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Chinitz L, Böhm M, Evonich R, Saba S, Sangriogoli R, Augostini R, O'Neill PG, Fellows C, Kim MY, Hettrick DA, Viktorova E, Ukena C. Long-Term Changes in Atrial Arrhythmia Burden After Renal Denervation Combined With Pulmonary Vein Isolation: SYMPLICITY-AF. JACC Clin Electrophysiol 2024:S2405-500X(24)00383-9. [PMID: 38934973 DOI: 10.1016/j.jacep.2024.04.035] [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: 11/29/2023] [Revised: 04/22/2024] [Accepted: 04/27/2024] [Indexed: 06/28/2024]
Abstract
BACKGROUND The autonomic nervous system plays an important role in atrial fibrillation (AF) and hypertension. Renal denervation (RDN) lowers blood pressure (BP), but its role in AF is poorly understood. OBJECTIVES The purpose of this study was to investigate whether RDN reduces AF recurrence after pulmonary vein isolation (PVI). METHODS This study randomized patients from 8 centers (United States, Germany) with drug-refractory AF for treatment with PVI+RDN vs PVI alone. A multielectrode radiofrequency Spyral catheter system was used for RDN. Insertable cardiac monitors were used for continuous rhythm monitoring. The primary efficacy endpoint was ≥2 minutes of AF recurrence or repeat ablation during all follow-up. The secondary endpoints included atrial arrhythmia (AA) burden, discontinuation of class I/III antiarrhythmic drugs, and BP changes from baseline. RESULTS A total of 70 patients with AF (52 paroxysmal, 18 persistent) and uncontrolled hypertension were randomized (RDN+PVI, n = 34; PVI, n = 36). At 3.5 years, 26.2% and 21.4% of patients in RDN+PVI and PVI groups, respectively, were free from the primary efficacy endpoint (log rank P = 0.73). Patients with mean ≥1 h/d AA had less daily AA burden after RDN+PVI vs PVI (4.1 hours vs 9.2 hours; P = 0.016). More patients discontinued class I/III antiarrhythmic drugs after RDN+PVI vs PVI (45% vs 14%; P = 0.040). At 1 year, systolic BP changed by -17.8 ± 12.8 mm Hg and -13.7 ± 18.8 mm Hg after RDN+PVI and PVI, respectively (P = 0.43). The composite safety endpoint was not significantly different between groups. CONCLUSIONS In patients with AF and uncontrolled BP, RDN+PVI did not prevent AF recurrence more than PVI alone. However, RDN+PVI may reduce AF burden and antiarrhythmic drug usage, but this needs further prospective validation.
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Affiliation(s)
- Larry Chinitz
- New York University Langone Medical Center, New York, New York, USA.
| | - Michael Böhm
- Universitätsklinikum des Saarlandes, Saarland University, Homburg, Germany
| | | | - Samir Saba
- University of Pittsburgh Heart and Vascular Institute, Pittsburgh, Pennsylvania, USA
| | | | - Ralph Augostini
- The Ohio State University Wexner, Medical Center, Columbus, Ohio, USA
| | | | | | | | | | | | - Christian Ukena
- Universitätsklinikum des Saarlandes, Saarland University, Homburg, Germany; Marien Hospital Herne, Ruhr University Bochum, Herne, Germany
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Yang N, Zou Y, Wen B, Wang Y, Mei J, Jiang Z. Development of neuromodulation for atrial fibrillation: a narrative review. J Thorac Dis 2024; 16:3472-3483. [PMID: 38883655 PMCID: PMC11170414 DOI: 10.21037/jtd-23-1981] [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: 12/31/2023] [Accepted: 04/23/2024] [Indexed: 06/18/2024]
Abstract
Background and Objective Atrial fibrillation (AF) is a prevalent clinical arrhythmia with a high incidence of disability and mortality. Autonomic nervous system (ANS) plays a crucial role in the onset and persistence of AF, and can lead to electrophysiological changes and alterations in atrial structure. Both animal models and clinical findings suggest that parasympathetic and sympathetic activity within the cardiac ANS could induce atrial remodeling and AF. Remodeling of the cardiac autonomic nerves is a significant structural basis for promoting AF. Given the challenges faced by conventional pharmacological and atrial ablation techniques in the treatment of AF, increasing attention has been paid to autonomic intervention strategies for AF. Current research has demonstrated that the frequency and severity of AF episodes can be significantly reduced by modulating the activity of ANS. ANS neuromodulation is expected to lead more effective and personalized treatment options for patients with AF. The objective of this review is to provide a broader perspective for future related studies by reviewing preclinical and clinical studies of neuromodulation methods for the treatment of AF, searching for relevant approaches to treat AF, as well as identifying the strengths and weaknesses demonstrated by current relevant studies, and providing researchers with a broader overview of the latest neurological treatments for AF. Methods A narrative review was conducted on the literature on PubMed, WanFang data, and Google Scholar, including all relevant studies published until November 2023. Key Content and Findings In this review, we delve into the innervation of cardiac autonomic nerves, the role of the ANS in the development and maintenance of AF, and the current neuromodulation methods for AF treatment. These methods include stellate ganglion (SG) resection or ablation, vagus nerve stimulation (VNS), thoracic subcutaneous nerve stimulation (ScNS), renal denervation (RDN) therapy, ganglionated plexus (GP) ablation, and epicardial botulinum toxin or CaCl2 injection. More and more research suggests that neuromodulation methods for the treatment of AF have broad prospects. Conclusions ANS plays a crucial role in AF development and maintenance through cardiac autonomic nerve remodeling. Modulating ANS activity can significantly reduce AF frequency and severity, offering more personalized treatment options. Current research on autonomic interventions for AF shows promise for more effective and personalized treatments.
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Affiliation(s)
- Ning Yang
- Department of Cardiothoracic Surgery, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yang Zou
- Department of Cardiothoracic Surgery, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Bohan Wen
- Department of Cardiothoracic Surgery, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yingman Wang
- Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ju Mei
- Department of Cardiothoracic Surgery, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zhaolei Jiang
- Department of Cardiothoracic Surgery, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Townsend RR, Ferdinand KC, Kandzari DE, Kario K, Mahfoud F, Weber MA, Schmieder RE, Pocock S, Tsioufis K, David S, Steigerwalt S, Walton A, Hopper I, Bertolet B, Sharif F, Fengler K, Fahy M, Hettrick DA, Brar S, Böhm M. Impact of Antihypertensive Medication Changes After Renal Denervation Among Different Patient Groups: SPYRAL HTN-ON MED. Hypertension 2024; 81:1095-1105. [PMID: 38314554 PMCID: PMC11025607 DOI: 10.1161/hypertensionaha.123.22251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 01/03/2024] [Indexed: 02/06/2024]
Abstract
BACKGROUND The SPYRAL HTN-ON MED (Global Clinical Study of Renal Denervation With the Symplicity Spyral Multi-electrode Renal Denervation System in Patients With Uncontrolled Hypertension in the Absence of Antihypertensive Medications)trial showed significant office and nighttime systolic blood pressure (BP) reductions in patients with hypertension following renal denervation (RDN) compared with sham-control patients, despite similar 24-hour BP reductions. We compared antihypertensive medication and BP changes among prespecified subpopulations. METHODS The multicenter, randomized, sham-controlled, blinded SPYRAL HTN-ON MED trial (n=337) evaluated BP changes after RDN compared with a sham procedure in patients with hypertension prescribed 1 to 3 antihypertensive drugs. Most patients (n=187; 54%) were enrolled outside the United States, while 156 (46%) US patients were enrolled, including 60 (18%) Black Americans. RESULTS Changes in detected antihypertensive drugs were similar between RDN and sham group patients in the outside US cohort, while drug increases were significantly more common in the US sham group compared with the RDN group. Patients from outside the United States showed significant reductions in office and 24-hour mean systolic BP at 6 months compared with the sham group, whereas BP changes were similar between RDN and sham in the US cohort. Within the US patient cohort, Black Americans in the sham control group had significant increases in medication burden from baseline through 6 months (P=0.003) but not in the RDN group (P=0.44). CONCLUSIONS Patients enrolled outside the United States had minimal antihypertensive medication changes between treatment groups and had significant office and 24-hour BP reductions compared with the sham group. Increased antihypertensive drug burden in the US sham cohort, especially among Black Americans, may have diluted the treatment effect in the combined trial population. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT02439775.
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Affiliation(s)
- Raymond R. Townsend
- Pereleman School of Medicine, University of Pennsylvania, Philadelphia (R.R.T.)
| | | | | | - Kazuomi Kario
- Department of Cardiovascular Medicine, Jichi Medical University School of Medicine, Tochigi, Japan (K.K.)
| | - Felix Mahfoud
- Universitätsklinikum des Saarlandes, Klinik für Kardiologie, Angiologie und Internistische Intensivmedizin, Saarland University, Homburg, Germany (F.M., M.B.)
| | | | | | - Stuart Pocock
- London School of Hygiene & Tropical Medicine, United Kingdom (S.P.)
| | | | - Shukri David
- Ascension Providence Hospital, Southfield, MI (S.D., S.S.)
| | | | - Antony Walton
- The Alfred Hospital, Melbourne, Australia (A.W., I.H.)
| | - Ingrid Hopper
- The Alfred Hospital, Melbourne, Australia (A.W., I.H.)
| | | | | | | | - Martin Fahy
- Medtronic, Santa Rosa, CA (M.F., D.A.H., S.B.)
| | | | | | - Michael Böhm
- Universitätsklinikum des Saarlandes, Klinik für Kardiologie, Angiologie und Internistische Intensivmedizin, Saarland University, Homburg, Germany (F.M., M.B.)
