418261.
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Affiliation(s)
- Felix Mahfoud
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Saarland University Hospital, Kirrberger Str., Geb. 40, Homburg/Saar 66421, Germany
- Corresponding author. Tel: +49 6841 16 15911, Fax: +49 6841 16 15910,
| | | | - Deepak L. Bhatt
- Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA, USA
| | - Murray Esler
- Baker IDI Heart and Diabetes Institute, Melbourne, Australia
| | - Sebastian Ewen
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Saarland University Hospital, Kirrberger Str., Geb. 40, Homburg/Saar 66421, Germany
| | | | | | - Kazuomi Kario
- Jichi Medical University School of Medicine, Tochigi, Japan
| | - Giuseppe Mancia
- University of Milano-Bicocca and Istituto Auxologico Italiano, Milan, Italy
| | | | - Michael Böhm
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Saarland University Hospital, Kirrberger Str., Geb. 40, Homburg/Saar 66421, Germany
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Fudim M, Sobotka AA, Yin YH, Wang JW, Levin H, Esler M, Wang J, Sobotka PA. Selective vs. Global Renal Denervation: a Case for Less Is More. Curr Hypertens Rep 2018; 20:37. [PMID: 29717380 DOI: 10.1007/s11906-018-0838-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW Review the renal nerve anatomy and physiology basics and explore the concept of global vs. selective renal denervation (RDN) to uncover some of the fundamental limitations of non-targeted renal nerve ablation and the potential superiority of selective RDN. RECENT FINDINGS Recent trials testing the efficacy of RDN showed mixed results. Initial investigations targeted global RDN as a therapeutic goal. The repeat observation of heterogeneous response to RDN including non-responders with lack of a BP reduction, or even more unsettling, BP elevations after RDN has raised concern for the detrimental effects of unselective global RDN. Subsequent studies have suggested the presence of a heterogeneous fiber population and the potential utility of renal nerve stimulation to identify sympatho-stimulatory fibers or "hot spots." The recognition that RDN can produce heterogeneous afferent sympathetic effects both change therapeutic goals and revitalize the potential of therapeutic RDN to provide significant clinical benefits. Renal nerve stimulation has emerged as potential tool to identify sympatho-stimulatory fibers, avoid sympatho-inhibitory fibers, and thus guide selective RDN.
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Affiliation(s)
- Marat Fudim
- Duke University Medical Center, Durham, NC, USA.,Duke Clinical Research Institute, Durham, NC, USA
| | | | - Yue-Hui Yin
- The 2nd Affiliated Hospital of Chongqing Medical University, Chongqin, China
| | | | | | - Murray Esler
- Baker Heart and Diabetes Institute, Melbourne, Australia
| | - Jie Wang
- Columbia University, New York, NY, USA.,SyMap Medical Ltd., Suzhou, China
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Osborn JW, Banek CT. Catheter-Based Renal Nerve Ablation as a Novel Hypertension Therapy: Lost, and Then Found, in Translation. Hypertension 2018; 71:383-388. [PMID: 29295850 DOI: 10.1161/hypertensionaha.117.08928] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- John W Osborn
- From the Department of Integrative Biology and Physiology, University of Minnesota Medical School, Minneapolis.
| | - Christopher T Banek
- From the Department of Integrative Biology and Physiology, University of Minnesota Medical School, Minneapolis
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Okamura K, Shirai K, Okuda T, Urata H. The Prevalence of Japanese Outpatients with Hypertension Who Meet the Definition of Treatment Resistant Hypertension and Are Eligible for Enrolment in Clinical Trials of Endovascular Ultrasound Renal Denervation. Intern Med 2018; 57:1-12. [PMID: 29033430 PMCID: PMC5799049 DOI: 10.2169/internalmedicine.9059-17] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Objective A clinical trial (REQUIRE) was started to investigate the use of an ultrasound renal denervation system in the treatment of resistant hypertension (RHT). We analyzed the prevalence of patients who were eligible for inclusion in this cross-sectional study at the time of screening. Methods Nine-hundred ninety-nine consecutive hypertension (HT) patients who were treated in our hospital as outpatients were classified into the following categories: patients treated with at least 3 types of antihypertensive drugs including diuretic agents who were eligible for enrolment in SYMPLICITY HTN-Japan (SH-J) with an office systolic blood pressure (SBP) of ≥160 mmHg, who were ≤80 years of age, and an estimated glomerular filtration rate (eGFR) of ≥45 mL/min/1.73 m2 (RHT-S); and patients who were treated similar medications and who were eligible for enrolment in REQUIRE, with an SBP of ≥150 mmHg, ≤75 years of age, and an eGFR of ≥40 mL/min/1.73 m2 (RHT-R). We investigated the proportion of patients in each category. We also investigated HT patients (1,423 cases) who were enrolled in the Chikushi Anti-Hypertension Trial (CHAT), a research network that includes general practitioners. Results Eleven patients (1.1%) with RHT-S and 18 patients (1.8%) with RHT-R were identified. After the exclusion of patients with secondary HT and a diastolic blood pressure (DBP) of <90 mmHg (applied in REQUIRE), 5 patients (0.5%) with RHT-S and 4 patients (0.4%) with RHT-R remained. In the analysis of the CHAT study, only 2 (0.1%) patients with RHT-R remained. Conclusion The number of eligible patients in the REQUIRE trial was decreased, largely due to the strict age restriction and the new DBP limitation. The prevalence of eligible patients in REQUIRE was estimated to be approximately 0.5 to 0.8 times that in SH-J. Since patient enrollment will be difficult, drastic measures may be required to recruit eligible patients.
