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Palermiti A, Pappaccogli M, Rabbia F, D'Avolio A, Veglio F. Multiple drug intolerance in antihypertensive patients: what is known and what is missing. J Hypertens 2024; 42:1289-1297. [PMID: 38690922 DOI: 10.1097/hjh.0000000000003737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2024]
Abstract
Drug allergy and intolerance are increasingly recognized as significant public health concerns, leading to adverse reactions in patients undergoing pharmacological treatments. Multiple drug intolerance syndrome (MDIS), characterized by adverse reactions to at least three different drug classes without a clear immunological mechanism, poses a substantial challenge, particularly in hypertensive patients. Despite its link to suboptimal adherence and uncontrolled blood pressure, MDIS in the context of hypertension remains insufficiently explored. This review synthesizes existing literature on MDIS, emphasizing clinical characteristics, pathogenesis, and psychiatric comorbidity. Furthermore, it delves into MDIS in the context of hypertension, highlighting the importance of a multidisciplinary approach in diagnosis and management, including innovative therapeutic strategies such as novel therapeutic algorithms or renal denervation. The review concludes by emphasizing the necessity for further research and clinical trials to enhance our understanding and address MDIS, especially in hypertensive patients.
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Affiliation(s)
| | - Marco Pappaccogli
- Division of Internal Medicine and Hypertension Unit, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Franco Rabbia
- Division of Internal Medicine and Hypertension Unit, Department of Medical Sciences, University of Turin, Turin, Italy
| | | | - Franco Veglio
- Division of Internal Medicine and Hypertension Unit, Department of Medical Sciences, University of Turin, Turin, Italy
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2
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Stabile E, Muiesan ML, Ribichini FL, Sangiorgi G, Taddei S, Versaci F, Villari B, Bacca A, Benedetto D, Fioretti V, Laurenzano E, Scapaticci M, Saia F, Tarantini G, Grassi G, Esposito G. Italian Society of Interventional Cardiology (GISE) and Italian Society of Arterial Hypertension (SIIA) Position Paper on the role of renal denervation in the management of the difficult-to-treat hypertension. Minerva Cardiol Angiol 2024; 72:313-328. [PMID: 38535984 DOI: 10.23736/s2724-5683.23.06433-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/28/2024]
Abstract
Renal denervation (RDN) is a safe and effective strategy for the treatment of difficult to treat hypertension. The blood pressure (BP)-lowering efficacy of RDN is comparable to those of many single antihypertensive medications and it allows to consider the RDN as a valuable option for the treatment of difficult to treat hypertension together with lifestyle modifications and medical therapy. A multidisciplinary team is of pivotal importance from the selection of the patient candidate for the procedure to the post-procedural management. Further studies are needed to investigate the effect of RDN on clinical outcomes and to better identify the predictors of BP response to RDN in order to recognize the patients who are more likely to benefit from the procedure.
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Affiliation(s)
- Eugenio Stabile
- Division of Cardiology, Cardiovascular Department, Azienda Ospedaliera Regionale "San Carlo", Potenza, Italy
| | - Maria L Muiesan
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Flavio L Ribichini
- Division of Cardiovascular Medicine, Department of Medicine, University of Verona, Verona, Italy
| | | | - Stefano Taddei
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | | | - Bruno Villari
- Division of Cardiology, Sacro Cuore di Gesù Hospital, Benevento, Italy
| | - Alessandra Bacca
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Daniela Benedetto
- Division of Cardiology, Tor Vergata University Hospital, Rome, Italy
| | - Vincenzo Fioretti
- Division of Cardiology, Cardiovascular Department, Azienda Ospedaliera Regionale "San Carlo", Potenza, Italy
- Division of Cardiology, Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | | | | | - Francesco Saia
- Cardiology Unit, Cardio-Thoraco-Vascular Department, IRCCS University Hospital of Bologna, Policlinico S. Orsola, Bologna, Italy
| | - Giuseppe Tarantini
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua Medical School, Padua, Italy
| | - Guido Grassi
- Clinica Medica, University of Milano-Bicocca, Milan, Italy
| | - Giovanni Esposito
- Division of Cardiology, Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy -
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Zhang H, Huo X, Ren L, Lu J, Li J, Zheng X, Liu J, Ma W, Yuan J, Diao X, Wu C, Zhang X, Wang J, Zhao W, Hu S. Design and rationale of the Comprehensive intelligent Hypertension managEment SyStem (CHESS) evaluation study: A cluster randomized controlled trial for hypertension management in primary care. Am Heart J 2024; 273:90-101. [PMID: 38575049 DOI: 10.1016/j.ahj.2024.03.018] [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: 12/11/2023] [Revised: 03/30/2024] [Accepted: 03/31/2024] [Indexed: 04/06/2024]
Abstract
BACKGROUND Hypertension management in China is suboptimal with high prevalence and low control rate due to various barriers, including lack of self-management awareness of patients and inadequate capacity of physicians. Digital therapeutic interventions including mobile health and computational device algorithms such as clinical decision support systems (CDSS) are scalable with the potential to improve blood pressure (BP) management and strengthen the healthcare system in resource-constrained areas, yet their effectiveness remains to be tested. The aim of this report is to describe the protocol of the Comprehensive intelligent Hypertension managEment SyStem (CHESS) evaluation study assessing the effect of a multifaceted hypertension management system for supporting patients and physicians on BP lowering in primary care settings. MATERIALS AND METHODS The CHESS evaluation study is a parallel-group, cluster-randomized controlled trial conducted in primary care settings in China. Forty-one primary care sites from 3 counties of China are randomly assigned to either the usual care or the intervention group with the implementation of the CHESS system, more than 1,600 patients aged 35 to 80 years with uncontrolled hypertension and access to a smartphone by themselves or relatives are recruited into the study and followed up for 12 months. In the intervention group, participants receive patient-tailored reminders and alerts via messages or intelligent voice calls triggered by uploaded home blood pressure monitoring data and participants' characteristics, while physicians receive guideline-based prescription instructions according to updated individual data from each visit, and administrators receive auto-renewed feedback of hypertension management performance from the data analysis platform. The multiple components of the CHESS system can work synergistically and have undergone rigorous development and pilot evaluation using a theory-informed approach. The primary outcome is the mean change in 24-hour ambulatory systolic BP from baseline to 12 months. DISCUSSION The CHESS trial will provide evidence and novel insight into the effectiveness and feasibility of an implementation strategy using a comprehensive digital BP management system for reducing hypertension burden in primary care settings. TRIAL REGISTRATION https://www. CLINICALTRIALS gov, NCT05605418.
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Affiliation(s)
- Haibo Zhang
- National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiqian Huo
- National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lixin Ren
- National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jiapeng Lu
- National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jing Li
- National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xin Zheng
- National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jiamin Liu
- National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wenjun Ma
- Hypertension Center of Fuwai Hospital, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences, and Peking Union Medical College, Beijing, China
| | - Jing Yuan
- Information Centre, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiaolin Diao
- Information Centre, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Chaoqun Wu
- National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiaoyan Zhang
- National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jin Wang
- National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wei Zhao
- National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shengshou Hu
- National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
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4
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Sharp AS, Sanderson A, Hansell N, Reddish K, Miller P, Moss J, Schmieder RE, McCool R. Renal denervation for uncontrolled hypertension: a systematic review and meta-analysis examining multiple subgroups. J Hypertens 2024; 42:1133-1144. [PMID: 38634457 PMCID: PMC11139244 DOI: 10.1097/hjh.0000000000003727] [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: 12/20/2023] [Revised: 03/04/2024] [Accepted: 03/12/2024] [Indexed: 04/19/2024]
Abstract
This systematic review and meta-analysis was conducted to assess the randomized controlled trial (RCT) evidence available for renal denervation (RDN) in uncontrolled arterial hypertension. Twenty-five RCTs met the eligibility criteria for the systematic review, and 16 RCTs were included in the meta-analysis. The results of the random effects meta-analysis estimated a mean difference of -8.5 mmHg [95% confidence interval (CI) -13.5 to -3.6] for office SBP, -3.6 mmHg (95% CI -5.2 to -2.0) for 24 h SBP and -3.9 mmHg (95% CI -5.6 to -2.2) for ambulatory daytime SBP in favour of RDN compared with control (medication and/or sham-only) at primary follow-up. Similarly favourable results were observed across a range of prespecified subgroup analyses, including treatment-resistant hypertension. This meta-analysis suggests that the use of RDN in uncontrolled hypertension leads to consistent reductions in blood pressure. Reductions appear to be statistically consistent in the presence or absence of medications and in populations resistant to the use of three medications.
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Affiliation(s)
| | - Alice Sanderson
- York Health Economics Consortium Ltd, York Science Park, York, UK
| | - Neil Hansell
- York Health Economics Consortium Ltd, York Science Park, York, UK
| | - Katie Reddish
- York Health Economics Consortium Ltd, York Science Park, York, UK
| | - Paul Miller
- York Health Economics Consortium Ltd, York Science Park, York, UK
| | - Joe Moss
- York Health Economics Consortium Ltd, York Science Park, York, UK
| | - Roland E. Schmieder
- Department of Nephrology and Hypertension University Hospital Erlangen, Friedrich Alexander University Erlangen/Nürnberg, Germany
| | - Rachael McCool
- York Health Economics Consortium Ltd, York Science Park, York, UK
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Agwuegbo CC, Antia AU, Shamaki GR, Bob-Manuel T. Controversies related to renal artery denervation and devices. Curr Opin Cardiol 2024; 39:244-250. [PMID: 38567924 DOI: 10.1097/hco.0000000000001146] [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] [Indexed: 06/05/2024]
Abstract
PURPOSE OF REVIEW This review article discusses the controversies, strengths, and limitations of the current literature on renal artery denervation in the management of resistant hypertension, as well as the future directions of this intervention. RECENT FINDINGS There have been conflicting data from the different randomized control trials assessing the efficacy of renal artery denervation in the management of resistant hypertension. SUMMARY Renal artery denervation is achieved by ablating the sympathetic nerves surrounding the renal arteries using endovascular ultrasound, radiofrequency, or alcohol. Our review article highlights that renal artery denervation is generally effective in improving blood pressure in patients with resistant hypertension. The Food and Drug Administration (FDA) has recently approved the ReCor Medical Paradise system, and the Symplicity Spyral RDN systems for renal artery denervation.
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Affiliation(s)
| | | | | | - Tamunoinemi Bob-Manuel
- Division of Cardiovascular Diseases, University of Tennessee Health Science Center, Memphis, Tennessee, USA
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Tang M, Hu J, Li W, Zhang N, Ning S, Yan Y, Cui Z. Effects of Renal Denervation on Ouabain-Induced Hypertension in Rats. Int J Hypertens 2024; 2024:4763189. [PMID: 38957519 PMCID: PMC11217579 DOI: 10.1155/2024/4763189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 05/04/2024] [Accepted: 05/28/2024] [Indexed: 07/04/2024] Open
Abstract
Background Ouabain, a Na+, K+-ATPase inhibitor, is elevated in hypertensive patients. Evidence suggests ouabain contributes to hypertension mainly through activation of the sympathetic nervous system (SNS). Renal nerves play a vital role in the regulation of SNS activity, so we hypothesize that renal denervation may attenuate the development of ouabain-induced hypertension. Methods and Results Forty Sprague-Dawley rats were divided into following groups (n = 10 each): control group (sham surgery plus intraperitoneal saline injection), RDN group (renal denervation (RDN) plus intraperitoneal saline injection), ouabain group (sham surgery plus intraperitoneal ouabain injection), and ouabain + RDN group (RDN plus intraperitoneal ouabain injection). After eight weeks, compared with the control group, rats in the ouabain group exhibited elevated blood pressure (P < 0.05), increased plasma epinephrine, norepinephrine, angiotensin II, and aldosterone levels (P < 0.05). These indexes could be significantly ameliorated by RDN. RDN also reduced the thickening of aortic tunica media and downregulated the expression of proliferating cell nuclear antigen (PCNA) in the thoracic aorta induced by ouabain. Masson staining and echocardiography showed that myocardial fibrosis and increased left ventricular mass in the ouabain group could be attenuated by RDN. Conclusions The present study reveals that renal nerves play an important role in the development of ouabain-induced hypertension. RDN could inhibit the pressor effect and the myocardial remodeling induced by ouabain potentially via inhibiting catecholamine release and vascular smooth muscle cell proliferation. Clinical studies are needed to explore whether RDN may exhibit better antihypertensive effects on hypertensive patients with high plasma ouabain levels as compared to those with normal plasma ouabain levels.