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Lauder L, Kandzari DE, Lüscher TF, Mahfoud F. Renal denervation in the management of hypertension. EUROINTERVENTION 2024; 20:e467-e478. [PMID: 38629418 PMCID: PMC11017226 DOI: 10.4244/eij-d-23-00836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 01/09/2024] [Indexed: 04/19/2024]
Abstract
Arterial hypertension is a global leading cause of cardiovascular, cerebrovascular, and renal disease, as well as mortality. Although pharmacotherapy is safe and effective in lowering blood pressure (BP) and cardiovascular disease risk, BP control remains poor, and the mortality rates associated with high BP have been steadily increasing. Device-based therapies have been investigated to overcome barriers to pharmacotherapy, including non-adherence and low rates of persistence to daily medications. Among these device-based therapies, catheter-based renal denervation (RDN) has been most extensively examined over the past 15 years. In this state-of-the-art article, we summarise the rationale for RDN, review the available evidence, provide recommendations for a safe procedure, and discuss the role of RDN in current guidelines and clinical practice.
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Affiliation(s)
- Lucas Lauder
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes and Saarland University, Homburg, Germany
| | | | - Thomas F Lüscher
- Center for Molecular Cardiology, University of Zurich, Schlieren, Switzerland
- Royal Brompton & Harefield Hospitals, London, United Kingdom
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
- School of Cardiovascular Medicine and Sciences, King's College London, London, United Kingdom
| | - Felix Mahfoud
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes and Saarland University, Homburg, Germany
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA
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5
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Al Ghorani H, Kulenthiran S, Lauder L, Recktenwald MJM, Dederer J, Kunz M, Götzinger F, Ewen S, Ukena C, Böhm M, Mahfoud F. Ultra-long-term efficacy and safety of catheter-based renal denervation in resistant hypertension: 10-year follow-up outcomes. Clin Res Cardiol 2024:10.1007/s00392-024-02417-2. [PMID: 38451261 DOI: 10.1007/s00392-024-02417-2] [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: 12/21/2023] [Accepted: 02/16/2024] [Indexed: 03/08/2024]
Abstract
BACKGROUND Randomized sham-controlled trials have confirmed the efficacy and safety of catheter-based renal denervation in hypertension. Data on the very long-term effects of renal denervation are scarce. AIMS This study evaluates the 10-year safety and efficacy of renal denervation in resistant hypertension. METHODS This prospective single-center study included patients with resistant hypertension undergoing radio-frequency renal denervation between 2010 and 2012. Office blood pressure, 24-h ambulatory blood pressure, antihypertensive medication, color duplex sonography, and renal function were assessed after 1-, 2- and 10-years. RESULTS Thirty-nine patients completed the 10-year follow-up (mean follow-up duration 9.4 ± 0.7 years). Baseline office and 24-h ambulatory systolic blood pressure were 164 ± 23 mmHg and 153 ± 16 mmHg, respectively. After 10 years, 24-h ambulatory and office systolic blood pressure were reduced by 16 ± 17 mmHg (P < 0.001) and 14 ± 23 mmHg (P = 0.001), respectively. The number of antihypertensive drugs remained unchanged from 4.9 ± 1.4 to 4.5 ± 1.2 drugs (P = 0.087). The estimated glomerular filtration rate declined within the expected range from 69 (95% CI 63 to 74) to 60 mL/min/1.73m2 (95% CI 53 to 68; P < 0.001) through 10-year follow-up. Three renal artery interventions were documented for progression of pre-existing renal artery stenosis in two patients and one patient with new-onset renal artery stenosis. No other adverse events were observed during the follow-up. CONCLUSION Renal denervation was safe and sustainedly reduced ambulatory and office blood pressure out to 10 years in patients with resistant hypertension.
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Affiliation(s)
- Hussam Al Ghorani
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University, Kirrberger Str. 100, Gebäude 41, 66421, Homburg/Saar, Germany.
| | - Saarraaken Kulenthiran
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University, Kirrberger Str. 100, Gebäude 41, 66421, Homburg/Saar, Germany
| | - Lucas Lauder
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University, Kirrberger Str. 100, Gebäude 41, 66421, Homburg/Saar, Germany
| | - Michael Johannes Maria Recktenwald
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University, Kirrberger Str. 100, Gebäude 41, 66421, Homburg/Saar, Germany
| | - Juliane Dederer
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University, Kirrberger Str. 100, Gebäude 41, 66421, Homburg/Saar, Germany
| | - Michael Kunz
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University, Kirrberger Str. 100, Gebäude 41, 66421, Homburg/Saar, Germany
| | - Felix Götzinger
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University, Kirrberger Str. 100, Gebäude 41, 66421, Homburg/Saar, Germany
| | - Sebastian Ewen
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University, Kirrberger Str. 100, Gebäude 41, 66421, Homburg/Saar, Germany
| | - Christian Ukena
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University, Kirrberger Str. 100, Gebäude 41, 66421, Homburg/Saar, Germany
- Medizinische Klinik II - Kardiologie/Angiologie, Marien Hospital Herne - Universitätsklinikum der Ruhr Universität Bochum, Hölkeskampring 40, 44625, Herne, Germany
| | - Michael Böhm
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University, Kirrberger Str. 100, Gebäude 41, 66421, Homburg/Saar, Germany
| | - Felix Mahfoud
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University, Kirrberger Str. 100, Gebäude 41, 66421, Homburg/Saar, Germany
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Giunta S, Xia S, Pelliccioni G, Olivieri F. Autonomic nervous system imbalance during aging contributes to impair endogenous anti-inflammaging strategies. GeroScience 2024; 46:113-127. [PMID: 37821752 PMCID: PMC10828245 DOI: 10.1007/s11357-023-00947-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 09/13/2023] [Indexed: 10/13/2023] Open
Abstract
Inflammaging refers to the age-related low grade, sterile, chronic, systemic, and long-lasting subclinical, proinflammatory status, currently recognized as the main risk factor for development and progression of the most common age-related diseases (ARDs). Extensive investigations were focused on a plethora of proinflammatory stimuli that can fuel inflammaging, underestimating and partly neglecting important endogenous anti-inflammaging mechanisms that could play a crucial role in such age-related proinflammatory state. Studies on autonomic nervous system (ANS) functions during aging highlighted an imbalance toward an overactive sympathetic nervous system (SNS) tone, promoting proinflammatory conditions, and a diminished parasympathetic nervous system (PNS) activity, playing anti-inflammatory effects mediated by the so called cholinergic anti-inflammatory pathway (CAP). At the molecular level, CAP is characterized by signals communicated via the vagus nerve (with the possible involvement of the splenic nerves) through acetylcholine release to downregulate the inflammatory actions of macrophages, key players of inflammaging. Notably, decreased vagal function and increased burden of activated/senescent macrophages (macrophaging) probably precede the development of several age-related risk factors and diseases, while increased vagal function and reduced macrophaging could be associated with relevant reduction of risk profiles. Hypothalamic-pituitary-adrenal axis (HPA axis) is another pathway related to ANS promoting some anti-inflammatory response mainly through increased cortisol levels. In this perspective review, we highlighted that CAP and HPA, representing broadly "anti-inflammaging" mechanisms, have a reduced efficacy and lose effectiveness in aged people, a phenomenon that could contribute to fuel inflammaging. In this framework, strategies aimed to re-balance PNS/SNS activities could be explored to modulate systemic inflammaging especially at an early subclinical stage, thus increasing the chances to reach the extreme limit of human lifespan in healthy status.
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Affiliation(s)
- Sergio Giunta
- Casa Di Cura Prof. Nobili (Gruppo Garofalo (GHC)), Castiglione Dei Pepoli, Bologna, Italy
| | - Shijin Xia
- Department of Geriatrics, Shanghai Institute of Geriatrics, Huadong Hospital, Fudan University, Shanghai, China
| | | | - Fabiola Olivieri
- Department of Clinical and Molecular Sciences, DISCLIMO, Università Politecnica Delle Marche, Via Tronto 10/A, 60126, Ancona, Italy.
- Clinical Laboratory and Molecular Diagnostic, IRCCS INRCA, Ancona, Italy.