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Affiliation(s)
- Keisuke Okamura
- Department of Cardiovascular Diseases, Fukuoka University Chikushi Hospital, Japan
| | - Kazuyuki Shirai
- Department of Cardiovascular Diseases, Fukuoka University Chikushi Hospital, Japan
| | - Tetsu Okuda
- Department of Cardiovascular Diseases, Fukuoka University Chikushi Hospital, Japan
| | - Hidenori Urata
- Department of Cardiovascular Diseases, Fukuoka University Chikushi Hospital, Japan
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Bönner F, Haberkorn S, Behm P, Schnackenburg B, Krüger S, Weiss S, Meyer C, Kelm M, Neizel-Wittke M. Magnetic resonance guided renal denervation using active tracking: first in vivo experience in Swine. Int J Cardiovasc Imaging 2017; 34:431-439. [DOI: 10.1007/s10554-017-1244-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Accepted: 09/08/2017] [Indexed: 10/18/2022]
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Becker BK, Feagans AC, Chen D, Kasztan M, Jin C, Speed JS, Pollock JS, Pollock DM. Renal denervation attenuates hypertension but not salt sensitivity in ET B receptor-deficient rats. Am J Physiol Regul Integr Comp Physiol 2017; 313:R425-R437. [PMID: 28701323 DOI: 10.1152/ajpregu.00174.2017] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Revised: 06/16/2017] [Accepted: 07/06/2017] [Indexed: 02/07/2023]
Abstract
Hypertension is a prevalent pathology that increases risk for numerous cardiovascular diseases. Because the etiology of hypertension varies across patients, specific and effective therapeutic approaches are needed. The role of renal sympathetic nerves is established in numerous forms of hypertension, but their contribution to salt sensitivity and interaction with factors such as endothelin-1 are poorly understood. Rats deficient of functional ETB receptors (ETB-def) on all tissues except sympathetic nerves are hypertensive and exhibit salt-sensitive increases in blood pressure. We hypothesized that renal sympathetic nerves contribute to hypertension and salt sensitivity in ETB-def rats. The hypothesis was tested through bilateral renal sympathetic nerve denervation and measuring blood pressure during normal salt (0.49% NaCl) and high-salt (4.0% NaCl) diets. Denervation reduced mean arterial pressure in ETB-def rats compared with sham-operated controls by 12 ± 3 (SE) mmHg; however, denervation did not affect the increase in blood pressure after 2 wk of high-salt diet (+19 ± 3 vs. +16 ± 3 mmHg relative to normal salt diet; denervated vs. sham, respectively). Denervation reduced cardiac sympathetic-to-parasympathetic tone [low frequency-high frequency (LF/HF)] during normal salt diet and vasomotor LF/HF tone during high-salt diet in ETB-def rats. We conclude that the renal sympathetic nerves contribute to the hypertension but not to salt sensitivity of ETB-def rats.