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Affiliation(s)
- Minna Tang
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, Shanghai, China
| | - Jialu Hu
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, Shanghai, China
| | - Wenshu Li
- School of Public Health, Fudan University, Shanghai, 200032, China
| | - Ningzhi Zhang
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, Shanghai, China
| | - Sisi Ning
- Department of Cardiology, Shanghai Changning Tianshan Traditional Chinese Medicine Hospital, Shanghai 200051, China
| | - Yan Yan
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, Shanghai, China
| | - Zhaoqiang Cui
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, Shanghai, China
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Schiffrin EL, Fisher NDL. Diagnosis and management of resistant hypertension. BMJ 2024; 385:e079108. [PMID: 38897628 DOI: 10.1136/bmj-2023-079108] [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] [Indexed: 06/21/2024]
Abstract
Resistant hypertension is defined as blood pressure that remains above the therapeutic goal despite concurrent use of at least three antihypertensive agents of different classes, including a diuretic, with all agents administered at maximum or maximally tolerated doses. Resistant hypertension is also diagnosed if blood pressure control requires four or more antihypertensive drugs. Assessment requires the exclusion of apparent treatment resistant hypertension, which is most often the result of non-adherence to treatment. Resistant hypertension is associated with major cardiovascular events in the short and long term, including heart failure, ischemic heart disease, stroke, and renal failure. Guidelines from several professional organizations recommend lifestyle modification and antihypertensive drugs. Medications typically include an angiotensin converting enzyme inhibitor or angiotensin receptor blocker, a calcium channel blocker, and a long acting thiazide-type/like diuretic; if a fourth drug is needed, evidence supports addition of a mineralocorticoid receptor antagonist. After a long pause since 2007 when the last antihypertensive class was approved, several novel agents are now under active development. Some of these may provide potent blood pressure lowering in broad groups of patients, such as aldosterone synthase inhibitors and dual endothelin receptor antagonists, whereas others may provide benefit by allowing treatment of resistant hypertension in special populations, such as non-steroidal mineralocorticoid receptor antagonists in patients with chronic kidney disease. Several device based approaches have been tested, with renal denervation being the best supported and only approved interventional device treatment for resistant hypertension.
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Affiliation(s)
- Ernesto L Schiffrin
- Lady Davis Institute for Medical Research and Department of Medicine, Sir Mortimer B. Davis-Jewish General Hospital, McGill University, Montréal, QC, Canada
| | - Naomi D L Fisher
- Department of Medicine, Brigham and Women's Hospital, Harvard University, Boston, MA, USA
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Vukadinović D, Lauder L, Kandzari DE, Bhatt DL, Kirtane A, Edelman ER, Schmieder RE, Azizi M, Böhm M, Mahfoud F. Effects of catheter-based renal denervation in hypertension: a systematic review and meta-analysis. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.06.12.24308869. [PMID: 38946962 PMCID: PMC11213059 DOI: 10.1101/2024.06.12.24308869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/02/2024]
Abstract
Background Several sham-controlled trials have investigated the efficacy and safety of catheter-based renal denervation (RDN) with mixed outcomes. Aim To perform a comprehensive meta-analysis of all randomized, sham-controlled trials investigating RDN with first- and second-generation devices in hypertension. Methods We searched MEDLINE and Cochrane Library for eligible trials. Outcomes included both efficacy (24-hour and office systolic [SBP] and diastolic blood pressure [DBP]) and safety (all-cause death, vascular complication, renal artery stenosis >70%, hypertensive crisis) of RDN. We performed a study-level, pairwise, random-effects meta-analysis of the summary data. Results Ten trials comprising 2,478 patients with hypertension while being either off- or on-treatment were included. Compared with sham, RDN reduced 24-hour and office systolic BP by 4.4 mmHg (95%CI -6.1, -2.7, p<0.00001) and 6.6 mmHg (95%CI -9.7, -3.6, p<0.0001), respectively. The 24-hour and office diastolic BP paralleled these findings (-2.6 mmHg, 95%CI - 3.6, -1.5, p<0.00001; -3.5 mmHg, 95%CI -5.4, -1.6, p=0.0003). There was no difference in 24-hour and office SBP reduction between trials with and without concomitant antihypertensive medication (p for interaction 0.62 and 0.73, respectively). There was no relevant difference concerning vascular complications (OR 1.69, 95%CI 0.57-5.0, p=0.34), renal artery stenosis (OR 1.50, 95%CI 0.06-36.97, p=0.80), hypertensive crisis (OR 0.65, 95%CI 0.30-1.38, p=0.26) and all-cause death (OR 1.76, 95%CI 0.34-9.20, p=0.50) between RDN and sham groups. Change of renal function based on eGFR was comparable between groups (p for interaction 0.84). There was significant heterogeneity between trials. Conclusions RDN safely reduces ambulatory and office SBP/DBP vs. a sham procedure in the presence and absence of antihypertensive medication. Clinical Perspective What is new?Several sham-controlled trials have investigated the efficacy and safety of catheter-based renal denervation (RDN) with mixed outcomes.This comprehensive meta-analysis comprising 2,478 patients shows that irrespective of the utilized method (radiofrequency-, ultrasound-or alcohol-mediated), renal denervation effectively reduced ambulatory and office systolic blood pressure.Renal denervation exhibited no additional risk concerning vascular injury or renal function impairment.What are the clinical implications?This meta-analysis supports current guidelines/consensus statements that renal denervation represents an additive treatment option in carefully selected patients with uncontrolled hypertension.
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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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10
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Kandzari DE, Weber MA, Pathak A, Zidar JP, Saxena M, David SW, Schmieder RE, Janas AJ, Langer C, Persu A, Mendelsohn FO, Ameloot K, Foster M, Fischell TA, Parise H, Mahfoud F. Effect of Alcohol-Mediated Renal Denervation on Blood Pressure in the Presence of Antihypertensive Medications: Primary Results From the TARGET BP I Randomized Clinical Trial. Circulation 2024; 149:1875-1884. [PMID: 38587557 DOI: 10.1161/circulationaha.124.069291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2024] [Accepted: 03/18/2024] [Indexed: 04/09/2024]
Abstract
BACKGROUND Renal denervation (RDN) has demonstrated clinically relevant reductions in blood pressure (BP) among individuals with uncontrolled hypertension despite lifestyle intervention and medications. The safety and effectiveness of alcohol-mediated RDN have not been formally studied in this indication. METHODS TARGET BP I is a prospective, international, sham-controlled, randomized, patient- and assessor-blinded trial investigating the safety and efficacy of alcohol-mediated RDN. Patients with office systolic BP (SBP) ≥150 and ≤180 mm Hg, office diastolic BP ≥90 mm Hg, and mean 24-hour ambulatory SBP ≥135 and ≤170 mm Hg despite prescription of 2 to 5 antihypertensive medications were enrolled. The primary end point was the baseline-adjusted change in mean 24-hour ambulatory SBP 3 months after the procedure. Secondary end points included mean between-group differences in office and ambulatory BP at additional time points. RESULTS Among 301 patients randomized 1:1 to RDN or sham control, RDN was associated with a significant reduction in 24-hour ambulatory SBP at 3 months (mean±SD, -10.0±14.2 mm Hg versus -6.8±12.1 mm Hg; treatment difference, -3.2 mm Hg [95% CI, -6.3 to 0.0]; P=0.0487). Subgroup analysis of the primary end point revealed no significant interaction across predefined subgroups. At 3 months, the mean change in office SBP was -12.7±18.3 and -9.7±17.3 mm Hg (difference, -3.0 [95% CI, -7.0 to 1.0]; P=0.173) for RDN and sham, respectively. No significant differences in ambulatory or office diastolic BP were observed. Adverse safety events through 6 months were uncommon, with one instance of accessory renal artery dissection in the RDN group (0.7%). No significant between-group differences in medication changes or patient adherence were identified. CONCLUSIONS Alcohol-mediated RDN was associated with a modest but statistically significant reduction in 24-hour ambulatory SBP compared with sham control. No significant differences between groups in office BP or 6-month major adverse events were observed. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT02910414.
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Affiliation(s)
| | - Michael A Weber
- Division of Cardiovascular Medicine, State University of New York (SUNY), New York (M.A.W.)
| | - Atul Pathak
- Department of Cardiovascular Medicine, Princess Grace Hospital and ESH Hypertension Excellence Center, Monaco (A.P.)
| | - James P Zidar
- University of North Carolina (UNC), Rex Healthcare, Raleigh, NC (J.P.Z.)
| | - Manish Saxena
- Barts Health NHS Trust, Queen Mary University of London, United Kingdom (M.S.)
| | | | - Roland E Schmieder
- Department of Nephrology and Hypertension, University Hospital Erlangen, Friedrich Alexander University Erlangen/Nürnberg, Germany (R.E.S.)
| | - Adam J Janas
- Collegium Medicum of Andrzej Frycz Modrzewski Krakow University, Kraków, Poland (A.J.J.)
- Center of Cardiovascular Research and Development, American Heart of Poland, Katowice (A.J.J.)
| | | | - Alexandre Persu
- Division of Cardiology, Cliniques Universitaires Saint-Luc and Pole of Cardiovascular Research, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium (A.P.)
| | | | - Koen Ameloot
- Department of Cardiology, Ziekenhuis Oost Limburg, Genk, Belgium (K.A.)
| | - Malcolm Foster
- Tennova Turkey Creek Medical Center, Knoxville, TN (M.F.)
| | - Tim A Fischell
- Ablative Solutions Inc, Wakefield, MA (T.A.F.)
- Yale University School of Medicine, New Haven, CT (T.A.F., H.P.)
| | - Helen Parise
- Yale University School of Medicine, New Haven, CT (T.A.F., H.P.)
| | - Felix Mahfoud
- Department of Internal Medicine III, Cardiology, Angiology, Intensive Care Medicine, Saarland University Medical Center, Homburg, Germany (F.M.)
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11
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Vogt A, Plehn A, Atti C, Nussbaum M, Tongers J, Sedding D, Dutzmann J. Left ventricular structure and function following renal sympathetic denervation in patients with HFpEF: an echocardiographic 9-year long-term follow-up. Front Cardiovasc Med 2024; 11:1408547. [PMID: 38919545 PMCID: PMC11196750 DOI: 10.3389/fcvm.2024.1408547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Accepted: 05/23/2024] [Indexed: 06/27/2024] Open
Abstract
Background High blood pressure is a major risk factor for cardiac remodeling and left ventricular hypertrophy, increasing cardiovascular risk and leading to heart failure with preserved ejection fraction (HFpEF). Since renal sympathetic denervation (RDN) reduces blood pressure in the long term, we aimed to investigate the long-term effect of RDN in patients with HFpEF in the present analysis. Methods Patients previously enrolled in a local RDN registry who underwent high-frequency RDN with the use of the Symplicity Flex® renal denervation system between 2011 and 2014 were followed up. The patients were assessed by 24-h ambulatory blood pressure measurement, transthoracic echocardiography, and laboratory tests. We used the echocardiographic and biomarker criteria of the Heart Failure Association (HFA)-PEFF (Pre-test assessment, Echocardiography and Natriuretic Peptide Score, Funkctional testing, and Final aetiology) score to identify patients with HFpEF. Results Echocardiographic assessment was available for 70 patients at a 9-year long-term follow-up. Of these patients, 21 had HFpEF according to the HFA-PEFF score. We found a significant reduction of the HFA-PEFF score from 5.48 ± 0.51 points at baseline to 4.33 ± 1.53 points at the 9-year follow-up (P < 0.01). This decrease was due to a greater reduction in morphological and biomarker subcategories [from 1.95 ± 0.22 to 1.43 ± 0.51 points (P < 0.01) and from 1.52 ± 0.52 to 0.90 ± 0.63 points (P < 0.01), respectively] than in the functional one. Morphologically, there was a reduction in left ventricular hypertrophy and left atrial dilation. Conclusions The present analysis suggests that RDN may lead to a regression of the extent of HFpEF beyond a reduction in blood pressure and thus possibly contribute to an improvement in prognosis. More detailed information will be provided by ongoing randomized sham-controlled trials.