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7
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Kandzari DE, Townsend RR, Kario K, Mahfoud F, Weber MA, Schmieder RE, Pocock S, Tsioufis K, Konstantinidis D, Choi J, East C, Lauder L, Cohen DL, Kobayashi T, Schmid A, Lee DP, Ma A, Weil J, Agdirlioglu T, Schlaich MP, Shetty S, Devireddy CM, Lea J, Aoki J, Sharp ASP, Anderson R, Fahy M, DeBruin V, Brar S, Böhm M. Safety and Efficacy of Renal Denervation in Patients Taking Antihypertensive Medications. J Am Coll Cardiol 2023; 82:1809-1823. [PMID: 37914510 DOI: 10.1016/j.jacc.2023.08.045] [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: 04/13/2023] [Revised: 08/22/2023] [Accepted: 08/28/2023] [Indexed: 11/03/2023]
Abstract
BACKGROUND Renal denervation (RDN) reduces blood pressure (BP) in patients with uncontrolled hypertension in the absence of antihypertensive medications. OBJECTIVES This trial assessed the safety and efficacy of RDN in the presence of antihypertensive medications. METHODS SPYRAL HTN-ON MED is a prospective, randomized, sham-controlled, patient- and assessor-blinded trial enrolling patients from 56 clinical centers worldwide. Patients were prescribed 1 to 3 antihypertensive medications. Patients were randomized to radiofrequency RDN or sham control procedure. The primary efficacy endpoint was the baseline-adjusted change in mean 24-hour ambulatory systolic BP at 6 months between groups using a Bayesian trial design and analysis. RESULTS The treatment difference in the mean 24-hour ambulatory systolic BP from baseline to 6 months between the RDN group (n = 206; -6.5 ± 10.7 mm Hg) and sham control group (n = 131; -4.5 ± 10.3 mm Hg) was -1.9 mm Hg (95% CI: -4.4 to 0.5 mm Hg; P = 0.12). There was no significant difference between groups in the primary efficacy analysis with a posterior probability of superiority of 0.51 (Bayesian treatment difference: -0.03 mm Hg [95% CI: -2.82 to 2.77 mm Hg]). However, there were changes and increases in medication intensity among sham control patients. RDN was associated with a reduction in office systolic BP compared with sham control at 6 months (adjusted treatment difference: -4.9 mm Hg; P = 0.0015). Night-time BP reductions and win ratio analysis also favored RDN. There was 1 adverse safety event among 253 assessed patients. CONCLUSIONS There was no significant difference between groups in the primary analysis. However, multiple secondary endpoint analyses favored RDN over sham control. (SPYRAL HTN-ON MED Study [Global Clinical Study of Renal Denervation With the Symplicity Spyral Multi-electrode Renal Denervation System in Patients With Uncontrolled Hypertension in the Absence of Antihypertensive Medications]; NCT02439775).
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Affiliation(s)
| | - Raymond R Townsend
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kazuomi Kario
- Departmnet of Cardiovascular Medicine, Jichi Medical University School of Medicine, Tochigi, Japan
| | - Felix Mahfoud
- Universitätsklinikum des Saarlandes, Saarland University, Homburg, Germany
| | | | | | - Stuart Pocock
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | | | - James Choi
- Baylor Research Institute, Jack and Jane Hamilton Heart and Vascular Hospital, Dallas, Texas, USA
| | - Cara East
- Baylor Research Institute, Jack and Jane Hamilton Heart and Vascular Hospital, Dallas, Texas, USA
| | - Lucas Lauder
- Universitätsklinikum des Saarlandes, Saarland University, Homburg, Germany
| | - Debbie L Cohen
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Taisei Kobayashi
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Axel Schmid
- University Hospital Erlangen, Erlangen, Germany
| | - David P Lee
- Stanford Hospital and Clinics, Stanford, California, USA
| | - Adrian Ma
- Stanford Hospital and Clinics, Stanford, California, USA
| | | | | | - Markus P Schlaich
- Department of Cardiology, Fiona Stanley and Royal Perth Hospitals, and Dobney Hypertension Centre, University of Western Australia, Perth, Western Australia, Australia
| | - Sharad Shetty
- Department of Cardiology, Fiona Stanley and Royal Perth Hospitals, and Dobney Hypertension Centre, University of Western Australia, Perth, Western Australia, Australia
| | | | - Janice Lea
- Emory University School of Medicine, Atlanta, Georgia, USA
| | - Jiro Aoki
- Mitsui Memorial Hospital, Tokyo, Japan
| | | | | | | | | | | | - Michael Böhm
- Universitätsklinikum des Saarlandes, Saarland University, Homburg, Germany
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8
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Camafort M, Ihm SH, Ruilope LM. Renal denervation for the treatment of hypertension and kidney disease. Curr Opin Nephrol Hypertens 2023; 32:544-550. [PMID: 37706512 DOI: 10.1097/mnh.0000000000000928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/15/2023]
Abstract
PURPOSE OF REVIEW Hypertension is a condition characterized by increased sympathetic activity and the autonomic nervous system. Resistant hypertension, a condition with a prevalence of 10% to 20% in the general hypertensive population, is more likely to experience poor outcomes and adverse cardiovascular events. Renal sympathetic denervation (RDN), a minimally invasive, catheter-based percutaneous intervention, has been considered for treating this condition. Clinical trials have used various catheters, such as the Symplicity Spyral catheter, Vessix Renal Denervation system, and Paradise endovascular ultrasound renal denervation system. RECENT FINDINGS After the first randomized clinical trials examining the effectiveness and safety of RDN for lowering blood pressure in hypertensive patients, new clinical trials have used various catheters based on radiofrequency, such as the Spyral catheter, Vessix Renal Denervation system, or based on radiofrequency as the Paradise endovascular ultrasound renal denervation system. Positive results on this trials have shown that endovascular RDN (radiofrequency energy or high focused ultrasound energy) could be considered as a treatment option for uncontrolled resistant hypertension. SUMMARY Therefore, endovascular RDN (radiofrequency energy or high focused ultrasound energy) could be considered as a treatment option for uncontrolled resistant hypertension, which can be considered as an alternative to increasing medication. Nevertheless more data are needed, mainly in cardiovascular outcomes. RDN should be performed in experienced and specialized centers with a multidisciplinary team, and the benefits and risks of RDN should be addressed in a shared-decision-making process.
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Affiliation(s)
- Miguel Camafort
- Hypertension and Vascular Risk Unit, Department of Internal Medicine, Hospital Clínic (IDIBAPS), University of Barcelona, Barcelona
- CIBER-OBN. ISCIII Madrid
- Faculty of Medicine, University of Barcelona, Spain
| | - Sang Hyun Ihm
- Division of cardiology, Department of Internal Medicine, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Bucheon
- Catholic Research Institute for Intractable Cardiovascular Disease, College of Medicine, the Catholic University of Korea, Seoul, Republic of Korea
| | - Luis Miguel Ruilope
- Cardiorenal Translational Laboratory and Hypertension Unit, Institute of Research imas12
- CIBER-CV, Hospital Universitario 12 de Octubre
- Faculty of Sport Sciences, European University of Madrid, Madrid, Spain
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9
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Wagener M, Dolan E, Arnous S, Galvin J, Murphy AW, Casserly I, Eustace J, O’Connor S, McCreery C, Shand J, Wall C, Matiullah S, Sharif F. Renal Denervation as a Complementary Treatment Option for Uncontrolled Arterial Hypertension: A Situation Assessment. J Clin Med 2023; 12:5634. [PMID: 37685701 PMCID: PMC10488551 DOI: 10.3390/jcm12175634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Revised: 08/20/2023] [Accepted: 08/25/2023] [Indexed: 09/10/2023] Open
Abstract
Uncontrolled arterial hypertension is a major global health issue. Catheter-based renal denervation has shown to lower blood pressure in sham-controlled trials and represents a device-based, complementary treatment option for hypertension. In this situation assessment, the authors, who are practicing experts in hypertension, nephrology, general practice and cardiology in the Republic of Ireland, discuss the current evidence base for the BP-lowering efficacy and safety of catheter-based renal denervation with different modalities. Although important questions remain regarding the identification of responders, and long-term efficacy and safety of the intervention, renal denervation has the potential to provide much-needed help to address hypertension and its adverse consequences. The therapeutic approach needs to be multidisciplinary and personalised to take into account the perspective of patients and healthcare professionals in a shared decision-making process.