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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
| | - Amanda C Feagans
- Cardio-Renal Physiology and Medicine, Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Daian Chen
- Cardio-Renal Physiology and Medicine, Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Malgorzata Kasztan
- Cardio-Renal Physiology and Medicine, Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Chunhua Jin
- Cardio-Renal Physiology and Medicine, Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Joshua S Speed
- Cardio-Renal Physiology and Medicine, Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Jennifer S Pollock
- Cardio-Renal Physiology and Medicine, Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - David M Pollock
- Cardio-Renal Physiology and Medicine, Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
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Abstract
The objective of this review is to provide an in-depth evaluation of how renal nerves regulate renal and cardiovascular function with a focus on long-term control of arterial pressure. We begin by reviewing the anatomy of renal nerves and then briefly discuss how the activity of renal nerves affects renal function. Current methods for measurement and quantification of efferent renal-nerve activity (ERNA) in animals and humans are discussed. Acute regulation of ERNA by classical neural reflexes as well and hormonal inputs to the brain is reviewed. The role of renal nerves in long-term control of arterial pressure in normotensive and hypertensive animals (and humans) is then reviewed with a focus on studies utilizing continuous long-term monitoring of arterial pressure. This includes a review of the effect of renal-nerve ablation on long-term control of arterial pressure in experimental animals as well as humans with drug-resistant hypertension. The extent to which changes in arterial pressure are due to ablation of renal afferent or efferent nerves are reviewed. We conclude by discussing the importance of renal nerves, relative to sympathetic activity to other vascular beds, in long-term control of arterial pressure and hypertension and propose directions for future research in this field. © 2017 American Physiological Society. Compr Physiol 7:263-320, 2017.
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Affiliation(s)
- John W Osborn
- Department of Integrative Biology and Physiology, Medical School, University of Minnesota, Minneapolis, Minnesota, USA
| | - Jason D Foss
- Department of Integrative Biology and Physiology, Medical School, University of Minnesota, Minneapolis, Minnesota, USA
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Bhatt N, Long SA, Gardner EA, Tay J, Ladich E, Chamberlain D, Fogarty TJ, Maguire PJ. Radiosurgical Ablation of the Renal Nerve in a Porcine Model: A Minimally Invasive Therapeutic Approach to Treat Refractory Hypertension. Cureus 2017; 9:e1055. [PMID: 28367392 PMCID: PMC5364090 DOI: 10.7759/cureus.1055] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Accepted: 02/26/2017] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Hypertension is strongly associated with cardiovascular diseases such as heart failure, stroke, kidney disease, and has been correlated with an increased risk for heart attack. Current treatment regimens for hypertension are highly inadequate, with reports indicating that only 50.1% of the clinical population with the disease has their blood pressure under control. OBJECTIVE To study the feasibility of using minimally invasive radiosurgery to ablate the renal nerves as a novel treatment for refractory hypertension, and to assess the safety and efficacy of such an approach. METHODS A Hanford porcine (miniswine) model (N = 6) was used to investigate the feasibility of using the CyberHeart radiosurgical platform (CyberHeart Inc., Mountain View, CA, USA) to create safe renal nerve ablations. Norepinephrine (NE) levels were measured pre and post treatment. Additionally, renal nerve and arterial histology were studied to examine effect. RESULTS Plasma norepinephrine levels showed a decrease over the six-month time point. Urea, nitrogen, and creatinine levels showed no changes post procedure. Histology documented no significant arterial injury in targeted areas. Renal nerves documented histologic change consistent with nerve ablation. CONCLUSION CyberHeart radiosurgery of the renal nerve is feasible and resulted in norepinephrine reduction and renal nerve injury consistent with radiosurgical targeted ablation.