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Affiliation(s)
- Alexander Vogt
- Department of Internal Medicine III, University Hospital Halle (Saale), Halle (Saale), Germany
| | - Alexander Plehn
- Department of Internal Medicine III, University Hospital Halle (Saale), Halle (Saale), Germany
- Praxisklinik Salzatal, Salzatal, Germany
| | - Carlo Atti
- Department of Internal Medicine, Medical University Graz, Graz, Austria
| | - Michael Nussbaum
- Department of Internal Medicine III, University Hospital Halle (Saale), Halle (Saale), Germany
| | - Jörn Tongers
- Department of Internal Medicine III, University Hospital Halle (Saale), Halle (Saale), Germany
| | - Daniel Sedding
- Department of Internal Medicine III, University Hospital Halle (Saale), Halle (Saale), Germany
| | - Jochen Dutzmann
- Department of Internal Medicine III, University Hospital Halle (Saale), Halle (Saale), Germany
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12
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Ogoyama Y, Abe M, Okamura K, Tada K, Katsurada K, Shibata S, Kai H, Rakugi H, Node K, Yokoi H, Kario K, Arima H. Effects of renal denervation on blood pressure in patients with hypertension: a latest systematic review and meta-analysis of randomized sham-controlled trials. Hypertens Res 2024:10.1038/s41440-024-01739-y. [PMID: 38831091 DOI: 10.1038/s41440-024-01739-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Revised: 04/29/2024] [Accepted: 05/13/2024] [Indexed: 06/05/2024]
Abstract
The efficacy of renal denervation (RDN) has been controversial, but recent randomized sham-controlled trials demonstrated significant blood pressure reductions after RDN in patients with hypertension. We conducted a systematic review and updated meta-analysis to evaluate the effects of RDN on ambulatory and office blood pressures in patients with hypertension. Databases were searched up to 15 November 2023 to identify randomized, sham-controlled trials of RDN. The primary endpoint was change in 24 h ambulatory systolic blood pressure (SBP) with RDN versus sham control. The secondary endpoints were changes in 24 h ambulatory diastolic blood pressure, daytime and nighttime blood pressure (BP), office BP, and home BP. A sub-analysis determined outcomes by medication, procedure, and device. From twelve trials, 2222 patients with hypertension were randomized to undergo RDN (n = 1295) or a sham procedure (n = 927). At 2-6 months after treatment, RDN significantly reduced 24 h ambulatory SBP by 2.81 mmHg (95% confidence interval: -4.09, -1.53; p < 0.001) compared with the sham procedure. RDN also reduced daytime SBP by 3.17 mmHg (- 4.75, - 1.58; p < 0.001), nighttime SBP by 3.41 mmHg (- 4.69, - 2.13; p < 0.001), office SBP by 4.95 mmHg (- 6.37, - 3.54; p < 0.001), and home SBP by 4.64 mmHg (- 7.44, - 1.84; p = 0.001) versus the sham control group. There were no significant differences in the magnitude of BP reduction between first- and second-generation trials, between devices, or between with or without medication. These data from randomized sham-controlled trials showed that RDN significantly reduced all blood pressure metrics in medicated or unmedicated patients with hypertension, including resistant/uncontrolled hypertension.
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Affiliation(s)
- Yukako Ogoyama
- Division of Cardiovascular Medicine, Jichi Medical University School of Medicine, Tochigi, Japan
| | - Makiko Abe
- Department of Preventive Medicine and Public Health, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Keisuke Okamura
- Department of Cardiology and Cardiovascular Center, Imamura Hospital, Tosu, Saga, Japan
| | - Kazuhiro Tada
- Division of Nephrology and Rheumatology, Department of Internal Medicine, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Kenichi Katsurada
- Division of Cardiovascular Medicine, Jichi Medical University School of Medicine, Tochigi, Japan
| | - Shigeru Shibata
- Division of Nephrology, Department of Internal Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Hisashi Kai
- Department of Cardiology, Kurume University Medical Center, Fukuoka, Japan
| | - Hiromi Rakugi
- Division of Health Sciences, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Koichi Node
- Department of Cardiovascular Medicine, Saga University, Saga, Japan
| | - Hiroyoshi Yokoi
- Cardiovascular Center, Fukuoka Sanno Hospital, Fukuoka, Japan
| | - Kazuomi Kario
- Division of Cardiovascular Medicine, Jichi Medical University School of Medicine, Tochigi, Japan.
| | - Hisatomi Arima
- Department of Preventive Medicine and Public Health, Faculty of Medicine, Fukuoka University, Fukuoka, Japan.
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13
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Lauder L, Siwy J, Mavrogeorgis E, Keller F, Kunz M, Wachter A, Emrich IE, Böhm M, Mischak H, Mahfoud F. Impact of Renal Denervation on Urinary Peptide-Based Biomarkers in Hypertension. Hypertension 2024; 81:1374-1382. [PMID: 38572643 DOI: 10.1161/hypertensionaha.124.22819] [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: 01/29/2024] [Accepted: 03/25/2024] [Indexed: 04/05/2024]
Abstract
BACKGROUND Catheter-based renal denervation (RDN) reduces blood pressure in hypertension. Urinary peptides are associated with cardiovascular and renal disease and provide prognostic information. We aimed to investigate the effect of RDN on urinary peptide-based classifiers associated with chronic kidney and heart disease and to identify urinary peptides affected by RDN. METHODS This single-arm, single-center study included patients undergoing catheter-based RDN. Urine samples were collected before and 24 months after RDN and were analyzed using capillary electrophoresis coupled with mass spectrometry. Predefined urinary peptide-based classifiers for chronic kidney disease (CKD273), coronary artery disease (CAD238), and heart failure (HF1) were applied. RESULTS This study included 48 patients (33% female) with uncontrolled hypertension. At 24 months after RDN, systolic blood pressure (165±17 versus 148±20 mm Hg; P<0.0001), diastolic blood pressure (90±17 versus 81±13 mm Hg; P<0.0001), and mean arterial pressure (115±15 versus 103±13 mm Hg; P<0.0001) decreased significantly. A total of 103 urinary peptides from 37 different proteins, mostly collagens, altered following RDN. CAD238, a 238 coronary artery-specific polypeptide-based classifier, significantly improved following RDN (Cohen's d, -0.632; P=0.0001). The classification scores of HF1 (P=0.8295) and CKD273 (P=0.6293) did not change significantly. CONCLUSIONS RDN beneficially affected urinary peptides associated with coronary artery disease. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT01888315.
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Affiliation(s)
- Lucas Lauder
- Klinik für Innere Medizin III - Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätskliniken des Saarlandes und Universität des Saarlandes, Homburg, Germany (L.L., M.K., A.W., I.E.E., M.B., F.M.)
| | - Justyna Siwy
- Mosaiques Diagnostics GmbH, Hannover, Germany (J.S., E.M., H.M.)
| | - Emmanouil Mavrogeorgis
- Mosaiques Diagnostics GmbH, Hannover, Germany (J.S., E.M., H.M.)
- Institute for Molecular Cardiovascular Research, Rheinisch-Westfälische Technische Hochschule Aachen University Hospital, Germany (E.M.)
| | - Felix Keller
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University Innsbruck, Austria (F.K.)
| | - Michael Kunz
- Klinik für Innere Medizin III - Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätskliniken des Saarlandes und Universität des Saarlandes, Homburg, Germany (L.L., M.K., A.W., I.E.E., M.B., F.M.)
| | - Angelika Wachter
- Klinik für Innere Medizin III - Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätskliniken des Saarlandes und Universität des Saarlandes, Homburg, Germany (L.L., M.K., A.W., I.E.E., M.B., F.M.)
| | - Insa E Emrich
- Klinik für Innere Medizin III - Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätskliniken des Saarlandes und Universität des Saarlandes, Homburg, Germany (L.L., M.K., A.W., I.E.E., M.B., F.M.)
| | - Michael Böhm
- Klinik für Innere Medizin III - Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätskliniken des Saarlandes und Universität des Saarlandes, Homburg, Germany (L.L., M.K., A.W., I.E.E., M.B., F.M.)
| | - Harald Mischak
- Mosaiques Diagnostics GmbH, Hannover, Germany (J.S., E.M., H.M.)
| | - Felix Mahfoud
- Klinik für Innere Medizin III - Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätskliniken des Saarlandes und Universität des Saarlandes, Homburg, Germany (L.L., M.K., A.W., I.E.E., M.B., F.M.)
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge (F.M.)
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14
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Wang J, Yin Y, Lu C, Lu Z, Hu J, Wang Y, Ge J, Jiang H, Yao C, Yan X, Ma W, Qi X, Dang Y, Chen S, Zhu J, Wang D, Ding C, Wang W, Liu J, Wang Y, Li H, Pan Z, Cui K, Li C, Liang X, Chen W, Sobotka PA, Zhang J, Esler M, Sun N, Chen M, Huo Y. Efficacy and safety of sympathetic mapping and ablation of renal nerves for the treatment of hypertension (SMART): 6-month follow-up of a randomised, controlled trial. EClinicalMedicine 2024; 72:102626. [PMID: 38756107 PMCID: PMC11096821 DOI: 10.1016/j.eclinm.2024.102626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Revised: 04/17/2024] [Accepted: 04/17/2024] [Indexed: 05/18/2024] Open
Abstract
Background Previous trials of renal denervation (RDN) have been designed to investigate reduction of blood pressure (BP) as the primary efficacy endpoint using non-selective RDN without intraoperatively verified RDN success. It is an unmet clinical need to map renal nerves, selectively denervate renal sympathetic nerves, provide readouts for the interventionalists and avoid futile RDN. We aimed to examine the safety and efficacy of renal nerve mapping/selective renal denervation (msRDN) in patients with uncontrolled hypertension (HTN) and determine whether antihypertensive drug burden is reduced while office systolic BP (OSBP) is controlled to target level (<140 mmHg). Methods We conducted a randomized, prospective, multicenter, single-blinded, sham-controlled trial. The study combined two efficacy endpoints at 6 months as primary outcomes: The control rate of patients with OSBP <140 mmHg (non-inferior outcome) and change in the composite index of antihypertensive drugs (Drug Index) in the treatment versus Sham group (superior outcome). This design avoids confounding from excess drug-taking in the Sham group. Antihypertensive drug burden was assessed by a composite index constructed as: Class N (number of classes of antihypertensive drugs) × (sum of doses). 15 hospitals in China participated in the study and 220 patients were enrolled in a 1:1 ratio (msRDN vs Sham). The key inclusion criteria included: age (18-65 years old), history of essential HTN (at least 6 months), heart rate (≥70 bpm), OSBP (≥150 mmHg and ≤180 mmHg), ambulatory BP monitoring (ABPM, 24-h SBP ≥130 mmHg or daytime SBP ≥135 mmHg or nighttime SBP ≥120 mmHg), renal artery stenosis (<50%) and renal function (eGFR >45 mL/min/1.73 m2). The catheter with both stimulation and ablation functions was inserted in the distal renal main artery. The RDN site (hot spot) was selected if SBP increased (≥5 mmHg) by intra-renal artery (RA) electrical stimulation; an adequate RDN was confirmed by repeated electronic stimulation if no increase in BP otherwise, a 2nd ablation was performed at the same site. At sites where there was decreased SBP (≥5 mmHg, cold spot) or no BP response (neutral spot) to stimulation, no ablation was performed. The mapping, ablation and confirmation procedure was repeated until the entire renal main artery had been tested then either treated or avoided. After msRDN, patients had to follow a predefined, vigorous drug titration regimen in order to achieve target OSBP (<140 mmHg). Drug adherence was monitored by liquid chromatography-tandem mass spectrometry analysis using urine. This study is registered with ClinicalTrials.gov (NCT02761811) and 5-year follow-up is ongoing. Findings Between July 8, 2016 and February 23, 2022, 611 patients were consented, 220 patients were enrolled in the study who received standardized antihypertensive drug treatments (at least two drugs) for at least 28 days, presented OSBP ≥150 mmHg and ≤180 mmHg and met all inclusion and exclusion criteria. In left RA and right RA, mapped sites were 8.2 (3.0) and 8.0 (2.7), hot/ablated sites were 3.7 (1.4) and 4.0 (1.6), cold spots were 2.4 (2.6) and 2.0 (2.2), neutral spots were 2.0 (2.1) and 2.0 (2.1), respectively. Hot, cold and neutral spots was 48.0%, 27.5% and 24.4% of total mapped sites, respectively. At 6 M, the Control Rate of OSBP was comparable between msRDN and Sham group (95.4% vs 92.8%, p = 0.429), achieved non-inferiority margin -10% (2.69%; 95% CI -4.11%, 9.83%, p < 0.001 for non-inferiority); the change in Drug Index was significantly lower in msRDN group compared to Sham group (4.37 (6.65) vs 7.61 (10.31), p = 0.010) and superior to Sham group (-3.25; 95% CI -5.56, -0.94, p = 0.003), indicating msRDN patients need significantly fewer drugs to control OSBP <140 mmHg. 24-hour ambulatory SBP decreased from 146.8 (13.9) mmHg by 10.8 (14.1) mmHg, and from 149.8 (12.8) mmHg by 10.0 (14.0) mmHg in msRDN and Sham groups, respectively (p < 0.001 from Baseline; p > 0.05 between groups). Safety profiles were comparable between msRDN and Sham groups, demonstrating the safety and efficacy of renal mapping/selective RDN to treat uncontrolled HTN. Interpretation The msRDN therapy achieved the goals of reducing the drug burden of HTN patients and controlling OSBP <140 mmHg, with only approximately four targeted ablations per renal main artery, much lower than in previous trials. Funding SyMap Medical (Suzhou), LTD, Suzhou, China.