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Affiliation(s)
- Max Wagener
- University Hospital Galway, University of Galway, H91 TK33 Galway, Ireland
| | - Eamon Dolan
- Stroke and Hypertension Unit, Connolly Hospital, D15 X40D Dublin, Ireland
| | - Samer Arnous
- University Hospital Limerick, V94 F858 Limerick, Ireland
| | - Joseph Galvin
- The Mater Misericordiae University Hospital, D07 R2WY Dublin, Ireland
| | - Andrew W. Murphy
- Turloughmore Medical Centre, University of Galway, H91 TK33 Galway, Ireland
| | - Ivan Casserly
- The Mater Misericordiae University Hospital, D07 R2WY Dublin, Ireland
| | | | | | | | - James Shand
- St. Vincent’s University Hospital, D04 T6F4 Dublin, Ireland
| | | | | | - Faisal Sharif
- University Hospital Galway, University of Galway, H91 TK33 Galway, Ireland
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10
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Kasprzycki K, Petkow-Dimitrow P, Krawczyk-Ożóg A, Bartuś S, Rajtar-Salwa R. Anatomic Variations of Renal Arteries as an Important Factor in the Effectiveness of Renal Denervation in Resistant Hypertension. J Cardiovasc Dev Dis 2023; 10:371. [PMID: 37754800 PMCID: PMC10531508 DOI: 10.3390/jcdd10090371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 08/20/2023] [Accepted: 08/23/2023] [Indexed: 09/28/2023] Open
Abstract
Hypertension remains the leading cause of death worldwide. Despite advances in drug-based treatment, many patients do not achieve target blood pressure. In recent years, there has been an increased interest in invasive hypertension treatment methods. Long-term effects and factors affecting renal denervation effectiveness are still under investigation. Some investigators found that the renal arteries' morphology is crucial in renal denervation effectiveness. Accessory renal arteries occur in 20-30% of the population and even more frequently in patients with resistant hypertension. Diversity in renal vascularization and innervation may complicate the renal denervation procedure and increase the number of people who will not benefit from treatment. Based on previous studies, it has been shown that the presence of accessory renal arteries, and in particular, the lack of their complete denervation, reduces the procedure's effectiveness. The following review presents the anatomical assessment of the renal arteries, emphasizing the importance of imaging tests. Examples of imaging and denervation methods to optimize the procedure are presented. The development of new-generation catheters and the advancement in knowledge of renal arteries anatomy may improve the effectiveness of treatment and reduce the number of patients who do not respond to treatment.
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Affiliation(s)
- Karol Kasprzycki
- Department of Cardiology and Cardiovascular Interventions, University Hospital, 30-688 Krakow, Poland
| | - Paweł Petkow-Dimitrow
- Department of Cardiology and Cardiovascular Interventions, University Hospital, 30-688 Krakow, Poland
- 2nd Department of Cardiology, Jagiellonian University Medical College, 30-688 Krakow, Poland
| | - Agata Krawczyk-Ożóg
- Department of Cardiology and Cardiovascular Interventions, University Hospital, 30-688 Krakow, Poland
- Department of Anatomy, Jagiellonian University Medical College, 33-332 Krakow, Poland
| | - Stanisław Bartuś
- Department of Cardiology and Cardiovascular Interventions, University Hospital, 30-688 Krakow, Poland
- 2nd Department of Cardiology, Jagiellonian University Medical College, 30-688 Krakow, Poland
| | - Renata Rajtar-Salwa
- Department of Cardiology and Cardiovascular Interventions, University Hospital, 30-688 Krakow, Poland
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11
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Hickey GL, Parvu V, Zhang Y, Cooper CK, Wan Y. A pragmatic approach for dynamically incorporating predicate device data in prospective diagnostic test studies. J Biopharm Stat 2023; 33:77-89. [PMID: 35649152 DOI: 10.1080/10543406.2022.2080690] [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: 01/06/2023]
Abstract
Clinical studies are generally required to characterize the accuracy of new diagnostic tests. In some cases, historical data are available from a predicate device, which is directly relevant to the new test. If this data can be appropriately incorporated into the new test study design, there is an opportunity to reduce the sample size and trial duration for the new test. One approach to achieve this is the Bayesian power prior method, which allows for the historical information to be down-weighted via a power parameter. We propose a dynamic method to calculate the power parameter based on first comparing the data between the historical and new data sources using a one-sided comparison, and second mapping the comparison probability through a scaled-Weibull discount function to tune the effective sample size borrowed. This pragmatic and conservative approach is embedded in an adaptive trial framework allowing for the trial to stop early for success. An example is presented for a new test developed to detect Methicillin-resistant Staphylococcus aureus present in the nasal carriage.
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Affiliation(s)
- Graeme L Hickey
- Becton, Dickinson and Company, Franklin Lakes, New Jersey, USA
| | - Valentin Parvu
- Becton, Dickinson and Company, Franklin Lakes, New Jersey, USA
| | | | - Charles K Cooper
- Siemens Healthcare Diagnostics, Siemens Healthineers, Tarrytown, New York, USA
| | - Ying Wan
- Becton, Dickinson and Company, Franklin Lakes, New Jersey, USA
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12
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Kandzari DE, Weber MA, Poulos C, Coulter J, Cohen SA, DeBruin V, Jones D, Pathak A. Patient Preferences for Pharmaceutical and Device-Based Treatments for Uncontrolled Hypertension: Discrete Choice Experiment. Circ Cardiovasc Qual Outcomes 2023; 16:e008997. [PMID: 36484251 PMCID: PMC9848220 DOI: 10.1161/circoutcomes.122.008997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Discrete choice experiment is a survey method used to understand how individuals make decisions and to quantify the relative importance of features. Using discrete choice experiment methods, we quantified patient benefit-risk preferences for hypertension treatments, including pharmaceutical and interventional treatments, like renal denervation. METHODS Respondents from the United States with physician-confirmed uncontrolled hypertension selected between treatments involving a procedure or pills, using a structured survey. Treatment features included interventional, noninterventional, or no hypertension treatment; number of daily blood pressure (BP) pills; expected reduction in office systolic BP; duration of effect; and risks of drug side effects, access site pain, or vascular injury. The results of a random-parameters logit model were used to estimate the importance of each treatment attribute. RESULTS Among 400 patients completing the survey between 2020 and 2021, demographics included: 52% women, mean age 59.2±13.0 years, systolic BP 155.1±12.3 mm Hg, and 1.8±0.9 prescribed antihypertensive medications. Reduction in office systolic BP was the most important treatment attribute. The remaining attributes, in decreasing order, were duration of effect, whether treatment was interventional, number of daily pills, risk of vascular injury, and risk of drug side effects. Risk of access site pain did not influence choice. In general, respondents preferred noninterventional over interventional treatments, yet only a 2.3 mm Hg reduction in office systolic BP was required to offset this preference. Small reductions in office systolic BP would offset risks of vascular injury or drug side effects. At least a 20% risk of vascular injury or drug side effects would be tolerated in exchange for improved BP. CONCLUSIONS Reduction in systolic BP was identified as the most important driver of patient treatment preference, while treatment-related risks had less influence. The results indicate that respondents would accept interventional treatments in exchange for modest reductions in systolic BP compared with those observed in renal denervation trials.
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Affiliation(s)
| | | | | | - Joshua Coulter
- RTI Health Solutions, Research Triangle Park, NC, (J.C.)
| | | | | | - Denise Jones
- Medtronic, Santa Rosa, CA (S.A.C., V.D.B., D.J.)
| | - Atul Pathak
- Department of Cardiovascular Medicine, Centre Hospitalier Princese Grace, Monaco (A.P.).,UMR UT CNRS 88 Hypertension and Heart Failure: molecular and clinical investigations. Toulouse, France, INI-CRCT F-CRIN, GREAT Networks (A.P.)
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13
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Wang TD. Consensus and inconsistency between different consensus documents on renal denervation worldwide: the way forward. Chin Med J (Engl) 2022; 135:2926-2937. [PMID: 36103983 PMCID: PMC10106155 DOI: 10.1097/cm9.0000000000002109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Indexed: 01/11/2023] Open
Abstract
ABSTRACT Given the unsatisfactory hypertension control rates and high rates of non-adherence to antihypertensive medications worldwide, device therapy which can safely provide durable blood pressure-lowering effects can fulfill the unmet need. A series of second-generation randomized sham-controlled renal denervation (RDN) trials have demonstrated the efficacy and safety of RDN in a wide range of hypertensive patients. The four representative consensus documents on RDN (from the Chinese Taiwan Hypertension Society and Taiwan Society of Cardiology [THS/TSOC 2019], Asia Renal Denervation Consortium 2019, European Society of Hypertension [ESH 2021], and Society for Cardiovascular Angiography & Intervention and National Kidney Foundation [SCAI/NKF 2021]) consistently recommend RDN as an alternative or complementary treatment strategy for patients with uncontrolled hypertension. In addition, both documents from Asia further recommend that RDN can be considered as an initial treatment strategy for drug-naïve hypertensive patients. There is still inconsistency regarding whether ambulatory blood pressure monitoring should be used routinely both before and after RDN, and whether patients with a secondary cause of hypertension could be treated with RDN if their blood pressure remains uncontrolled after definitive treatment (treatment-resistant secondary hypertension). The THS/TSOC consensus provides acronyms to summarize key aspects of patient selection (RDNi2) and pre-RDN assessments (RAS). The ESH and SCAI/NKF documents recommend establishing structured pathways for clinical practice and issues regarding reimbursement. All documents identify knowledge gaps in RDN, from identifying predictors of super-responders to demonstrating effects on cardiovascular events. These gaps should be urgently filled to facilitate the wider application of this device therapy for patients with hypertension.