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Affiliation(s)
| | | | | | | | - Elena Ladich
- Cardiovascular Pathology, Memorial Regional Hospital
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Abstract
BACKGROUND Resistant hypertension is highly prevalent among the general hypertensive population and the clinical management of this condition remains problematic. Different approaches, including a more intensified antihypertensive therapy, lifestyle modifications, or both, have largely failed to improve patients' outcomes and to reduce cardiovascular and renal risk. As renal sympathetic hyperactivity is a major driver of resistant hypertension, renal sympathetic ablation (renal denervation) has been recently proposed as a possible therapeutic alternative to treat this condition. OBJECTIVES We sought to evaluate the short- and long-term effects of renal denervation in individuals with resistant hypertension on clinical end points, including fatal and non-fatal cardiovascular events, all-cause mortality, hospital admissions, quality of life, blood pressure control, left ventricular hypertrophy, cardiovascular and metabolic profile, and kidney function, as well as the potential adverse events related to the procedure. SEARCH METHODS We searched the following databases to 17 February 2016 using relevant search terms: the Cochrane Hypertension Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE and ClinicalTrials.gov SELECTION CRITERIA: We considered randomised controlled trials (RCTs) that compared renal denervation to standard therapy or sham procedure to treat resistant hypertension, without language restriction. DATA COLLECTION AND ANALYSIS Two authors independently extracted data and assessed study risks of bias. We summarised treatment effects on available clinical outcomes and adverse events using random-effects meta-analyses. We assessed heterogeneity in estimated treatment effects using Chi² and I² statistics. We calculated summary treatment estimates as a mean difference (MD) or standardised mean difference (SMD) for continuous outcomes, and a risk ratio (RR) for dichotomous outcomes, together with their 95% confidence intervals (CI). MAIN RESULTS We found 12 eligible studies (1149 participants). In four studies, renal denervation was compared to sham procedure; one study compared a proximal ablation to a complete renal artery denervation; in the remaining, renal denervation was tested against standard or intensified antihypertensive therapy.None of the included trials was designed to look at hard clinical end points as primary outcomes.When compared to control, there was low quality evidence that renal denervation did not reduce the risk of myocardial infarction (4 studies, 742 participants; RR 1.31, 95% CI 0.45 to 3.84), ischaemic stroke (4 studies, 823 participants; RR 1.15, 95% CI 0.36 to 3.72), or unstable angina (2 studies, 201 participants; RR 0.63, 95% CI 0.08 to 5.06), and moderate quality evidence that it had no effect on 24-hour ambulatory blood pressure monitoring (ABPM) systolic BP (5 studies, 797 participants; MD 0.28 mmHg, 95% CI -3.74 to 4.29), diastolic BP (4 studies, 756 participants; MD 0.93 mmHg, 95% CI -4.50 to 6.36), office measured systolic BP (6 studies, 886 participants; MD -4.08 mmHg, 95% CI -15.26 to 7.11), or diastolic BP (5 studies, 845 participants; MD -1.30 mmHg, 95% CI -7.30 to 4.69). Furthermore, low quality evidence suggested that this procedure produced no effect on either serum creatinine (3 studies, 736 participants, MD 0.01 mg/dL; 95% CI -0.12 to 0.14), estimated glomerular filtration rate (eGFR), or creatinine clearance (4 studies, 837 participants; MD -2.09 mL/min, 95% CI -8.12 to 3.95). Based on low-quality evidence, renal denervation significantly increased bradycardia episodes compared to control (3 studies, 220 participants; RR 6.63, 95% CI 1.19 to 36.84), while the risk of other adverse events was comparable or not assessable.Data were sparse or absent for all cause mortality, hospitalisation, fatal cardiovascular events, quality of life, atrial fibrillation episodes, left ventricular hypertrophy, sleep apnoea severity, need for renal replacement therapy, and metabolic profile.The quality of the evidence was low for cardiovascular outcomes and adverse events and moderate for lack of effect on blood pressure and renal function. AUTHORS' CONCLUSIONS In patients with resistant hypertension, there is low quality evidence that renal denervation does not change major cardiovascular events, and renal function. There was moderate quality evidence that it does not change blood pressure and and low quality evidence that it caused an increaseof bradycardia episodes. Future trials measuring patient-centred instead of surrogate outcomes, with longer follow-up periods, larger sample size and more standardized procedural methods are necessary to clarify the utility of this procedure in this population.
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Affiliation(s)
- Giuseppe Coppolino
- "Pugliese‐Ciaccio" General HospitalNephrology and Dialysis UnitViale pio XCatanzaroCatanzaroItaly88100
| | - Anna Pisano
- CNR ‐ Italian National Council of ResearchInstitute of Clinical PhysiologyCNR‐IFC Via Vallone Petrara c/o Ospedali RiunitiReggio CalabriaItaly89100
| | - Laura Rivoli
- University "Magna Graecia"Department of Medical and Surgical Sciences, Nephrology and Dialysis UnitViale EuropaCatanzaroItaly88100
| | - Davide Bolignano
- CNR ‐ Italian National Council of ResearchInstitute of Clinical PhysiologyCNR‐IFC Via Vallone Petrara c/o Ospedali RiunitiReggio CalabriaItaly89100
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Qian P, Barry M, Al-Raisi S, Kovoor P, Pouliopoulos J, Nalliah C, Bhaskaran A, Chik W, Kurup R, James V, Varikatt W, McEwan A, Thiagalingam A, Thomas S. Transcatheter non-contact microwave ablation may enable circumferential renal artery denervation while sparing the vessel intima and media. EUROINTERVENTION 2017; 12:e1907-e1915. [DOI: 10.4244/eij-d-16-00509] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Šochman J, Bürgelová M, Peregrin JH. Renal denervation in the most serious form of resistant arterial hypertension. Physiol Res 2016; 65:909-916. [PMID: 27539107 DOI: 10.33549/physiolres.933238] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
The aim of our observation was to establish whether or not renal sympathetic denervation (RSD) may help control blood pressure (BP) levels in patients with severe hypertension refractory to pharmacological therapy. Out of a group of 12 patients, candidates for RSD, with uncontrolled hypertension and a systolic BP over 190 mm Hg on repeated measurements despite optimal medication, four patients were excluded for multiple renal arteries and one for hyperaldosteronism. Seven patients had RSD using a Symplicity device (5M, 2 F) with a mean age of 64.9 years. While all were followed up for a minimum of 6 months, follow-up duration in the majority of them was substantially longer (12-20 months). At six months post-RSD, six of the seven patients showed a decrease in systolic BP by at least 15 mm Hg while receiving the same or fewer doses of antihypertensive agents. A similar response was seen in diastolic BP. The BP decrease was maintained throughout whole follow-up. In a small group of patients with severe hypertension, we demonstrated that renal sympathetic denervation is capable of reducing blood pressure even in patients with severe hypertension.