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Affiliation(s)
- Jie Wang
- The First Affiliated Hospital with Nanjing Medical University, Nanjing, 210029, China
- Division of Cardiology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, NY, 10032, USA
| | - Yuehui Yin
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China
| | - Chengzhi Lu
- Department of Cardiology, Tianjin First Central Hospital, Tianjin, 300190, China
| | - Zhibing Lu
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, 430060, China
- Department of Cardiology, Zhongnan Hospital, Wuhan University, Wuhan, 430071, China
| | - Jialu Hu
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai, 200032, China
| | - Yue Wang
- The First Affiliated Hospital with Nanjing Medical University, Nanjing, 210029, China
| | - Junbo Ge
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai, 200032, China
| | - Hong Jiang
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, 430060, China
| | - Chen Yao
- Peking University Health Science Center, Beijing, 100034, China
| | - Xiaoyan Yan
- Peking University Health Science Center, Beijing, 100034, China
| | - Wei Ma
- Department of Cardiology, Peking University First Hospital, Beijing, 100034, China
| | - Xiaoyong Qi
- Department of Cardiology, Hebei General Hospital, Shijiazhuang, 050057, China
| | - Yi Dang
- Department of Cardiology, Hebei General Hospital, Shijiazhuang, 050057, China
| | - Shaoliang Chen
- Department of Cardiology, Nanjing First Hospital, Nanjing, 210012, China
| | - Jiancheng Zhu
- Department of Cardiology, Nanjing First Hospital, Nanjing, 210012, China
| | - Dongmei Wang
- Department of Cardiology, Norman Bethune International Peace Hospital, Shijiazhuang, 050082, China
| | - Chao Ding
- Department of Cardiology, Norman Bethune International Peace Hospital, Shijiazhuang, 050082, China
| | - Weimin Wang
- Department of Cardiology, Peking University People's Hospital, Beijing, 100044, China
| | - Jian Liu
- Department of Cardiology, Peking University People's Hospital, Beijing, 100044, China
| | - Yanbin Wang
- Department of Cardiology, Taiyuan Central Hospital, Taiyuan, 030009, China
| | - Hui Li
- Department of Cardiology, Daqing Oilfield General Hospital, Daqing, 163458, China
| | - Zhenhua Pan
- Department of Cardiology, Daqing Oilfield General Hospital, Daqing, 163458, China
| | - Kaijun Cui
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, 332001, China
| | - Chengzong Li
- Department of Cardiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, 221002, China
| | - Xinjian Liang
- Department of Cardiology, Shenzhen People's Hospital, Shenzhen, Guangdong, 430060, China
| | - Weijie Chen
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China
| | - Paul A. Sobotka
- Department of Cardiology, The Ohio State University College of Medicine, Columbus, OH, 43210, USA
| | | | - Murray Esler
- Baker IDI Heart and Diabetes Institute, Melbourne, Australia
| | - Ningling Sun
- Department of Hypertension, Heart Center, Peking University People's Hospital, Beijing, 100044, China
| | - Minglong Chen
- Department of Cardiology, The First Affiliated Hospital with Nanjing Medical University, Nanjing, 210029, China
| | - Yong Huo
- Department of Cardiology, Peking University First Hospital, Beijing, 100034, China
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Sarafidis P, Schmieder R, Burnier M, Persu A, Januszewicz A, Halimi JM, Arici M, Ortiz A, Wanner C, Mancia G, Kreutz R. A European Renal Association (ERA) synopsis for nephrology practice of the 2023 European Society of Hypertension (ESH) Guidelines for the Management of Arterial Hypertension. Nephrol Dial Transplant 2024; 39:929-943. [PMID: 38365947 PMCID: PMC11139525 DOI: 10.1093/ndt/gfae041] [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: 12/09/2023] [Indexed: 02/18/2024] Open
Abstract
In June 2023, the European Society of Hypertension (ESH) presented and published the new 2023 ESH Guidelines for the Management of Arterial Hypertension, a document that was endorsed by the European Renal Association (ERA). Following the evolution of evidence in recent years, several novel recommendations relevant to the management of hypertension in patients with chronic kidney disease (CKD) appeared in these Guidelines. These include recommendations for target office blood pressure (BP) <130/80 mmHg in most and against target office BP <120/70 mmHg in all patients with CKD; recommendations for use of spironolactone or chlorthalidone for patients with resistant hypertension with estimated glomerular filtration rate (eGFR) higher or lower than 30 mL/min/1.73 m2, respectively; use of a sodium-glucose cotransporter 2 inhibitor for patients with CKD and estimated eGFR ≥20 mL/min/1.73 m2; use of finerenone for patients with CKD, type 2 diabetes mellitus, albuminuria, eGFR ≥25 mL/min/1.73 m2 and serum potassium <5.0 mmol/L; and revascularization in patients with atherosclerotic renovascular disease and secondary hypertension or high-risk phenotypes if stenosis ≥70% is present. The present report is a synopsis of sections of the ESH Guidelines that are relevant to the daily clinical practice of nephrologists, prepared by experts from ESH and ERA. The sections summarized are those referring to the role of CKD in hypertension staging and cardiovascular risk stratification, the evaluation of hypertension-mediated kidney damage and the overall management of hypertension in patients with CKD.
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Affiliation(s)
- Pantelis Sarafidis
- 1st Department of Nephrology, Aristotle University of Thessaloniki, Hippokration Hospital, Thessaloniki, Greece
| | - Roland Schmieder
- Department of Nephrology and Hypertension, University Hospital Erlangen, Germany
| | - Michel Burnier
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - Alexandre Persu
- Division of Cardiology, Cliniques Universitaires Saint-Luc and Pole of Cardiovascular Research, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
| | - Andrzej Januszewicz
- Department of Hypertension, National Institute of Cardiology, Warsaw, Poland
| | - Jean-Michel Halimi
- Service de Néphrologie-Hypertension, Dialyses, Transplantation rénale, CHRU Tours, Tours, France and INSERM SPHERE U1246, Université Tours, Université de Nantes, Tours, France
| | - Mustafa Arici
- Department of Nephrology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Alberto Ortiz
- Department of Nephrology and Hypertension, IIS-Fundacion Jimenez Diaz UAM, Madrid, Spain
| | | | | | - Reinhold Kreutz
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institut für Klinische Pharmakologie und Toxikologie, Berlin, Germany
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16
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Yamazaki D, Konishi Y, Kitada K. Effects of renal denervation on the kidney: albuminuria, proteinuria, and renal function. Hypertens Res 2024:10.1038/s41440-024-01709-4. [PMID: 38760521 DOI: 10.1038/s41440-024-01709-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Revised: 04/02/2024] [Accepted: 04/07/2024] [Indexed: 05/19/2024]
Abstract
Renal denervation has attracted attention as a novel antihypertensive treatment for hypertensive patients who are poorly controlled by medicine. Clinical studies have shown the antihypertensive effects of renal denervation in patients with treatment-resistant hypertension. However, renal denervation potentially has other beneficial effects, such as improving glucose metabolism and cardioprotection beyond its antihypertensive effects. In this mini-review article, we summarize and discuss the effects of renal denervation on proteinuria, albuminuria, and renal function based on the recent findings of clinical studies, and review the renoprotective effects of renal denervation.
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Affiliation(s)
- Daisuke Yamazaki
- Department of Pharmacology, Faculty of Medicine, Kagawa University, Kagawa, 7610793, Japan
- Division on Nephrology & Hypertension, Osaka City General Hospital, Osaka, 5340021, Japan
| | - Yoshio Konishi
- Division on Nephrology & Hypertension, Osaka City General Hospital, Osaka, 5340021, Japan
| | - Kento Kitada
- Department of Pharmacology, Faculty of Medicine, Kagawa University, Kagawa, 7610793, Japan.
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17
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Silvinato A, Floriano I, Bernardo WM. Renal denervation by radiofrequency in patients with hypertension: systematic review and meta-analysis. REVISTA DA ASSOCIACAO MEDICA BRASILEIRA (1992) 2024; 70:e2023D704. [PMID: 38747880 PMCID: PMC11095971 DOI: 10.1590/1806-9282.2023d704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/16/2024] [Accepted: 03/18/2024] [Indexed: 05/18/2024]
Abstract
The Guidelines Project, which is an initiative of the Brazilian Medical Association, aims to combine information from the medical field to standardize how to conduct and assist in the reasoning and decision-making of doctors. The information provided by this project must be critically evaluated by the physician responsible for the conduct that will be adopted, depending on the conditions and the clinical condition of each patient.
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Affiliation(s)
- Antonio Silvinato
- Evidence-Based Medicine, Brazilian Medical Association – São Paulo (SP), Brazil
| | - Idevaldo Floriano
- Evidence-Based Medicine, Brazilian Medical Association – São Paulo (SP), Brazil
| | - Wanderley Marques Bernardo
- Evidence-Based Medicine, Brazilian Medical Association – São Paulo (SP), Brazil
- Universidade de São Paulo, Faculty of Medicine – São Paulo (SP), Brazil
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18
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Lee SY. Using Bayesian statistics in confirmatory clinical trials in the regulatory setting: a tutorial review. BMC Med Res Methodol 2024; 24:110. [PMID: 38714936 PMCID: PMC11077897 DOI: 10.1186/s12874-024-02235-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 04/24/2024] [Indexed: 05/12/2024] Open
Abstract
Bayesian statistics plays a pivotal role in advancing medical science by enabling healthcare companies, regulators, and stakeholders to assess the safety and efficacy of new treatments, interventions, and medical procedures. The Bayesian framework offers a unique advantage over the classical framework, especially when incorporating prior information into a new trial with quality external data, such as historical data or another source of co-data. In recent years, there has been a significant increase in regulatory submissions using Bayesian statistics due to its flexibility and ability to provide valuable insights for decision-making, addressing the modern complexity of clinical trials where frequentist trials are inadequate. For regulatory submissions, companies often need to consider the frequentist operating characteristics of the Bayesian analysis strategy, regardless of the design complexity. In particular, the focus is on the frequentist type I error rate and power for all realistic alternatives. This tutorial review aims to provide a comprehensive overview of the use of Bayesian statistics in sample size determination, control of type I error rate, multiplicity adjustments, external data borrowing, etc., in the regulatory environment of clinical trials. Fundamental concepts of Bayesian sample size determination and illustrative examples are provided to serve as a valuable resource for researchers, clinicians, and statisticians seeking to develop more complex and innovative designs.