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Affiliation(s)
- Tzung-Dau Wang
- Department of Internal Medicine, Cardiovascular Center and Divisions of Cardiology and Hospital Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan 100225, China
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14
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Weber MA, Schmieder RE, Kandzari DE, Townsend RR, Mahfoud F, Tsioufis K, Kario K, Pocock S, Tatakis F, Ewen S, Choi JW, East C, Lee DP, Ma A, Cohen DL, Wilensky R, Devireddy CM, Lea JP, Schmid A, Fahy M, Böhm M. Hypertension urgencies in the SPYRAL HTN-OFF MED Pivotal trial. Clin Res Cardiol 2022; 111:1269-1275. [PMID: 35852582 PMCID: PMC9622517 DOI: 10.1007/s00392-022-02064-5] [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: 05/12/2022] [Accepted: 07/04/2022] [Indexed: 11/03/2022]
Abstract
The SPYRAL HTN-OFF MED Pivotal trial ( https://clinicaltrials.gov/ct2/show/NCT02439749 ) demonstrated significant reductions in blood pressure (BP) after renal denervation (RDN) compared to sham control in the absence of anti-hypertensive medications. Prior to the 3-month primary endpoint, medications were immediately reinstated for patients who met escape criteria defined as office systolic BP (SBP) ≥ 180 mmHg or other safety concerns. Our objective was to compare the rate of hypertensive urgencies in RDN vs. sham control patients. Patients were enrolled with office SBP ≥ 150 and < 180 mmHg, office diastolic BP (DBP) ≥ 90 mmHg and mean 24 h SBP ≥ 140 and < 170 mmHg. Patients had been required to discontinue any anti-hypertensive medications and were randomized 1:1 to RDN or sham control. In this post-hoc analysis, cumulative incidence curves with Kaplan-Meier estimates of rate of patients meeting escape criteria were generated for RDN and sham control patients. There were 16 RDN (9.6%) and 28 sham control patients (17.0%) who met escape criteria between baseline and 3 months. There was a significantly higher rate of sham control patients meeting escape criteria compared to RDN for all escape patients (p = 0.032), as well as for patients with a hypertensive urgency with office SBP ≥ 180 mmHg (p = 0.046). Rate of escape was similar between RDN and sham control for patients without a measured BP exceeding 180 mmHg (p = 0.32). In the SPYRAL HTN-OFF MED Pivotal trial, RDN patients were less likely to experience hypertensive urgencies that required immediate use of anti-hypertensive medications compared to sham control.
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Affiliation(s)
- Michael A Weber
- Professor of Medicine, Division of Cardiovascular Medicine, Downstate Medical Center, SUNY Downstate College of Medicine, State University of New York, Brooklyn, NY, USA.
| | | | | | - Raymond R Townsend
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Felix Mahfoud
- Klinik Für Innere Medizin III, Universitätsklinikum Des Saarlandes, Saarland University, HomburgSaar, Germany
| | - Konstantinos Tsioufis
- Hippocratio Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Kazuomi Kario
- School of Medicine, Jichi Medical University, Tochigi, Japan
| | - Stuart Pocock
- London School of Hygiene and Tropical Medicine, London, UK
| | - Fotis Tatakis
- Hippocratio Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Sebastian Ewen
- Klinik Für Innere Medizin III, Universitätsklinikum Des Saarlandes, Saarland University, HomburgSaar, Germany
| | - James W Choi
- Baylor Research Institute, Jack and Jane Hamilton Heart and Vascular Hospital, Dallas, TX, USA
| | - Cara East
- Baylor Research Institute, Jack and Jane Hamilton Heart and Vascular Hospital, Dallas, TX, USA
| | - David P Lee
- Stanford Hospital and Clinics, Stanford, CA, USA
| | - Adrian Ma
- Stanford Hospital and Clinics, Stanford, CA, USA
| | - Debbie L Cohen
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Robert Wilensky
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Janice P Lea
- School of Medicine, Emory University, Atlanta, GA, USA
| | - Axel Schmid
- University Hospital Erlangen, Erlangen, Germany
| | | | - Michael Böhm
- Klinik Für Innere Medizin III, Universitätsklinikum Des Saarlandes, Saarland University, HomburgSaar, Germany
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15
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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: 9] [Impact Index Per Article: 4.5] [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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Al Ghorani H, Götzinger F, Böhm M, Mahfoud F. Arterial hypertension - Clinical trials update 2021. Nutr Metab Cardiovasc Dis 2022; 32:21-31. [PMID: 34690044 PMCID: PMC8444354 DOI: 10.1016/j.numecd.2021.09.007] [Citation(s) in RCA: 36] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 08/26/2021] [Accepted: 09/06/2021] [Indexed: 02/07/2023]
Abstract
AIM This review aims to summarize and discuss some of the most relevant clinical trials in epidemiology, diagnostics, and treatment of hypertension published in 2020 and 2021. DATA SYNTHESIS The trials included in this review are related to hypertension onset age and risk for future cardiovascular disease, reliability of different blood pressure monitoring methods, role of exercise-induced hypertension, treatment of hypertension in patients with SARS-CoV-2 infection, management of hypertension high-risk patient groups, e.g., in the elderly (≥80 years) and patients with atrial fibrillation, and the interplay between nutrition and hypertension, as well as recent insights into renal denervation for treatment of hypertension. CONCLUSIONS Hypertension onset age, nighttime blood pressure levels and a riser pattern are relevant for the prognosis of future cardiovascular diseases. The risk of coronary heart disease appears to increase linearly with increasing exercise systolic blood pressure. Renin-angiotensin system blockers are not associated with an increased risk for a severe course of COVID-19. In elderly patients, a risk-benefit assessment of intensified blood pressure control should be individually evaluated. A J-shaped association between cardiovascular disease and achieved blood pressure could also be demonstrated in patients with atrial fibrillation on anticoagulation. Salt restriction and lifestyle modification remain effective options in treating hypertensive patients at low cardiovascular risk. Sodium glucose co-transporter 2 inhibitors and Glucagon-like peptide-1 receptor agonists show BP-lowering effects. Renal denervation should be considered as an additional or alternative treatment option in selected patients with uncontrolled hypertension.
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Affiliation(s)
- Hussam Al Ghorani
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University, Homburg, Germany
| | - Felix Götzinger
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University, Homburg, Germany
| | - Michael Böhm
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University, Homburg, Germany
| | - Felix Mahfoud
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University, Homburg, Germany.
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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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Pulmonary and Systemic Hemodynamics following Multielectrode Radiofrequency Catheter Renal Denervation in Acutely Induced Pulmonary Arterial Hypertension in Swine. BIOMED RESEARCH INTERNATIONAL 2021; 2021:4248111. [PMID: 34765677 PMCID: PMC8577935 DOI: 10.1155/2021/4248111] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 09/17/2021] [Accepted: 10/15/2021] [Indexed: 11/29/2022]
Abstract
Objective We aimed to assess the effects of renal denervation (RDN) on systemic and pulmonary hemodynamics in a swine model of thromboxane A2- (TXA2-) induced pulmonary arterial hypertension (PAH). Methods The study protocol comprised two PAH inductions with a target mean pulmonary artery pressure (PAP) of 40 mmHg at baseline and following either the RDN or sham procedure. Ten Landrace pigs underwent the first PAH induction; then, nine animals were randomly allocated in 1 : 1 ratio to RDN or sham procedure; the second PAH induction was performed in eight animals (one animal died of pulmonary embolism during the first PAH induction, and one animal died after RDN). In the RDN group, ablation was performed in all available renal arteries, and balloon inflation within artery branches was performed in controls. An autopsy study of the renal arteries was performed. Results At baseline, the target mean PAP was achieved in all animals with 25.0 [20.1; 25.2] mcg of TXA2. The second PAH induction required the same mean TXA2 dose and infusion time. There was no statistically significant difference in the mean PAP at second PAH induction between the groups (39.0 ± 5.3 vs. 39.75 ± 0.5 mmHg, P > 0.05). In the RDN group, the second PAH induction resulted in a numerical but insignificant trend toward a decrease in the mean systemic blood pressure and systemic vascular resistance, when compared with the baseline induction (74 ± 18.7 vs. 90.25 ± 28.1 mmHg and 1995.3 ± 494.3 vs. 2433.7 ± 1176.7 dyn∗sec∗cm−5, P > 0.05, respectively). No difference in hemodynamic parameters was noted in the sham group between the first and second PAH induction. Autopsy demonstrated artery damage in both groups, but RDN resulted in more severe lesions. Conclusions According to our results, RDN does not result in significant acute pulmonary or systemic hemodynamic changes in the TXA2-induced PAH model. The potential chronic effects of RDN on PAH require further research.