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Affiliation(s)
- J Šochman
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic. ,
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Regression to the Mean in SYMPLICITY HTN-3. J Am Coll Cardiol 2016; 68:2016-2025. [DOI: 10.1016/j.jacc.2016.07.775] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Revised: 06/25/2016] [Accepted: 07/20/2016] [Indexed: 11/23/2022]
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Affiliation(s)
- Raymond R. Townsend
- From the Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Division of Nephrology and Hypertension, University of Miami Miller School of Medicine, FL
| | - Murray Epstein
- From the Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Division of Nephrology and Hypertension, University of Miami Miller School of Medicine, FL
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VonAchen P, Hamann J, Houghland T, Lesser JR, Wang Y, Caye D, Rosenthal K, Garberich RF, Daniels M, Schwartz RS. Accessory renal arteries: Prevalence in resistant hypertension and an important role in nonresponse to radiofrequency renal denervation. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2016; 17:470-473. [PMID: 27493150 DOI: 10.1016/j.carrev.2016.07.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2016] [Accepted: 07/18/2016] [Indexed: 10/21/2022]
Abstract
OBJECTIVE The aim of this study was to understand the role of accessory renal arteries in resistant hypertension, and to establish their role in nonresponse to radiofrequency renal denervation (RDN) procedures. BACKGROUND Prior studies suggest a role for accessory renal arteries in hypertensive syndromes, and recent clinical trials of renal denervation report that these anomalies are highly prevalent in resistant hypertension. This study evaluated the relationships among resistant hypertension, accessory renal arteries, and the response to radiofrequency (RF) renal denervation. METHODS Computed Tomography Angiography (CTA) and magnetic resonance imaging (MRI) scans from 58 patients with resistant hypertension undergoing RF renal denervation (RDN) were evaluated. Results were compared with CT scans in 57 healthy, normotensive subjects undergoing screening as possible renal transplant donors. All scans were carefully studied for accessory renal arteries, and were correlated with long term blood pressure reduction. RESULTS Accessory renal arteries were markedly more prevalent in the hypertensive patients than normotensive renal donors (59% vs 32% respectively, p=0.004). RDN had an overall nonresponse rate of 29% (response rate 71%). Patients without accessory vessels had a borderline higher response rate to RDN than those with at least one accessory vessel (83% vs 62% respectively, p=0.076) and a higher RDN response than patients with untreated accessory arteries (83% vs 55%; p=0.040). For accessory renal arteries and nonresponse, the sensitivity was 76%, specificity 49%, with positive and negative predictive values 38% and 83% respectively. CONCLUSIONS Accessory renal arteries were markedly over-represented in resistant hypertensives compared with healthy controls. While not all patients with accessory arteries were nonresponders, nonresponse was related to both the presence and non-treatment of accessory arteries. Addressing accessory renal arteries in future clinical trials may improve RDN therapeutic efficacy.