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Affiliation(s)
- Se Yoon Lee
- Department of Statistics, Texas A &M University, 3143 TAMU, College Station, TX, 77843, USA.
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Migliaro S, Petrolini A, Mariani S, Tomai F. Impact of renal denervation on patients with coronary microvascular dysfunction: study rationale and design. J Cardiovasc Med (Hagerstown) 2024; 25:379-385. [PMID: 38477865 DOI: 10.2459/jcm.0000000000001609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2024]
Abstract
AIMS Long-standing hypertension may cause an impairment in microvascular coronary circulation, which is involved in many different cardiac conditions. Renal sympathetic denervation (RDN) has been successfully proven as a valuable therapeutic choice for patients with resistant hypertension; moreover, the procedure looks promising in other settings, such as heart failure and atrial fibrillation, given its ability to downregulate the sympathetic nervous system, which is a recognized driver in these conditions as well as in microvascular dysfunction progression. The aim of this study is to explore the effect of RDN on coronary physiology in patients with ascertained coronary microvascular dysfunction and resistant hypertension. METHODS This is a multicenter, prospective, nonrandomized, open-label, interventional study. Consecutive patients with resistant hypertension, nonobstructive coronary artery disease (NOCAD) and documented microvascular dysfunction will be enrolled. Patients will undergo RDN by Spyral Symplicity 3 (Medtronic Inc, Minneapolis, Minnesota, USA) and reassessment of coronary microvascular function 6 months after the procedure. Primary endpoint will be the difference in the index of microcirculatory resistance. CONCLUSION The IMPRESSION study seeks to evaluate if there is any pleiotropic effect of the RDN procedure that results in modulation of microvascular function; if observed, this would be the first evidence showing RDN as a valuable therapy to revert hypertension-related microvascular dysfunction.
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Affiliation(s)
| | - Alessandro Petrolini
- Department of Cardiovascular Sciences, Aurelia Hospital
- Department of Cardiovascular Sciences, European Hospital, Rome, Italy
| | | | - Fabrizio Tomai
- Department of Cardiovascular Sciences, Aurelia Hospital
- Department of Cardiovascular Sciences, European Hospital, Rome, Italy
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20
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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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21
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Shinohara K. Renal denervation in patients with chronic kidney disease: an approach using CO 2 angiography. Hypertens Res 2024; 47:1431-1433. [PMID: 38467794 DOI: 10.1038/s41440-024-01635-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 02/18/2024] [Indexed: 03/13/2024]
Affiliation(s)
- Keisuke Shinohara
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan.
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22
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Sesa-Ashton G, Carnagarin R, Nolde JM, Muente I, Lee R, Macefield VG, Dawood T, Sata Y, Lambert EA, Lambert GW, Walton A, Kiuchi MG, Esler MD, Schlaich MP. Salt sensitivity risk derived from nocturnal dipping and 24-h heart rate predicts long-term blood pressure reduction following renal denervation. J Hypertens 2024; 42:922-927. [PMID: 38230602 DOI: 10.1097/hjh.0000000000003655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2024]
Abstract
BACKGROUND Renal denervation (RDN) has been consistently shown in recent sham-controlled clinical trials to reduce blood pressure (BP). Salt sensitivity is a critical factor in hypertension pathogenesis, but cumbersome to assess by gold-standard methodology. Twenty-four-hour average heart rate (HR) and mean arterial pressure (MAP) dipping, taken by ambulatory blood pressure monitoring (ABPM), stratifies patients into high, moderate, and low salt sensitivity index (SSI) risk categories. OBJECTIVES We aimed to assess whether ABPM-derived SSI risk could predict the systolic blood pressure reduction at long-term follow-up in a real-world RDN patient cohort. METHODS Sixty participants had repeat ABPM as part of a renal denervation long-term follow-up. Average time since RDN was 8.9 ± 1.2 years. Based on baseline ABPM, participants were stratified into low (HR < 70 bpm and MAP dipping > 10%), moderate (HR ≥70 bpm or MAP dipping ≤ 10%), and high (HR ≥ 70 bpm and MAP dipping ≤ 10%) SSI risk groups, respectively. RESULTS One-way ANOVA indicated a significant treatment effect ( P = 0.03) between low ( n = 15), moderate ( n = 35), and high ( n = 10) SSI risk with systolic BP reduction of 9.6 ± 3.7 mmHg, 8.4 ± 3.5 mmHg, and 28.2 ± 9.6 mmHg, respectively. Baseline BP was not significantly different between SSI Risk groups ( P = 0.18). High SSI risk independently correlated with systolic BP reduction ( P = 0.02). CONCLUSIONS Our investigation indicates that SSI risk may be a simple and accessible measure for predicting the BP response to RDN. However, the influence of pharmacological therapy on these participants is an important extraneous variable requiring testing in prospective or drug naive RDN cohorts.
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Affiliation(s)
- Gianni Sesa-Ashton
- Human Neurotransmitter and Neurovascular Hypertension & Kidney Diseases Laboratories, Baker Heart and Diabetes Institute, Melbourne
- Human Autonomic Neurophysiology Laboratory, Baker Heart and Diabetes Institute
| | - Revathy Carnagarin
- Dobney Hypertension Centre, Medical School - Royal Perth Hospital Unit and RPH Research Foundation, The University of Western Australia, Perth, Western Australia
| | - Janis M Nolde
- Dobney Hypertension Centre, Medical School - Royal Perth Hospital Unit and RPH Research Foundation, The University of Western Australia, Perth, Western Australia
| | - Ida Muente
- Dobney Hypertension Centre, Medical School - Royal Perth Hospital Unit and RPH Research Foundation, The University of Western Australia, Perth, Western Australia
| | - Rebecca Lee
- Human Neurotransmitter and Neurovascular Hypertension & Kidney Diseases Laboratories, Baker Heart and Diabetes Institute, Melbourne
| | - Vaughan G Macefield
- Human Autonomic Neurophysiology Laboratory, Baker Heart and Diabetes Institute
| | - Tye Dawood
- Human Autonomic Neurophysiology Laboratory, Baker Heart and Diabetes Institute
| | - Yusuke Sata
- Human Neurotransmitter and Neurovascular Hypertension & Kidney Diseases Laboratories, Baker Heart and Diabetes Institute, Melbourne
- Department of Cardiology, Alfred Health, Melbourne, Victoria
| | - Elisabeth A Lambert
- Iverson Health Innovation Research Institute and School of Health Sciences, Swinburne University of Technology, Melbourne
| | - Gavin W Lambert
- Iverson Health Innovation Research Institute and School of Health Sciences, Swinburne University of Technology, Melbourne
| | - Antony Walton
- Department of Cardiology, Alfred Health, Melbourne, Victoria
| | - Marcio G Kiuchi
- Dobney Hypertension Centre, Medical School - Royal Perth Hospital Unit and RPH Research Foundation, The University of Western Australia, Perth, Western Australia
| | - Murray D Esler
- Human Neurotransmitter and Neurovascular Hypertension & Kidney Diseases Laboratories, Baker Heart and Diabetes Institute, Melbourne
- Department of Cardiology, Alfred Health, Melbourne, Victoria
| | - Markus P Schlaich
- Human Neurotransmitter and Neurovascular Hypertension & Kidney Diseases Laboratories, Baker Heart and Diabetes Institute, Melbourne
- Dobney Hypertension Centre, Medical School - Royal Perth Hospital Unit and RPH Research Foundation, The University of Western Australia, Perth, Western Australia
- Departments of Cardiology and Nephrology, Royal Perth Hospital, Perth, Western Australia, Australia
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23
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Parodi R, Brandani L, Romero C, Klein M. Resistant hypertension: Diagnosis, evaluation, and treatment practical approach. Eur J Intern Med 2024; 123:23-28. [PMID: 38228447 DOI: 10.1016/j.ejim.2023.12.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 12/24/2023] [Accepted: 12/29/2023] [Indexed: 01/18/2024]
Abstract
The term RH describes a subgroup of hypertensive patients whose BP is uncontrolled despite the use of at least three antihypertensive drugs in an appropriate combination at optimal or best tolerated doses. True RH is considered when appropriate lifestyle measures and treatment with optimal or best tolerated doses of three or more drugs (a thiazide/thiazide-like diuretic, plus renin-angiotensin system -RAS- blocker and a calcium channel blocker -CCB-) fail to lower office BP to <140/90 mmHg; besides the inadequate BP control should be confirmed by home blood pressure monitoring (HBPM) or 24-hour ambulatory; and evidence of adherence to therapy and exclusion of secondary causes of hypertension are required. RH patients are at a high risk of cardiovascular events and death. RH is associated with a higher prevalence of end-organ damage. When stricter criteria are applied, a reasonable estimate of the prevalence of true RH is 5 % of the total hypertensive population. The predominant hemodynamic pattern appears to be increased systemic vascular resistance and plasma volume with normal or even low cardiac output. We must rule out pseudo-resistance before diagnosing true drug resistance. RH is a therapeutic challenge, and its management includes lifestyle interventions, avoiding nonadherence to treatment, avoiding inertia, appropriate use of antihypertensive drugs based on current evidence, especially long-acting diuretics, and the addition of mineralocorticoid receptor antagonists. RCTs to identify the most protective medical therapy in RH are needed. A series of drugs in different stages of investigation could significantly impact RH treatment in the future.
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Affiliation(s)
- Roberto Parodi
- Rosario National University, Hospital Provincial del Centenario, Rosario, Argentina.
| | - Laura Brandani
- Favaloro Foundation University Hospital, Buenos Aires, Buenos Aires, Argentina
| | - César Romero
- Renal Division, Emory University School of Medicine, Atlanta, GA, USA
| | - Manuel Klein
- Argentina Society of Medicine, Buenos Aires, Argentina
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24
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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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25
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Sharp ASP, Kandzari DE, Townsend RR, Kario K, Mahfoud F, Weber MA, Schmieder RE, Tsioufis K, Böhm M, Choi JW, Liu M, DeBruin V, Lee DP. A novel, proof-of-concept radiofrequency renal denervation strategy to improve procedural efficiency: 12-month results from the SPYRAL DYSTAL pilot study. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2024:S1553-8389(24)00150-7. [PMID: 38616460 DOI: 10.1016/j.carrev.2024.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Revised: 04/02/2024] [Accepted: 04/03/2024] [Indexed: 04/16/2024]
Abstract
BACKGROUND Catheter-based renal sympathetic denervation (RDN) reduced blood pressure (BP) in multiple randomized sham-controlled trials of patients with uncontrolled hypertension (HTN). We tested proof-of-concept for a more selective treatment strategy, exclusively targeting these areas to improve the efficiency of the procedure. METHODS The SPYRAL DYSTAL Pilot study was designed to mirror the SPYRAL HTN-OFF MED Pivotal study, enabling comparison with a propensity score adjusted active-control group. Patients were antihypertensive medication-free for one month before undergoing BP assessment. Those with office BP of 150-180/>90 mmHg and with an ambulatory systolic BP of 140-170 mmHg were selected to undergo open label treatment, delivering energy only to the distal main renal arteries and first order branches. Patients from DYSTAL were compared with patients who underwent maximized RF RDN treatment in the prior randomized OFF MED trial at 3 months. After 3 months, patients resumed antihypertensive medications as indicated. Safety and efficacy outcomes were assessed post hoc through 12 months. RESULTS The SPYRAL DYSTAL Pilot study treated 56 HTN patients. Baseline office systolic BP (OSBP) and 24-h ambulatory systolic BP (ASBP) were similar between DYSTAL and OFF MED patient groups. The number of ablations (32.3 ± 8.0 vs 46.6 ± 15.3, p < 0.001), procedure time (67 ± 21 min vs 99 ± 36 min; p < 0.001), and contrast volume (173 ± 77 cc vs 208 ± 96 cc; p = 0.014) were significantly lower with the simplified treatment strategy. OSBP and ASBP changes compared with baseline were -9.0 and -1.4 mmHg at 3 months, -20.3 and -13.9 mmHg at 6 months, and -20.3 and -16.6 mmHg at 12 months, respectively. During the medication up-titration phase, BP reductions among DYSTAL patients were similar to reductions observed in OFF MED through 12 months, with comparable number of drugs (1.4 and 1.5 medications, respectively (P=NS)). Two adverse events related to guidewire placement were reported. CONCLUSION In this pilot study, focusing ablation treatment on the distal main and proximal branch renal arteries was performed, resulting in fewer RF lesions, and reduced contrast volume and procedure time. Whether BP reductions are similar between a selective vs. maximized RDN approach requires further prospective study.