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Böhm M, Tsioufis K, Kandzari DE, Kario K, Weber MA, Schmieder RE, Townsend RR, Kulenthiran S, Ukena C, Pocock S, Ewen S, Weil J, Fahy M, Mahfoud F. Effect of Heart Rate on the Outcome of Renal Denervation in Patients With Uncontrolled Hypertension. J Am Coll Cardiol 2021; 78:1028-1038. [PMID: 34474735 DOI: 10.1016/j.jacc.2021.06.044] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 06/25/2021] [Accepted: 06/28/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Sham-controlled trials demonstrated safety and efficacy of renal denervation (RDN) to lower blood pressure (BP). Association of baseline heart rate with BP reduction after RDN is incompletely understood. OBJECTIVES The purpose of this analysis was to evaluate the impact of baseline heart rate on BP reduction without antihypertensive medications in the SPYRAL HTN-OFF MED (Global Clinical Study of Renal Denervation With the Symplicity Spyral Multi-electrode Renal Denervation System in Patients With Uncontrolled Hypertension in the Absence of Antihypertensive Medications) Pivotal trial. METHODS Patients removed from any antihypertensive medications were enrolled with office systolic blood pressure (SBP) ≥150 and <180 mm Hg and randomized 1:1 to RDN or sham control. Patients were separated according to baseline office heart rate <70 or ≥70 beats/min. BP changes from baseline to 3 months between treatment arms were adjusted for baseline SBP using analysis of covariance. RESULTS Scatter plots of 3-month changes in 24-hour and office SBP illustrate a wide range of changes in SBP for different baseline heart rates. Treatment difference at 3 months between RDN and sham control with baseline office heart rate ≥70 beats/min for 24-hour SBP was -6.2 mm Hg (95% CI: -9.0 to -3.5 mm Hg) (P < 0.001) and for baseline office heart rate <70 beats/min it was -0.1 mm Hg (-3.8 to 3.6 mm Hg) (P = 0.97) with an interaction P value of 0.008. Results were similar for changes in office, daytime, and nighttime SBP at 3 months, with a greater reduction in SBP with baseline office heart rate ≥70 beats/min. CONCLUSIONS Reduction in mean office, 24-hour, daytime, and nighttime SBP for RDN at 3 months was greater with baseline office heart rate ≥70 than <70 beats/min, suggesting an association between baseline heart rate and BP reduction after RDN. (SPYRAL PIVOTAL-SPYRAL HTN-OFF MED Study; NCT02439749).
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Affiliation(s)
- Michael Böhm
- Klinik für Innere Medizin III, Universitätsklinikum des Saarlandes, Saarland University, Homburg/Saar, Germany.
| | - Konstantinos Tsioufis
- National and Kapodistrian University of Athens, Hippocratio Hospital, Athens, Greece
| | | | - Kazuomi Kario
- Jichi Medical University School of Medicine, Tochigi, Japan
| | | | | | - Raymond R Townsend
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Saarraaken Kulenthiran
- Klinik für Innere Medizin III, Universitätsklinikum des Saarlandes, Saarland University, Homburg/Saar, Germany
| | - Christian Ukena
- Klinik für Innere Medizin III, Universitätsklinikum des Saarlandes, Saarland University, Homburg/Saar, Germany
| | - Stuart Pocock
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Sebastian Ewen
- Klinik für Innere Medizin III, Universitätsklinikum des Saarlandes, Saarland University, Homburg/Saar, Germany
| | - Joachim Weil
- Department of Cardiology, Sana Cardiomed Heart Center, Lübeck, Germany
| | | | - Felix Mahfoud
- Klinik für Innere Medizin III, Universitätsklinikum des Saarlandes, Saarland University, Homburg/Saar, Germany. https://twitter.com/FelixMahfoud
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20
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An Update on Catheter-Based Renal Denervation for the Treatment of Hypertension. CURRENT CARDIOVASCULAR RISK REPORTS 2021. [DOI: 10.1007/s12170-021-00682-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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21
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A re-examination of the SPYRAL HTN-OFF MED Pivotal trial with respect to the underlying model assumptions. Contemp Clin Trials Commun 2021; 23:100818. [PMID: 34258470 PMCID: PMC8256182 DOI: 10.1016/j.conctc.2021.100818] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 06/22/2021] [Accepted: 06/27/2021] [Indexed: 11/29/2022] Open
Abstract
Background The SPYRAL HTN-OFF MED Pivotal trial demonstrated that RDN was efficacious compared to a sham control. The underlying model was an extension of the analysis of covariance (ANCOVA) model, adjusted for baseline blood pressure (BP), and allowed borrowing of information from the previously reported feasibility study using a novel Bayesian method. Fundamental to the estimation of a treatment effect for efficacy are a multitude of statistical modelling assumptions, including the role of outliers, linearity of the association between baseline BP and outcome, and parallelism of the treatment effect difference over the baseline BP range. In this report, we examine the validity of these assumptions to verify the robustness of the treatment effect measured. Methods We examined the requisite modelling assumptions of the ANCOVA model fitted to the SPYRAL HTN-OFF MED Pivotal trial using Bayesian methods. To address outliers, we fit a robust regression model (with heavy tailed errors) to the data with diffuse weakly informative prior distributions on the parameters. To address linearity, we replaced the linear baseline term by a natural spline term with 4 degrees of freedom. To address parallelism, we refit the ANCOVA model with an interaction term for treatment arm and baseline BP. Results ANCOVA models were fitted to the trial data (pooled across the feasibility and pivotal cohorts) using Bayesian methodology with diffuse (non-informative) prior distributions. The modelling assumptions inherent to the ANCOVA models were shown to be broadly satisfied. A robust ANCOVA model yielded a posterior treatment effect of -4.1 mmHg (95% credible interval: -6.3 to -1.9) indicating the influence of outlier values was small. There was moderate evidence of an interaction term effect between baseline BP and treatment, but no evidence of gross violation of linearity in baseline BP. Conclusion The posterior treatment effect estimate is shown to be robust to underlying model assumptions, thus further supporting the evidence of RDN to be an efficacious treatment for resistant hypertension.
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22
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Böhm M, Lauder L. Blood pressure and renal denervation with ultrasound: another step forward. Lancet 2021; 397:2441-2443. [PMID: 34010610 DOI: 10.1016/s0140-6736(21)00989-2] [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: 04/07/2021] [Accepted: 04/21/2021] [Indexed: 11/23/2022]
Affiliation(s)
- Michael Böhm
- Klinik für Innere Medizin III, Universitätsklinikum des Saarlandes, Saarland University, 66421 Homburg/Saar, Germany.
| | - Lucas Lauder
- Klinik für Innere Medizin III, Universitätsklinikum des Saarlandes, Saarland University, 66421 Homburg/Saar, Germany
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23
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Mahfoud F, Townsend RR, Kandzari DE, Kario K, Schmieder RE, Tsioufis K, Pocock S, David S, Patel K, Rao A, Walton A, Bloom JE, Weber T, Suppan M, Lauder L, Cohen SA, McKenna P, Fahy M, Böhm M, Weber MA. Changes in Plasma Renin Activity After Renal Artery Sympathetic Denervation. J Am Coll Cardiol 2021; 77:2909-2919. [PMID: 33957242 DOI: 10.1016/j.jacc.2021.04.044] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 03/23/2021] [Accepted: 04/12/2021] [Indexed: 12/25/2022]
Abstract
BACKGROUND The renin-angiotensin-aldosterone system plays a key role in blood pressure (BP) regulation and is the target of several antihypertensive medications. Renal denervation (RDN) is thought to interrupt the sympathetic-mediated neurohormonal pathway as part of its mechanism of action to reduce BP. OBJECTIVES The purpose of this study was to evaluate plasma renin activity (PRA) and aldosterone before and after RDN and to assess whether these baseline neuroendocrine markers predict response to RDN. METHODS Analyses were conducted in patients with confirmed absence of antihypertensive medication. Aldosterone and PRA levels were compared at baseline and 3 months post-procedure for RDN and sham control groups. Patients in the SPYRAL HTN-OFF MED Pivotal trial were separated into 2 groups, those with baseline PRA ≥0.65 ng/ml/h (n = 110) versus <0.65 ng/ml/h (n = 116). Follow-up treatment differences between RDN and sham control groups were adjusted for baseline values using multivariable linear regression models. RESULTS Baseline PRA was similar between RDN and control groups (1.0 ± 1.1 ng/ml/h vs. 1.1 ± 1.1 ng/ml/h; p = 0.37). Change in PRA at 3 months from baseline was significantly greater for RDN compared with control subjects (-0.2 ± 1.0 ng/ml/h; p = 0.019 vs. 0.1 ± 0.9 ng/ml/h; p = 0.14), p = 0.001 for RDN versus control subjects, and similar differences were seen for aldosterone: RDN compared with control subjects (-1.2 ± 6.4 ng/dl; p = 0.04 vs. 0.4 ± 5.4 ng/dl; p = 0.40), p = 0.011. Treatment differences at 3 months in 24-h and office systolic blood pressure (SBP) for RDN versus control patients were significantly greater for patients with baseline PRA ≥0.65 ng/ml/h versus <0.65 ng/ml/h, despite similar baseline BP. Differences in office SBP changes according to baseline PRA were also observed earlier at 2 weeks post-RDN. CONCLUSIONS Plasma renin activity and aldosterone levels for RDN patients were significantly reduced at 3 months when compared with baseline as well as when compared with sham control. Higher baseline PRA levels were associated with a significantly greater reduction in office and 24-h SBP. (SPYRAL PIVOTAL - SPYRAL HTN-OFF MED Study; NCT02439749).