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Affiliation(s)
- Paige VonAchen
- Minneapolis Heart Institute and Foundation at Abbott Northwestern Hospital, Minneapolis, MN
| | | | - Thomas Houghland
- Minneapolis Heart Institute and Foundation at Abbott Northwestern Hospital, Minneapolis, MN
| | - John R Lesser
- Minneapolis Heart Institute and Foundation at Abbott Northwestern Hospital, Minneapolis, MN
| | - Yale Wang
- Minneapolis Heart Institute and Foundation at Abbott Northwestern Hospital, Minneapolis, MN
| | - David Caye
- Minneapolis Heart Institute and Foundation at Abbott Northwestern Hospital, Minneapolis, MN
| | - Kristi Rosenthal
- Minneapolis Heart Institute and Foundation at Abbott Northwestern Hospital, Minneapolis, MN
| | - Ross F Garberich
- Minneapolis Heart Institute and Foundation at Abbott Northwestern Hospital, Minneapolis, MN
| | | | - Robert S Schwartz
- Minneapolis Heart Institute and Foundation at Abbott Northwestern Hospital, Minneapolis, MN.
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Skowerski M, Roleder T, Bańska-Kisiel K, Pysz P, Ochała A, Wojakowski W, Gąsior Z. Long-term follow-up after radio-frequency catheter-based denervation in patients with resistant hypertension. Int J Cardiol 2016; 215:472-5. [PMID: 27131767 DOI: 10.1016/j.ijcard.2016.04.093] [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: 02/11/2016] [Accepted: 04/11/2016] [Indexed: 11/25/2022]
Abstract
UNLABELLED The aim of this single-center study was to asses the long-term clinical data of patients with resistant hypertension who underwent radiofrequency renal denervation (RND). METHODS Out of 86 patients with resistant-hypertension, 15 pts fulfilled the study criteria for performing RND using Simplicity system by Medtronic. RESULTS Baseline office systolic BP was 204±32.7 and diastolic BP 107.7±15.1mmHg. Baseline 24h ambulatory systolic BP was 151.8±13.9 and diastolic BP 86.8±13.8mmHg. Patients were treated with an average of 5 antihypertensive agents in maximally tolerated doses (including diuretic) during the whole trial and were followed up at 1,6,24month after RND. At every appointment an echocardiography, blood test, and blood pressure (office and ABMP) measurements were performed. The mean reduction in office systolic (SBP) and diastolic (DBP) blood pressure were the following: There were no procedural complications. All denervations were performed by experienced operator. CONCLUSIONS We regard RND as a safe and effective procedure in resistant hypertension, although more studies and trials are needed to find the most adequate model of a patient that would be a good responder to RND.
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Affiliation(s)
- Mariusz Skowerski
- 2nd Department of Cardiology, Medical University of Silesia, Katowice, Poland.
| | - Tomasz Roleder
- 2nd Department of Cardiology, Medical University of Silesia, Katowice, Poland.
| | | | - Piotr Pysz
- 2nd Department of Cardiology, Medical University of Silesia, Katowice, Poland.
| | - Andrzej Ochała
- 2nd Department of Cardiology, Medical University of Silesia, Katowice, Poland.
| | - Wojciech Wojakowski
- 2nd Department of Cardiology, Medical University of Silesia, Katowice, Poland.
| | - Zbigniew Gąsior
- 2nd Department of Cardiology, Medical University of Silesia, Katowice, Poland.
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Li P, Nader M, Arunagiri K, Papademetriou V. Device-Based Therapy for Drug-Resistant Hypertension: An Update. Curr Hypertens Rep 2016; 18:64. [PMID: 27402013 DOI: 10.1007/s11906-016-0671-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Drug-resistant hypertension (RH) remains a significant and common cardiovascular risk despite the availability of multiple potent antihypertensive medications. Uncontrolled resistant hypertension contributes substantially to excessive cardiovascular and renal morbidity and mortality. Clinical and experimental evidence suggest that sympathetic nervous system over-activity is the main culprit for the development and maintenance of drug-resistant hypertension. Both medical and interventional strategies, targeting the sympathetic over-activation, have been designed in patients with hypertension over the past few decades. Minimally invasive, catheter-based, renal sympathetic denervation (RDN) and carotid baroreceptor activation therapy (BAT) have been extensively evaluated in patients with RH in clinical trials. Current trial outcomes, though at times impressive, have been mostly uncontrolled trials in need of validation. Device-based therapy for drug-resistant hypertension has the potential to provide alternative treatment options to certain groups of patients who are refractory or intolerant to current antihypertensive medications. However, more research is needed to prove its efficacy in both animal models and in humans. In this article, we will review the evidence from recent renal denervation, carotid baroreceptor stimulation therapy, and newly emerged central arteriovenous anastomosis trials to pinpoint the weak links, and speculate on potential alternative approaches.