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Affiliation(s)
- Andrew S P Sharp
- University Hospital of Wales and Cardiff University, Cardiff, UK.
| | | | - Raymond R Townsend
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Kazuomi Kario
- Department of Cardiovascular Medicine, Jichi Medical University of Medicine, Tochigi, Japan
| | - Felix Mahfoud
- Universitatsklinikum des Saarlandes, Klinik für Kardiologie, Angiologie und Internistische Intensivmedizin, Saarland University, Homburg, Germany
| | | | | | | | - Michael Böhm
- Universitatsklinikum des Saarlandes, Klinik für Kardiologie, Angiologie und Internistische Intensivmedizin, Saarland University, Homburg, Germany
| | - James W Choi
- Baylor Research Institute, Jack and Jane Hamilton Heart and Vascular Hospital, Dallas, TX, USA
| | | | | | - David P Lee
- Stanford Hospital and Clinics, Stanford, CA, USA
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26
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Leahy N, Wagener M, Shahzad S, Murphy D, McMorrow A, Coen E, Sharif R, Sharif F. Exploring Potential Referral Pathways for Renal Artery Denervation and Developing a Centre of Excellence in Ireland. SN COMPREHENSIVE CLINICAL MEDICINE 2024; 6:32. [PMID: 38500967 PMCID: PMC10944407 DOI: 10.1007/s42399-024-01647-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 01/22/2024] [Indexed: 03/20/2024]
Abstract
Arterial hypertension is one of the most significant and prevalent risk factors for cardiovascular disease. Despite widespread awareness of the condition, as well as a multitude of available antihypertensive drug classes, rates of uncontrolled hypertension remain high on a global scale. Frequently, poor compliance with anti-hypertensive medication plays a big role in patients' inability to attain adequate blood pressure control. In individuals with resistant and/or uncontrolled hypertension, renal denervation is an emerging device-based therapy that has shown to be efficacious and safe in reducing blood pressure in several sham controlled trials. Additionally, it represents a treatment option for patients intolerant to oral pharmacotherapy. University Hospital Galway has been performing renal denervation procedures over the past number of years within multicentre, international sham-controlled trials and registries. Representing a novel and emerging antihypertensive treatment option, sources of referral for renal denervation are diverse and multiple; thus, there is an unmet need for standardised referral structures in Ireland. Herein, we review current and developing referral pathways for renal denervation at our institution, and discuss streamlined patient management and requirements to establish a centre of excellence.
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Affiliation(s)
- Niall Leahy
- Cardiology Department, University Hospital Galway, Saolta Healthcare Group, Newcastle Road, Galway, H91 YR71 Ireland
- University of Galway, University Road, Galway, Ireland
| | - Max Wagener
- Cardiology Department, University Hospital Galway, Saolta Healthcare Group, Newcastle Road, Galway, H91 YR71 Ireland
- University of Galway, University Road, Galway, Ireland
| | - Shirjeel Shahzad
- Cardiology Department, University Hospital Galway, Saolta Healthcare Group, Newcastle Road, Galway, H91 YR71 Ireland
| | - Darragh Murphy
- Cardiology Department, University Hospital Galway, Saolta Healthcare Group, Newcastle Road, Galway, H91 YR71 Ireland
- University of Galway, University Road, Galway, Ireland
| | - Amy McMorrow
- Cardiology Department, University Hospital Galway, Saolta Healthcare Group, Newcastle Road, Galway, H91 YR71 Ireland
- University of Galway, University Road, Galway, Ireland
| | - Eileen Coen
- Cardiology Department, University Hospital Galway, Saolta Healthcare Group, Newcastle Road, Galway, H91 YR71 Ireland
- University of Galway, University Road, Galway, Ireland
| | - Ruth Sharif
- Cardiology Department, University Hospital Galway, Saolta Healthcare Group, Newcastle Road, Galway, H91 YR71 Ireland
- University of Galway, University Road, Galway, Ireland
| | - Faisal Sharif
- Cardiology Department, University Hospital Galway, Saolta Healthcare Group, Newcastle Road, Galway, H91 YR71 Ireland
- University of Galway, University Road, Galway, Ireland
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27
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Haider SA, Wagener M, Iqbal T, Shahzad S, Del Sole PA, Leahy N, Murphy D, Sharif R, Ullah I, Sharif F. Does renal denervation require cardiovascular outcome-driven data? Hypertens Res 2024:10.1038/s41440-024-01598-7. [PMID: 38462663 DOI: 10.1038/s41440-024-01598-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 01/01/2024] [Accepted: 01/13/2024] [Indexed: 03/12/2024]
Abstract
Hypertension is a major driver of cardiovascular disease with a prevalence of 32-34% in adults worldwide. This poses a formidable unmet challenge for healthcare systems, highlighting the need for enhanced treatment strategies. Since 2017, eight major sham-controlled randomised controlled trials have examined the effectiveness and safety of renal denervation (RDN) as therapy for BP control. Although most trials demonstrated a reduction in systolic 24-hour/daytime ambulatory BP compared to control groups, open to discussion is whether major adverse cardiovascular events (MACE)-driven RDN trials are necessary or whether the proof of BP reduction as a surrogate for better cardiovascular outcomes is sufficient. We conducted an analysis of the statistical methods used in various trials to assess endpoint definitions and determine the necessity for MACE-driven outcome data. Such comprehensive analysis provides further evidence to confidently conclude that RDN significantly reduces blood pressure compared to sham controls. Importantly, this enables the interpolation of RDN trial endpoints with other studies that report on outcome data, such as pharmacological trials which demonstrate a significant reduction in MACE risk with a decrease in BP. Moreover, limitations associated with directly evaluating outcome data further support the use of BP as a surrogate endpoint. For example, conducting lengthier trials with larger numbers of participants to ensure robust statistical power presents a substantial challenge to evaluating outcome data. Thus, in light of the crucial need to tackle hypertension, there are notable advantages of considering BP as a surrogate for outcome data.
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Affiliation(s)
- Syedah Aleena Haider
- Department of Cardiology, University Hospital Galway, Galway, Ireland.
- Department of Medicine, University of Galway, Galway, Ireland.
| | - Max Wagener
- Department of Cardiology, University Hospital Galway, Galway, Ireland
| | - Talha Iqbal
- Department of Mathematics, University of Galway, Galway, Ireland
| | - Shirjeel Shahzad
- Department of Cardiology, University Hospital Galway, Galway, Ireland
| | | | - Niall Leahy
- Department of Cardiology, University Hospital Galway, Galway, Ireland
| | - Darragh Murphy
- Department of Cardiology, University Hospital Galway, Galway, Ireland
- Department of Medicine, University of Galway, Galway, Ireland
| | - Ruth Sharif
- Department of Cardiology, University Hospital Galway, Galway, Ireland
| | - Ihsan Ullah
- Department of Mathematics, University of Galway, Galway, Ireland
| | - Faisal Sharif
- Department of Cardiology, University Hospital Galway, Galway, Ireland.
- Department of Medicine, University of Galway, Galway, Ireland.
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28
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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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Vongpatanasin W, Addo T. The Next Chapter of Renal Denervation After US Food and Drug Administration Approval. Circulation 2024; 149:760-763. [PMID: 38437485 DOI: 10.1161/circulationaha.123.067983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/06/2024]
Affiliation(s)
- Wanpen Vongpatanasin
- Hypertension Section (W.V.), Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas
- Cardiology Division (W.V., T.A.)., Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas
| | - Tayo Addo
- Cardiology Division (W.V., T.A.)., Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas
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Azizi M, Sharp ASP, Fisher NDL, Weber MA, Lobo MD, Daemen J, Lurz P, Mahfoud F, Schmieder RE, Basile J, Bloch MJ, Saxena M, Wang Y, Sanghvi K, Jenkins JS, Devireddy C, Rader F, Gosse P, Claude L, Augustin DA, McClure CK, Kirtane AJ. Patient-Level Pooled Analysis of Endovascular Ultrasound Renal Denervation or a Sham Procedure 6 Months After Medication Escalation: The RADIANCE Clinical Trial Program. Circulation 2024; 149:747-759. [PMID: 37883784 DOI: 10.1161/circulationaha.123.066941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 10/24/2023] [Indexed: 10/28/2023]
Abstract
BACKGROUND The randomized, sham-controlled RADIANCE-HTN (A Study of the Recor Medical Paradise System in Clinical Hypertension) SOLO, RADIANCE-HTN TRIO, and RADIANCE II (A Study of the Recor Medical Paradise System in Stage II Hypertension) trials independently met their primary end point of a greater reduction in daytime ambulatory systolic blood pressure (SBP) 2 months after ultrasound renal denervation (uRDN) in patients with hypertension. To characterize the longer-term effectiveness and safety of uRDN versus sham at 6 months, after the blinded addition of antihypertensive treatments (AHTs), we pooled individual patient data across these 3 similarly designed trials. METHODS Patients with mild to moderate hypertension who were not on AHT or with hypertension resistant to a standardized combination triple AHT were randomized to uRDN (n=293) versus sham (n=213); they were to remain off of added AHT throughout 2 months of follow-up unless specified blood pressure (BP) criteria were exceeded. In each trial, if monthly home BP was ≥135/85 mm Hg from 2 to 5 months, standardized AHT was sequentially added to target home BP <135/85 mm Hg under blinding to initial treatment assignment. Six-month outcomes included baseline- and AHT-adjusted change in daytime ambulatory, home, and office SBP; change in AHT; and safety. Linear mixed regression models using all BP measurements and change in AHT from baseline through 6 months were used. RESULTS Patients (70% men) were 54.1±9.3 years of age with a baseline daytime ambulatory/home/office SBP of 150.5±9.8/151.0±12.4/155.5±14.4 mm Hg, respectively. From 2 to 6 months, BP decreased in both groups with AHT titration, but fewer uRDN patients were prescribed AHT (P=0.004), and fewer additional AHT were prescribed to uRDN patients versus sham patients (P=0.001). Whereas the unadjusted between-group difference in daytime ambulatory SBP was similar at 6 months, the baseline and medication-adjusted between-group difference at 6 months was -3.0 mm Hg (95% CI, -5.7, -0.2; P=0.033), in favor of uRDN+AHT. For home and office SBP, the adjusted between-group differences in favor of uRDN+AHT over 6 months were -5.4 mm Hg (-6.8, -4.0; P<0.001) and -5.2 mm Hg (-7.1, -3.3; P<0.001), respectively. There was no heterogeneity between trials. Safety outcomes were few and did not differ between groups. CONCLUSIONS This individual patient-data analysis of 506 patients included in the RADIANCE trials demonstrates the maintenance of BP-lowering efficacy of uRDN versus sham at 6 months, with fewer added AHTs. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifiers: NCT02649426 and NCT03614260.
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Affiliation(s)
- Michel Azizi
- Université Paris Cité, France (M.A.)
- AP-HP, Hôpital Européen Georges-Pompidou, Hypertension Department and DMU CARTE, Paris, France (M.A.)