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Affiliation(s)
- Felix Mahfoud
- Klinik für Innere Medizin III, Universitätsklinikum des Saarlandes, Saarland University, Homburg/Saar, Germany.
| | - Raymond R Townsend
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David E Kandzari
- Department of Interventional Cardiology, Piedmont Heart Institute, Atlanta, Georgia, USA
| | - Kazuomi Kario
- Department of Cardiovascular Medicine and Department of Sleep and Circadian Cardiology, Jichi Medical University School of Medicine, Tochigi, Japan
| | - Roland E Schmieder
- Department of Nephrology and Hypertension, Universitätsklinikum Erlangen, Erlangen, Germany
| | - Konstantinos Tsioufis
- Department of Cardiology, University of Athens, Hippocratio Hospital, Athens, Greece
| | - Stuart Pocock
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Shukri David
- Department of Cardiology, Providence Hospital, Southfield, Michigan, USA
| | - Kiritkumar Patel
- Department of Cardiology, Saint Joseph Mercy Oakland, Bloomfield Hills, Michigan, USA
| | - Anjani Rao
- Department of Cardiology, Saint Joseph Mercy Oakland, Bloomfield Hills, Michigan, USA
| | - Antony Walton
- Department of Cardiology, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Jason E Bloom
- Department of Cardiology, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Thomas Weber
- Department of Cardiology, Klinikum Wels-Grieskirchen, Wels, Austria
| | - Markus Suppan
- Department of Cardiology, Klinikum Wels-Grieskirchen, Wels, Austria
| | - Lucas Lauder
- Klinik für Innere Medizin III, Universitätsklinikum des Saarlandes, Saarland University, Homburg/Saar, Germany
| | - Sidney A Cohen
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Coronary and Renal Denervation Division, Medtronic PLC, Santa Rosa, California, USA
| | - Pamela McKenna
- Coronary and Renal Denervation Division, Medtronic PLC, Santa Rosa, California, USA
| | - Martin Fahy
- Coronary and Renal Denervation Division, Medtronic PLC, Santa Rosa, California, USA
| | - Michael Böhm
- Klinik für Innere Medizin III, Universitätsklinikum des Saarlandes, Saarland University, Homburg/Saar, Germany
| | - Michael A Weber
- Department of Medicine, SUNY Downstate College of Medicine, Brooklyn, New York, USA
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24
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Lauder L, Böhm M, Mahfoud F. The current status of renal denervation for the treatment of arterial hypertension. Prog Cardiovasc Dis 2021; 65:76-83. [PMID: 33587963 DOI: 10.1016/j.pcad.2021.02.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 02/08/2021] [Indexed: 02/08/2023]
Abstract
Despite the availability of safe and effective antihypertensive drugs, blood pressure (BP) control to guideline-recommended target values is poor. Several device-based therapies have been introduced to lower BP. The most extensively investigated approach is catheter-based renal sympathetic denervation (RDN), which aims to interrupt the activity of afferent and efferent renal sympathetic nerves by applying radiofrequency energy, ultrasound energy, or injection of alcohol in the perivascular space. The second generation of placebo-controlled trials have provided solid evidence for the BP-lowering efficacy of radiofrequency- and ultrasound-based RDN in patients with and without concomitant pharmacological therapy. In addition, the safety profile of RDN appears to be excellent in all registries and clinical trials. However, there remain unsolved issues to be addressed. This review summarizes the rationale as well as the current evidence and discusses open questions and possible future indications of catheter-based RDN.
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Affiliation(s)
- Lucas Lauder
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University, Homburg/Saar, Germany
| | - Michael Böhm
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University, Homburg/Saar, Germany
| | - Felix Mahfoud
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University, Homburg/Saar, Germany; Institute for Medical Engineering and Science, MIT, Cambridge, MA, USA.
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25
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Abstract
PURPOSE OF REVIEW Of the roughly 1.4 billion people with hypertension worldwide, only about one in seven has their blood pressure (BP) successfully treated and adequately controlled. This review will focus on new therapeutic approaches of hypertension. RECENT FINDINGS Several recent clinical studies and guidelines have favoured the assessment of target organ damage and cardiovascular risk scores for the diagnosis and treatment approach of hypertension. Paradigm shifts recommended in the guidelines are the initiation of antihypertensive treatment with combination (not mono) therapy and the recommendation of single-pill combinations (SPC), which improve adherence and result in rapid and effective BP control. In clinical trials with optimized design and renal denervation (RDN) technology, the biological proof of concept has been established. Consistent, durable ambulatory and office BP reductions without procedure associated serious adverse events have been documented. The challenges are now to identify patients who respond best to interventional treatment. SUMMARY Major key points in the treatment strategy for hypertension are: individualization of the therapy according to total cardiovascular risk, combination therapy as initial step, recommendation of SPC and RDN as promising interventional therapy.
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Affiliation(s)
- Agnes Bosch
- Department of Nephrology and Hypertension, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany
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26
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Schmieder RE. Renal denervation: where do we stand and what is the relevance to the nephrologist? Nephrol Dial Transplant 2020; 37:638-644. [DOI: 10.1093/ndt/gfaa237] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Indexed: 01/21/2023] Open
Abstract
Abstract
Catheter-based renal denervation to reduce high blood pressure (BP) has received well-deserved attention after a recent series of sham-controlled trials reported significant antihypertensive efficacy and very favourable tolerability and safety of the intervention. This emerging treatment option is of high relevance to nephrologists. Patients with chronic kidney disease (CKD) are at elevated risk of cardiovascular adverse events and often present with hypertension, which is very difficult to control with medication. Renal denervation promises a new tool to reduce BP and to prevent loss of renal function in this population. The current review considers the role of the kidney and neurohormonal activation in the development of hypertension and the rationale for renal denervation. The current state of the evidence for the effectiveness and tolerability of the procedure is considered from the nephrologists’ perspective, with a focus on the potential future role of renal denervation in the management of CKD patients with hypertension.
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Affiliation(s)
- Roland E Schmieder
- Department of Nephrology and Hypertension, University Hospital Erlangen, Friedrich-Alexander-University, Erlangen-Nuremberg, Germany
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27
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Kandzari DE, Mahfoud F, Bhatt DL, Böhm M, Weber MA, Townsend RR, Hettrick DA, Schmieder RE, Tsioufis K, Kario K. Confounding Factors in Renal Denervation Trials: Revisiting Old and Identifying New Challenges in Trial Design of Device Therapies for Hypertension. Hypertension 2020; 76:1410-1417. [PMID: 32981360 DOI: 10.1161/hypertensionaha.120.15745] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Recent randomized sham-controlled trials have demonstrated significant blood pressure reductions following renal denervation (RDN) in patients with hypertension, both in the presence and absence of antihypertensive therapy. These new data encouraged us to revisit previously published insights into potential clinical trial confounding factors that informed the design and conduct of forthcoming trials. Initially identified confounders related to procedural technique, medication variability, and selected patient subgroups have been addressed in contemporary trial design. Regarding procedural method and technology, blood pressure reductions may be improved by ensuring circumferential lesion creation in the distal renal arteries and branch vessels. Safety of the RDN procedure has been demonstrated in multiple independent meta-analyses including thousands of treated patients with low reported rates of renal vessel complications and maintenance of renal function. However, a newer generation of RDN trials has also introduced insights related to medication adherence, patient selection, and the definition of treatment response. Evolving evidence indicates that RDN therapy may be considered in higher risk populations of uncontrolled hypertension regardless of ethnicity and in patients expressing a strong preference for a nondrug therapy option. Despite advances in procedural technique and clinical trial conduct, inconsistent antihypertensive-drug adherence behavior remains perhaps the most critical clinical trial design issue for device-based hypertension therapies. As the balance in clinical equipoise increasingly favors RDN, justification of sham-controlled trial designs will be revisited, and novel study designs may be required to evaluate the safety and efficacy of novel devices and procedures intended to address the escalating prevalence of poorly controlled hypertension.
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Affiliation(s)
- David E Kandzari
- From the Piedmont Heart Institute, Atlanta, GA (D.E.K.).,Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School (D.L.B.)
| | - Felix Mahfoud
- University Hospital of Saarland, Saarland University, Homburg, Germany (F.M., M.B.)
| | | | - Michael Böhm
- University Hospital of Saarland, Saarland University, Homburg, Germany (F.M., M.B.)
| | - Michael A Weber
- SUNY Downstate College of Medicine, Brooklyn, New York (M.A.W.)
| | - Raymond R Townsend
- Perelman School of Medicine, University of Pennsylvania, Philadelphia (R.R.T.)
| | | | | | - Konstantinos Tsioufis
- National and Kapodistrian University of Athens, Hippocration Hospital, Athens Medical Center, Greece (K.T.)
| | - Kazuomi Kario
- Jichi Medical University School of Medicine, Tochigi, Japan (K.K.)