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Affiliation(s)
- Ping Li
- Washington Veterans Affairs Medical Center, 50 Irving Street, N.W., Washington, DC, 20422, USA
- Georgetown University Hospital, Washington, DC, USA
- George Washington University Hospital, Washington, DC, USA
| | - Mark Nader
- Georgetown University Hospital, Washington, DC, USA
| | | | - Vasilios Papademetriou
- Washington Veterans Affairs Medical Center, 50 Irving Street, N.W., Washington, DC, 20422, USA.
- Georgetown University Hospital, Washington, DC, USA.
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Gierthmuehlen M, Aguirre D, Cota O, Zentner J, Stieglitz T, Plachta DTT. Influence of Clonidine on Antihypertensive Selective Afferent Vagal Nerve Stimulation in Rats. Neuromodulation 2016; 19:597-606. [DOI: 10.1111/ner.12463] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Revised: 04/22/2016] [Accepted: 05/09/2016] [Indexed: 11/29/2022]
Affiliation(s)
- Mortimer Gierthmuehlen
- Department of Neurosurgery; Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg; Germany
| | - Debora Aguirre
- Laboratory for Biomedical Microtechnology, Department of Microsystems Engineering-IMTEK; University of Freiburg; Freiburg Germany
- Neuroloop GmbH; Freiburg Germany
| | - Oscar Cota
- Laboratory for Biomedical Microtechnology, Department of Microsystems Engineering-IMTEK; University of Freiburg; Freiburg Germany
- Neuroloop GmbH; Freiburg Germany
| | - Josef Zentner
- Department of Neurosurgery; Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg; Germany
| | - Thomas Stieglitz
- Laboratory for Biomedical Microtechnology, Department of Microsystems Engineering-IMTEK; University of Freiburg; Freiburg Germany
| | - Dennis T. T. Plachta
- Department of Neurosurgery; Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg; Germany
- Laboratory for Biomedical Microtechnology, Department of Microsystems Engineering-IMTEK; University of Freiburg; Freiburg Germany
- Neuroloop GmbH; Freiburg Germany
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Ardell JL, Andresen MC, Armour JA, Billman GE, Chen PS, Foreman RD, Herring N, O'Leary DS, Sabbah HN, Schultz HD, Sunagawa K, Zucker IH. Translational neurocardiology: preclinical models and cardioneural integrative aspects. J Physiol 2016; 594:3877-909. [PMID: 27098459 DOI: 10.1113/jp271869] [Citation(s) in RCA: 116] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Accepted: 03/14/2016] [Indexed: 12/15/2022] Open
Abstract
Neuronal elements distributed throughout the cardiac nervous system, from the level of the insular cortex to the intrinsic cardiac nervous system, are in constant communication with one another to ensure that cardiac output matches the dynamic process of regional blood flow demand. Neural elements in their various 'levels' become differentially recruited in the transduction of sensory inputs arising from the heart, major vessels, other visceral organs and somatic structures to optimize neuronal coordination of regional cardiac function. This White Paper will review the relevant aspects of the structural and functional organization for autonomic control of the heart in normal conditions, how these systems remodel/adapt during cardiac disease, and finally how such knowledge can be leveraged in the evolving realm of autonomic regulation therapy for cardiac therapeutics.