- INSERM, Paris, France (M.A.)
| | - Andrew S P Sharp
- University Hospital of Wales and Cardiff University, Cardiff, UK (A.S.P.S.)
| | | | - Michael A Weber
- Division of Cardiovascular Medicine, State University of New York, Downstate Medical Center, New York (M.A.W., M.S.)
| | - Melvin D Lobo
- Barts NIHR Biomedical Research Centre, William Harvey Research Institute, Queen Mary University of London, UK (M.D.L.)
| | - Joost Daemen
- Department of Cardiology, Erasmus University Medical Center Rotterdam, the Netherlands (J.D.)
| | - Philipp Lurz
- Zentrum für Kardiologie, Universitätsmedizin Mainz, Germany (P.L.)
| | - Felix Mahfoud
- Klinik für Innere Medizin III, Saarland University Hospital, Homburg/Saar, Germany (F.M.)
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge (F.M.)
| | - Roland E Schmieder
- Nephrology and Hypertension, University Hospital Erlangen, Friedrich Alexander University, Erlangen, Germany (R.E.S.)
| | - Jan Basile
- Division of Cardiovascular Medicine, Medical University of South Carolina, Ralph H. Johnson VA Medical Center, Charleston (J.B.)
| | - Michael J Bloch
- Department of Medicine, University of Nevada School of Medicine, Vascular Care, Renown Institute of Heart and Vascular Health, Reno (M.J.B.)
| | - Manish Saxena
- Division of Cardiovascular Medicine, State University of New York, Downstate Medical Center, New York (M.A.W., M.S.)
| | - Yale Wang
- Minneapolis Heart Institute, Abbott Northwestern Hospital, MN (Y.W.)
| | | | | | - Chandan Devireddy
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA (C.D.)
| | - Florian Rader
- Cedars-Sinai Heart Institute, Los Angeles, CA (F.R.)
| | | | - Lisa Claude
- Recor Medical, Inc., Palo Alto, CA (L.C., D.A.A.)
| | | | | | - Ajay J Kirtane
- Columbia University Irving Medical Center/New York-Presbyterian Hospital and the Cardiovascular Research Foundation, New York, NY (A.J.K.)
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Chitturi KR, Haberman D, Wermers JP, Waksman R. Overview of the 2023 FDA Circulatory System Devices Advisory Panel Meeting on the Symplicity Spyral Renal Denervation System. Am Heart J 2024; 269:108-117. [PMID: 38128897 DOI: 10.1016/j.ahj.2023.12.005] [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: 09/19/2023] [Revised: 12/04/2023] [Accepted: 12/10/2023] [Indexed: 12/23/2023]
Abstract
Hypertension remains a leading preventable cause of myocardial infarction, stroke, kidney disease, and cardiovascular death worldwide. Despite lifestyle modifications and intensification of medical therapy, suboptimal blood pressure control is common, spurring the development of device-based therapies for hypertension. The US Food and Drug Administration (FDA) assembled the Circulatory System Devices Panel on August 22-23, 2023, to discuss the safety and effectiveness of renal denervation devices manufactured by Recor Medical and Medtronic. After reviewing the ultrasound-based Recor Paradise renal denervation system the day prior, the panel reconvened to discuss the radiofrequency-based Medtronic Symplicity Spyral Renal Denervation System. In this manuscript, we summarize the data presented by the sponsor and FDA and detail the deliberation and discussion during the meeting.
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Affiliation(s)
- Kalyan R Chitturi
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, Washington, DC
| | - Dan Haberman
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, Washington, DC
| | - Jason P Wermers
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, Washington, DC.
| | - Ron Waksman
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, Washington, DC.
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Lu Y, Keeley EC, Barrette E, Cooper-DeHoff RM, Dhruva SS, Gaffney J, Gamble G, Handke B, Huang C, Krumholz H, Rowe C, Schulz W, Shaw K, Smith M, Woodard J, Young P, Ervin K, Ross J. Use of Electronic Health Records to Characterize Patients with Uncontrolled Hypertension in Two Large Health System Networks. RESEARCH SQUARE 2024:rs.3.rs-3943912. [PMID: 38410433 PMCID: PMC10896369 DOI: 10.21203/rs.3.rs-3943912/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/28/2024]
Abstract
Background Improving hypertension control is a public health priority. However, consistent identification of uncontrolled hypertension using computable definitions in electronic health records (EHR) across health systems remains uncertain. Methods In this retrospective cohort study, we applied two computable definitions to the EHR data to identify patients with controlled and uncontrolled hypertension and to evaluate differences in characteristics, treatment, and clinical outcomes between these patient populations. We included adult patients (≥ 18 years) with hypertension receiving ambulatory care within Yale-New Haven Health System (YNHHS; a large US health system) and OneFlorida Clinical Research Consortium (OneFlorida; a Clinical Research Network comprised of 16 health systems) between October 2015 and December 2018. We identified patients with controlled and uncontrolled hypertension based on either a single blood pressure (BP) measurement from a randomly selected visit or all BP measurements recorded between hypertension identification and the randomly selected visit). Results Overall, 253,207 and 182,827 adults at YNHHS and OneFlorida were identified as having hypertension. Of these patients, 83.1% at YNHHS and 76.8% at OneFlorida were identified using ICD-10-CM codes, whereas 16.9% and 23.2%, respectively, were identified using elevated BP measurements (≥ 140/90 mmHg). Uncontrolled hypertension was observed among 32.5% and 43.7% of patients at YNHHS and OneFlorida, respectively. Uncontrolled hypertension was disproportionately higher among Black patients when compared with White patients (38.9% versus 31.5% in YNHHS; p < 0.001; 49.7% versus 41.2% in OneFlorida; p < 0.001). Medication prescription for hypertension management was more common in patients with uncontrolled hypertension when compared with those with controlled hypertension (overall treatment rate: 39.3% versus 37.3% in YNHHS; p = 0.04; 42.2% versus 34.8% in OneFlorida; p < 0.001). Patients with controlled and uncontrolled hypertension had similar rates of short-term (at 3 and 6 months) and long-term (at 12 and 24 months) clinical outcomes. The two computable definitions generated consistent results. Conclusions Our findings illustrate the potential of leveraging EHR data, employing computable definitions, to conduct effective digital population surveillance in the realm of hypertension management.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Keondae Ervin
- National Evaluation System for health Technology Coordinating Center (NESTcc), Medical Device Innovation Consortium
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Chodakowski P, Sokal A, Manka A, Szwarc B, Bogus P, Cornelussen R, Eggen M, Kornet L. Electrical Diuretics: Dorsal Root Ganglion Stimulation to Increase Diuresis. Neuromodulation 2024:S1094-7159(24)00029-1. [PMID: 38363246 DOI: 10.1016/j.neurom.2023.12.006] [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: 08/21/2023] [Revised: 11/20/2023] [Accepted: 12/07/2023] [Indexed: 02/17/2024]
Abstract
BACKGROUND Stimulation of diuresis is an essential component of heart failure treatment to reduce fluid overload. Over time, increasing doses of loop diuretics are required to achieve adequate urine output, and approximately 30% to 45% of patients develop diuretic resistance. We investigated the feasibility of affecting renal afferent sensory nerves by dorsal root ganglion neurostimulation as an alternative to medication to increase diuresis. MATERIALS AND METHODS Acute volume overload with an elevated and stable pulmonary capillary wedge pressure (PCWP) was induced by infusion of isotonic fluid in swine (N = 7). In each experiment, diuresis and blood electrolyte levels were measured during cycles of up to two hours (baseline, stimulation, poststimulation) through bladder catheterization. Efficacy was tested using bilateral dorsal root ganglion (bDRG) stimulation at the T11 and/or T12 vertebral levels. RESULTS An elevated, stable PCWP (15 ± 4 mm Hg, N = 7) was obtained after uploading. Under these conditions, average diuresis increased 20% to 205% compared with no stimulation. Side effects such as motor stimulation were mitigated by decreasing current or terminated spontaneously without intervention. There was no negative effect on acute kidney function because blood electrolyte concentrations remained stable. When stimulation was deactivated, urine output decreased significantly but did not return to baseline levels, suggesting a carry-over effect of up to two hours. CONCLUSIONS Electrical stimulation (bDRG) at T11 and/or T12 increased diuresis in an acute volume overload model. Side effects caused by unintended (motor) stimulation could be eliminated by reducing the electrical current while sustaining increased diuresis.
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Affiliation(s)
- Pawel Chodakowski
- Department of Neurosurgery, Jan Paul II Hospital, Jastrzebie Zdroj, Poland
| | - Adam Sokal
- Department of Cardiology and Angiology Silesian Centre for Heart Diseases, Zabrze, Poland; Medical University of Silesia, WNOZ Bytom, Poland
| | | | - Bartlomiej Szwarc
- Research and Technology, Medtronic, Bakken Research Center, Maastricht, the Netherlands
| | - Piotr Bogus
- Silesian Park of Medical Technology, Kardio-Med Silesia, Zabrze, Poland
| | - Richard Cornelussen
- Research and Technology, Medtronic, Bakken Research Center, Maastricht, the Netherlands
| | - Michael Eggen
- Research and Technology, Medtronic, Bakken Research Center, Maastricht, the Netherlands
| | - Lilian Kornet
- Research and Technology, Medtronic, Bakken Research Center, Maastricht, the Netherlands.
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Nistor M, Schmidt M, Klingner C, Klingner C, Matziolis G, Shayganfar S, Schiffner R. Effect of Low-Frequency Renal Nerve Stimulation on Renal Glucose Release during Normoglycemia and a Hypoglycemic Clamp in Pigs. Int J Mol Sci 2024; 25:2041. [PMID: 38396718 PMCID: PMC10888375 DOI: 10.3390/ijms25042041] [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: 12/14/2023] [Revised: 01/22/2024] [Accepted: 01/29/2024] [Indexed: 02/25/2024] Open
Abstract
Previously, we demonstrated that renal denervation in pigs reduces renal glucose release during a hypoglycemic episode. In this study we set out to examine changes in side-dependent renal net glucose release (SGN) through unilateral low-frequency stimulation (LFS) of the renal plexus with a pulse generator (2-5 Hz) during normoglycemia (60 min) and insulin-induced hypoglycemia ≤3.5 mmol/L (75 min) in seven pigs. The jugular vein, carotid artery, renal artery and vein, and both ureters were catheterized for measurement purposes, blood pressure management, and drug and fluid infusions. Para-aminohippurate (PAH) and inulin infusions were used to determine side-dependent renal plasma flow (SRP) and glomerular filtration rate (GFR). In a linear mixed model, LFS caused no change in SRP but decreased sodium excretion (p < 0.0001), as well as decreasing GFR during hypoglycemia (p = 0.0176). In a linear mixed model, only hypoglycemic conditions exerted significant effects on SGN (p = 0.001), whereas LFS did not. In a Wilcoxon signed rank exact test, LFS significantly increased SGN (p = 0.03125) and decreased sodium excretion (p = 0.0017) and urinary flow rate (p = 0.0129) when only considering the first instance LFS followed a preceding period of non-stimulation during normoglycemia. To conclude, this study represents, to our knowledge, the first description of an induction of renal gluconeogenesis by LFS.
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Affiliation(s)
- Marius Nistor
- Orthopaedic Department, Jena University Hospital, 07747 Jena, Germany (G.M.)
| | - Martin Schmidt
- Institute for Biochemistry II, Jena University Hospital, 07747 Jena, Germany;
| | - Carsten Klingner
- Department of Neurology, Jena University Hospital, 07747 Jena, Germany; (C.K.); (C.K.)
| | - Caroline Klingner
- Department of Neurology, Jena University Hospital, 07747 Jena, Germany; (C.K.); (C.K.)
| | - Georg Matziolis
- Orthopaedic Department, Jena University Hospital, 07747 Jena, Germany (G.M.)
| | - Sascha Shayganfar
- Emergency Department, Helios University Clinic Wuppertal, 42283 Wuppertal, Germany;
- Faculty of Health/School of Medicine, Lehrstuhl für Klinische Akut- und Notfallmedizin, Witten/Herdecke University, Alfred-Herrhausen-Straße 50, 58448 Witten, Germany
| | - René Schiffner
- Orthopaedic Department, Jena University Hospital, 07747 Jena, Germany (G.M.)