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28
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Pastormerlo LE, Burchielli S, Ciardetti M, Aquaro GD, Grigoratos C, Castiglione V, Pucci A, Franzini M, Giorgetti A, Marzullo P, Benelli E, Masotti S, Musetti V, Bernini F, Berti S, Passino C, Emdin M. Myocardial salvage is increased after sympathetic renal denervation in a pig model of acute infarction. Clin Res Cardiol 2020; 110:711-724. [PMID: 32514602 DOI: 10.1007/s00392-020-01685-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 06/02/2020] [Indexed: 12/16/2022]
Abstract
RATIONALE Despite advances in treatment of acute myocardial infarction (AMI), many patients suffer significant myocardial damage with cardiac dysfunction. Sympathetic renal denervation (RD) may reduce adrenergic activation following AMI. OBJECTIVE To investigate the potential role of RD limiting myocardial damage and remodeling when performed immediately after AMI. METHODS AND RESULTS Sixteen farm pigs underwent 90 min left anterior descending artery balloon occlusion. Eight pigs underwent RD immediately after reperfusion. LV function, extent of myocardium at risk, and myocardial necrosis were quantified by cardiac magnetic resonance 5 and 30 days after AMI. 123I-MIBG scintigraphy was performed 31 days after AMI to image myocardial sympathetic innervation. Heart norepinephrine was quantified (from necrotic, border and remote zone). RD and control did not differ in myocardium at risk extent (59 ± 9 vs 55 ± 11% of LV mass) at 5 days. At 30 days CMR, RD pigs had smaller necrotic areas than control as assessed by gadolinium delay enhancement (18 ± 7 vs 30 ± 12% of LV mass, p = 0.021) resulting in improved myocardial salvage index (60 ± 11 vs 44 ± 27%, p < 0.001). RD pigs had higher cardiac output (3.7 ± 0.8 vs 2.66 ± 0.7 L/min, p < 0.001) and lower LV end diastolic volume (98 ± 16 vs 113 ± 31 ml, p = 0.041). 123I-MIBG defect extension was smaller in RD than control (60 ± 28 vs 78 ± 17%, p < 0.05) with significant reduction in the difference between innervation and perfusion defects (25 ± 12 vs 36 ± 30%, p = 0.013). NE content from necrotic area (238; IQR 464 vs 2546; IQR 1727 ng/g in RD and control, respectively, p < 0.001) and from border zone (295; IQR 264 vs 837; IQR 207 in RD and control, respectively, p = 0.031) was significantly lower in RD than control. CONCLUSIONS RD results in increased myocardial salvage and better cardiac function, when performed immediately after AMI. Reduction of sympathetic activation with preservation of cardiac sympathetic functionality warranted by RD may sustain these effects.
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Affiliation(s)
- Luigi Emilio Pastormerlo
- Fondazione G. Monasterio CNR-Regione Toscana, Massa, Pisa, Italy. .,Life Sciences Institute, Scuola Superiore Sant'Anna, Pisa, Italy. .,Division of Cardiovascular Medicine, Fondazione Toscana Gabriele Monasterio CNR-Regione Toscana, Via Giuseppe Moruzzi 1, 56124, Pisa, Italy.
| | | | - Marco Ciardetti
- Fondazione G. Monasterio CNR-Regione Toscana, Massa, Pisa, Italy
| | | | - Chrysantos Grigoratos
- Fondazione G. Monasterio CNR-Regione Toscana, Massa, Pisa, Italy.,Life Sciences Institute, Scuola Superiore Sant'Anna, Pisa, Italy
| | | | - Angela Pucci
- Institute of Clinical Pathology, University of Pisa, Pisa, Italy
| | - Maria Franzini
- Institute of Clinical Pathology, University of Pisa, Pisa, Italy
| | | | - Paolo Marzullo
- Fondazione G. Monasterio CNR-Regione Toscana, Massa, Pisa, Italy
| | - Eleonora Benelli
- Fondazione G. Monasterio CNR-Regione Toscana, Massa, Pisa, Italy
| | - Silvia Masotti
- Fondazione G. Monasterio CNR-Regione Toscana, Massa, Pisa, Italy
| | - Veronica Musetti
- Fondazione G. Monasterio CNR-Regione Toscana, Massa, Pisa, Italy
| | - Fabio Bernini
- Life Sciences Institute, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Sergio Berti
- Fondazione G. Monasterio CNR-Regione Toscana, Massa, Pisa, Italy
| | - Claudio Passino
- Fondazione G. Monasterio CNR-Regione Toscana, Massa, Pisa, Italy.,Life Sciences Institute, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Michele Emdin
- Fondazione G. Monasterio CNR-Regione Toscana, Massa, Pisa, Italy.,Life Sciences Institute, Scuola Superiore Sant'Anna, Pisa, Italy
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29
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Böhm M, Kario K, Kandzari DE, Mahfoud F, Weber MA, Schmieder RE, Tsioufis K, Pocock S, Konstantinidis D, Choi JW, East C, Lee DP, Ma A, Ewen S, Cohen DL, Wilensky R, Devireddy CM, Lea J, Schmid A, Weil J, Agdirlioglu T, Reedus D, Jefferson BK, Reyes D, D'Souza R, Sharp ASP, Sharif F, Fahy M, DeBruin V, Cohen SA, Brar S, Townsend RR. Efficacy of catheter-based renal denervation in the absence of antihypertensive medications (SPYRAL HTN-OFF MED Pivotal): a multicentre, randomised, sham-controlled trial. Lancet 2020; 395:1444-1451. [PMID: 32234534 DOI: 10.1016/s0140-6736(20)30554-7] [Citation(s) in RCA: 288] [Impact Index Per Article: 72.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Revised: 02/28/2020] [Accepted: 03/02/2020] [Indexed: 01/11/2023]
Abstract
BACKGROUND Catheter-based renal denervation has significantly reduced blood pressure in previous studies. Following a positive pilot trial, the SPYRAL HTN-OFF MED (SPYRAL Pivotal) trial was designed to assess the efficacy of renal denervation in the absence of antihypertensive medications. METHODS In this international, prospective, single-blinded, sham-controlled trial, done at 44 study sites in Australia, Austria, Canada, Germany, Greece, Ireland, Japan, the UK, and the USA, hypertensive patients with office systolic blood pressure of 150 mm Hg to less than 180 mm Hg were randomly assigned 1:1 to either a renal denervation or sham procedure. The primary efficacy endpoint was baseline-adjusted change in 24-h systolic blood pressure and the secondary efficacy endpoint was baseline-adjusted change in office systolic blood pressure from baseline to 3 months after the procedure. We used a Bayesian design with an informative prior, so the primary analysis combines evidence from the pilot and Pivotal trials. The primary efficacy and safety analyses were done in the intention-to-treat population. This trial is registered at ClinicalTrials.gov, NCT02439749. FINDINGS From June 25, 2015, to Oct 15, 2019, 331 patients were randomly assigned to either renal denervation (n=166) or a sham procedure (n=165). The primary and secondary efficacy endpoints were met, with posterior probability of superiority more than 0·999 for both. The treatment difference between the two groups for 24-h systolic blood pressure was -3·9 mm Hg (Bayesian 95% credible interval -6·2 to -1·6) and for office systolic blood pressure the difference was -6·5 mm Hg (-9·6 to -3·5). No major device-related or procedural-related safety events occurred up to 3 months. INTERPRETATION SPYRAL Pivotal showed the superiority of catheter-based renal denervation compared with a sham procedure to safely lower blood pressure in the absence of antihypertensive medications. FUNDING Medtronic.
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Affiliation(s)
- Michael Böhm
- Klinik für Innere Medizin III, Universitätsklinikum des Saarlandes, Saarland University, Homburg (Saar), Germany.
| | - Kazuomi Kario
- Jichi Medical University School of Medicine, Tochigi, Japan
| | | | - Felix Mahfoud
- Klinik für Innere Medizin III, Universitätsklinikum des Saarlandes, Saarland University, Homburg (Saar), Germany; Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA
| | | | | | - Konstantinos Tsioufis
- National and Kapodistrian University of Athens, Hippocratio Hospital, Athens, Greece
| | - Stuart Pocock
- London School of Hygiene & Tropical Medicine, London, UK
| | | | - James W Choi
- Baylor Scott and White Heart and Vascular Hospital, Dallas, TX, USA
| | - Cara East
- Baylor Scott and White Heart and Vascular Hospital, Dallas, TX, USA
| | - David P Lee
- Stanford Hospital and Clinics, Stanford, CA, USA
| | - Adrian Ma
- Stanford Hospital and Clinics, Stanford, CA, USA
| | - Sebastian Ewen
- Klinik für Innere Medizin III, Universitätsklinikum des Saarlandes, Saarland University, Homburg (Saar), Germany
| | - Debbie L Cohen
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Robert Wilensky
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Janice Lea
- Emory University School of Medicine, Atlanta, GA, USA
| | - Axel Schmid
- Universitätsklinikum Erlangen, Erlangen, Germany
| | | | | | | | | | - David Reyes
- TriStar Centennial Medical Center, Nashville, TN, USA
| | | | - Andrew S P Sharp
- University Hospital of Wales, Cardiff, UK; University of Exeter, Exeter, UK
| | - Faisal Sharif
- Galway University Hospitals and National University of Ireland Galway, Galway, Ireland
| | | | | | - Sidney A Cohen
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Medtronic, Santa Rosa, CA, USA
| | | | - Raymond R Townsend
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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