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Affiliation(s)
- J L Ardell
- University of California - Los Angeles (UCLA) Cardiac Arrhythmia Center, David Geffen School of Medicine, Los Angeles, CA, USA.,UCLA Neurocardiology Research Center of Excellence, David Geffen School of Medicine, Los Angeles, CA, USA
| | - M C Andresen
- Department of Physiology and Pharmacology, Oregon Health and Science University, Portland, OR, USA
| | - J A Armour
- University of California - Los Angeles (UCLA) Cardiac Arrhythmia Center, David Geffen School of Medicine, Los Angeles, CA, USA.,UCLA Neurocardiology Research Center of Excellence, David Geffen School of Medicine, Los Angeles, CA, USA
| | - G E Billman
- Department of Physiology and Cell Biology, The Ohio State University, Columbus, OH, USA
| | - P-S Chen
- The Krannert Institute of Cardiology and Division of Cardiology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - R D Foreman
- Department of Physiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - N Herring
- Department of Physiology, Anatomy and Genetics, University of Oxford, Oxford, UK
| | - D S O'Leary
- Department of Physiology, Wayne State University, Detroit, MI, USA
| | - H N Sabbah
- Department of Medicine, Henry Ford Hospital, Detroit, MI, USA
| | - H D Schultz
- Cellular and Integrative Physiology, University of Nebraska Medical Center, Omaha, NE, USA
| | - K Sunagawa
- Department of Cardiovascular Medicine, Kyushu University, Fukuoka, Japan
| | - I H Zucker
- Cellular and Integrative Physiology, University of Nebraska Medical Center, Omaha, NE, USA
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Impact of number of prescribed medications on visit-to-visit variability of blood pressure: implications for design of future trials of renal denervation. J Hypertens 2016; 33:2359-67. [PMID: 26372316 DOI: 10.1097/hjh.0000000000000708] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Visit-to-visit blood pressure (BP) variability limits the ability to detect therapeutic effects in hypertension trials. METHODS To enable future renal denervation trials to detect smaller effect sizes and reliably identify technical improvements, we examined within-patient visit-to-visit BP variability, quantified as SD of change from baseline to final BP (SDΔ), in renal denervation (RDN) trials, trials of BP-lowering tablets, and the VOLTAGE study including 4151 patients. RESULTS The control arms of RDN trials had more visit-to-visit BP variability than tablet trials (SDΔ 23.6 versus 13.5 mmHg; P < 0.001). This might be explained by more prescribed antihypertensive patients in the RDN trials (5.19 ± 0.13 versus 0.11 ± 0.11; P < 0.001). In the VOLTAGE study, as the number of medications prescribed rose from 0 to 4, SDΔ rose: 11.9, 11.2, 12.9, 14.4 and 18.0 mmHg (P < 0.001 for trend). Neither baseline BP, nor demographics, nor diabetes independently affected variability. The sample size required for a trial rises proportionally to the square of the number of medications prescribed (rather than just linearly). The relationship between the number of background medications prescribed in a cohort and the excess test-retest variance closely fitted this quadratic formula (R = 0.98, P = 0.001). CONCLUSION Visit-to-visit variability in BP is dramatically larger in patients with more background medications prescribed. If this is due to variable adherence, then future RDN trials, needing to detect smaller effect sizes, would benefit from measures to guarantee adherence. Conceivable measures include enrolling patients on no background medication, preceding each BP measurement with a period off medication, or directly supervising medication intake.
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Pourafshar N, Karimi A, Anderson RD, Alaei-Andabili SH, Kandzari DE. Renal Denervation: Past, Present, and Future. CARDIOVASCULAR INNOVATIONS AND APPLICATIONS 2016. [DOI: 10.15212/cvia.2016.0016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Kario K, Bhatt DL, Kandzari DE, Brar S, Flack JM, Gilbert C, Oparil S, Robbins M, Townsend RR, Bakris G. Impact of Renal Denervation on Patients With Obstructive Sleep Apnea and Resistant Hypertension - Insights From the SYMPLICITY HTN-3 Trial. Circ J 2016; 80:1404-12. [PMID: 27118620 DOI: 10.1253/circj.cj-16-0035] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Obstructive sleep apnea (OSA) is associated with activation of the sympathetic nervous system, and patients with this condition often experience elevated blood pressure (BP), increased BP variability, and nocturnal BP surges. METHODS AND RESULTS The SYMPLICITY HTN-3 trial was a large prospective, randomized, blinded, sham-controlled trial of renal denervation for treatment of uncontrolled, apparently treatment-resistant hypertension. In a post hoc analysis, we examined the effect of renal denervation vs. sham control on office and ambulatory (including nocturnal) systolic BP in patients with and without OSA. 26% (94/364) of renal denervation subjects and 32% (54/171) of sham control subjects had OSA. Baseline office and nighttime systolic BP values were similar in both arms, including in subjects with and without OSA. Compared with sham control, renal denervation reduced the 6-month office systolic BP in subjects with (-17.0±22.4 vs. -6.3±26.1 mmHg, P=0.01) but not in subjects without OSA (-14.7±24.5 vs. -13.4±26.4 mmHg, P=0.64), P=0.07 for the interaction between treatment arm and OSA status. In those with sleep apnea, renal denervation was also associated with a reduction in maximum (-4.8±21.8 vs. 4.5±24.6 mmHg, P=0.03) and average peak (-5.6±20.4 vs. 3.2±22.4 mmHg, P=0.02) nighttime systolic BP. CONCLUSIONS OSA subjects appeared to be responsive to renal denervation therapy. However, this hypothesis requires prospective testing. (Circ J 2016; 80: 1404-1412).
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Affiliation(s)
- Kazuomi Kario
- Department of Cardiovascular Medicine, Jichi Medical University School of Medicine
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