- Emergency Department, Helios University Clinic Wuppertal, 42283 Wuppertal, Germany;
- Faculty of Health/School of Medicine, Lehrstuhl für Klinische Akut- und Notfallmedizin, Witten/Herdecke University, Alfred-Herrhausen-Straße 50, 58448 Witten, Germany
- Emergency Department, Otto-von-Guericke University, 39120 Magdeburg, Germany
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35
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Azzam O, Nejad SH, Carnagarin R, Nolde JM, Galindo-Kiuchi M, Schlaich MP. Taming resistant hypertension: The promise of novel pharmacologic approaches and renal denervation. Br J Pharmacol 2024; 181:319-339. [PMID: 37715452 DOI: 10.1111/bph.16247] [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: 04/08/2023] [Revised: 08/11/2023] [Accepted: 09/02/2023] [Indexed: 09/17/2023] Open
Abstract
Resistant hypertension is associated with an exceedingly high cardiovascular risk and there remains an unmet therapeutic need driven by pathophysiologic pathways unaddressed by guideline-recommended therapy. While spironolactone is widely considered as the preferable fourth-line drug, its broad application is limited by its side effect profile, especially off-target steroid receptor-mediated effects and hyperkalaemia in at-risk subpopulations. Recent landmark trials have reported promising safety and efficacy results for a number of novel compounds targeting relevant pathophysiologic pathways that remain unopposed by contemporary drugs. These include the dual endothelin receptor antagonist, aprocitentan, the aldosterone synthase inhibitor, baxdrostat and the nonsteroidal mineralocorticoid receptor antagonist finerenone. Furthermore, the evidence base for consideration of catheter-based renal denervation as a safe and effective adjunct therapeutic approach across the clinical spectrum of hypertension has been further substantiated. This review will summarise the recently published evidence on novel antihypertensive drugs and renal denervation in the context of resistant hypertension.
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Affiliation(s)
- Omar Azzam
- Dobney Hypertension Centre, Medical School-Royal Perth Hospital Unit, Royal Perth Hospital Medical Research Foundation, The University of Western Australia, Perth, Western Australia, Australia
- Department of Nephrology, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Sayeh Heidari Nejad
- Dobney Hypertension Centre, Medical School-Royal Perth Hospital Unit, Royal Perth Hospital Medical Research Foundation, The University of Western Australia, Perth, Western Australia, Australia
| | - Revathy Carnagarin
- Dobney Hypertension Centre, Medical School-Royal Perth Hospital Unit, Royal Perth Hospital Medical Research Foundation, The University of Western Australia, Perth, Western Australia, Australia
| | - Janis M Nolde
- Dobney Hypertension Centre, Medical School-Royal Perth Hospital Unit, Royal Perth Hospital Medical Research Foundation, The University of Western Australia, Perth, Western Australia, Australia
| | - Marcio Galindo-Kiuchi
- Dobney Hypertension Centre, Medical School-Royal Perth Hospital Unit, Royal Perth Hospital Medical Research Foundation, The University of Western Australia, Perth, Western Australia, Australia
| | - Markus P Schlaich
- Dobney Hypertension Centre, Medical School-Royal Perth Hospital Unit, Royal Perth Hospital Medical Research Foundation, The University of Western Australia, Perth, Western Australia, Australia
- Department of Nephrology, Royal Perth Hospital, Perth, Western Australia, Australia
- Department of Cardiology, Royal Perth Hospital, Perth, Western Australia, Australia
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Guenes-Altan M, Schmid A, Kannenkeril D, Linz P, Ott C, Bosch A, Schiffer M, Uder M, Schmieder RE. Skin sodium content as a predictor of blood pressure response to renal denervation. Hypertens Res 2024; 47:361-371. [PMID: 37880499 PMCID: PMC10838764 DOI: 10.1038/s41440-023-01450-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 08/24/2023] [Accepted: 08/26/2023] [Indexed: 10/27/2023]
Abstract
Patients with treatment resistant hypertension (TRH) are known to have elevated sodium (Na) content in muscle and skin. Renal denervation (RDN) emerged as an adjacent therapeutic option in this group of patients. This analysis aimed at evaluating whether tissue Na content predicts blood pressure (BP) response after RDN in patients with TRH. Radiofrequency-device based RDN was performed in 58 patients with uncontrolled TRH. Office and 24-h ambulatory BP were measured at baseline and after 6 months. To assess tissue Na content Na magnetic resonance imaging (Na-MRI) was performed at baseline prior to RDN. We splitted the study cohort into responders and non-responders based on the median of systolic 24-h ambulatory blood pressure (ABP) reduction after 6 months and evaluated the association between BP response to RDN and tissue Na content in skin and muscle. The study was registered at http://www.clinicaltrials.gov (NCT01687725). Six months after RDN 24-h ABP decreased by -8.6/-4.7 mmHg. BP-Responders were characterized by the following parameters: low tissue sodium content in the skin (p = 0.040), female gender (p = 0.027), intake of aldosterone antagonists (p = 0.032), high baseline 24-h night-time heart rate (p = 0.045) and high LDL cholesterol (p < 0.001). These results remained significant after adjustment for baseline 24-h systolic BP. Similar results were obtained when the median of day-time and night-time ABP reduction after 6 months were used as cut-off criteria for defining BP response to RDN. We conclude that in addition to clinical factors including baseline 24-h ABP Na-MRI may assist to select patients with uncontrolled TRH for RDN treatment.
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Affiliation(s)
- Merve Guenes-Altan
- Department of Nephrology and Hypertension, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nuremberg (FAU), Erlangen, Germany
| | - Axel Schmid
- Institute of Radiology, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nuremberg (FAU), Erlangen, Germany
| | - Dennis Kannenkeril
- Department of Nephrology and Hypertension, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nuremberg (FAU), Erlangen, Germany
| | - Peter Linz
- Institute of Radiology, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nuremberg (FAU), Erlangen, Germany
| | - Christian Ott
- Department of Nephrology and Hypertension, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nuremberg (FAU), Erlangen, Germany
| | - Agnes Bosch
- Department of Nephrology and Hypertension, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nuremberg (FAU), Erlangen, Germany
| | - Mario Schiffer
- Department of Nephrology and Hypertension, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nuremberg (FAU), Erlangen, Germany
| | - Michael Uder
- Institute of Radiology, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nuremberg (FAU), Erlangen, Germany
| | - Roland E Schmieder
- Department of Nephrology and Hypertension, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nuremberg (FAU), Erlangen, Germany.
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Scalise F, Quarti-Trevano F, Toscano E, Sorropago A, Vanoli J, Grassi G. Renal Denervation in End-Stage Renal Disease: Current Evidence and Perspectives. High Blood Press Cardiovasc Prev 2024; 31:7-13. [PMID: 38267652 PMCID: PMC10925565 DOI: 10.1007/s40292-023-00621-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 12/22/2023] [Indexed: 01/26/2024] Open
Abstract
In patients with end-stage renal disease (ESRD) undergoing haemodialysis, hypertension is of common detection and frequently inadequately controlled. Multiple pathophysiological mechanisms are involved in the development and progression of the ESRD-related high blood pressure state, which has been implicated in the increased cardiovascular risk reported in this hypertensive clinical phenotype. Renal sympathetic efferent and afferent nerves play a relevant role in the development and progression of elevated blood pressure values in patients with ESRD, often leading to resistant hypertension. Catheter-based bilateral renal nerves ablation has been shown to exert blood pressure lowering effects in resistant hypertensive patients with normal kidney function. Promising data on the procedure in ESRD patients with resistant hypertension have been reported in small scale pilot studies. Denervation of the native non-functioning kidney's neural excitatory influences on central sympathetic drive could reduce the elevated cardiovascular morbidity and mortality seen in ESRD patients. The present review article will focus on the promising results obtained with renal denervation in patients with ESRD, its mechanisms of action and future perspectives in these high risk patients.
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Affiliation(s)
- Filippo Scalise
- Department of Interventional Cardiology, Policlinico di Monza, Monza, Italy
| | - Fosca Quarti-Trevano
- Clinica Medica, Department of Medicine and Surgery, University of Milano-Bicocca, Via Pergolesi 33, 20052, Monza, Milan, Italy
| | - Evelina Toscano
- Department of Interventional Cardiology, Policlinico di Monza, Monza, Italy
| | - Antonio Sorropago
- Department of Interventional Cardiology, Policlinico di Monza, Monza, Italy
| | - Jennifer Vanoli
- Clinica Medica, Department of Medicine and Surgery, University of Milano-Bicocca, Via Pergolesi 33, 20052, Monza, Milan, Italy
| | - Guido Grassi
- Clinica Medica, Department of Medicine and Surgery, University of Milano-Bicocca, Via Pergolesi 33, 20052, Monza, Milan, Italy.
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Günes-Altan M, Schmid A, Ott C, Bosch A, Pietschner R, Schiffer M, Uder M, Schmieder RE, Kannenkeril D. Blood pressure reduction after renal denervation in patients with or without chronic kidney disease. Clin Kidney J 2024; 17:sfad237. [PMID: 38186882 PMCID: PMC10768756 DOI: 10.1093/ckj/sfad237] [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: 08/14/2023] [Indexed: 01/09/2024] Open
Abstract
Background Renal denervation (RDN) has emerged as an adjacent option for the treatment of hypertension. This analysis of the Erlanger registry aimed to compare the blood pressure (BP)-lowering effects and safety of RDN in patients with and without chronic kidney disease (CKD). Methods In this single-center retrospective analysis, 47 patients with and 127 without CKD underwent radiofrequency-, ultrasound- or alcohol-infusion-based RDN. Office and 24-h ambulatory BP and estimated glomerular filtration rate (eGFR) were measured at baseline, and after 6 and 12 months. Results A total of 174 patients with a mean age of 59.0 ± 10 years were followed up for 12 months. At baseline, mean eGFR was 55.8 ± 21 mL/min/1.73 m2 in patients with CKD and 87.3 ± 13 mL/min/1.73 m2 in patients without CKD. There was no significant eGFR decline in either of the groups during 12 months of follow-up. In patients without CKD, office systolic and diastolic BP were reduced by -15.3 ± 17.5/-7.9 ± 10.8 mmHg 6 months after RDN and by -16.1 ± 18.2/-7.7 ± 9.6 mmHg 12 months after RDN. In patients with CKD, office systolic and diastolic BP were reduced by -10.7 ± 24.0/-5.8 ± 13.2 mmHg 6 months after RDN and by -15.1 ± 24.9/-5.9 ± 12.9 mmHg 12 months after RDN. Accordingly, in patients without CKD, 24-h ambulatory systolic and diastolic BP were reduced by -7.2 ± 15.8/-4.9 ± 8.8 mmHg 6 months after RDN and by -9.0 ± 17.0/-6.2 ± 9.8 mmHg 12 months after RDN. In patients with CKD, 24-h systolic and diastolic BP were reduced by -7.4 ± 12.9/-4.2 ± 9.9 mmHg 6 months after RDN and by -8.0 ± 14.0/-3.6 ± 9.6 mmHg 12 months after RDN. There was no difference in the reduction of office and 24-h ambulatory BP between the two groups at any time point (all P > .2). Similar results have been found for the 6 months data. With exception of rare local adverse events, we did not observe any safety signals. Conclusion According to our single-center experience, we observed a similar reduction in 24-h, day and night-time ambulatory BP as well as in-office BP in patients with and without CKD at any time point up to 12 months. We conclude that RDN is an effective and safe treatment option for patients with hypertension and CKD.
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Affiliation(s)
- Merve Günes-Altan
- Department of Nephrology and Hypertension, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nuremberg (FAU), Erlangen, Germany
| | - Axel Schmid
- Institute of Radiology, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nuremberg (FAU), Erlangen, Germany
| | - Christian Ott
- Department of Nephrology and Hypertension, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nuremberg (FAU), Erlangen, Germany
| | - Agnes Bosch
- Department of Nephrology and Hypertension, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nuremberg (FAU), Erlangen, Germany
| | - Robert Pietschner
- Department of Nephrology and Hypertension, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nuremberg (FAU), Erlangen, Germany
| | - Mario Schiffer
- Department of Nephrology and Hypertension, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nuremberg (FAU), Erlangen, Germany
| | - Michael Uder
- Institute of Radiology, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nuremberg (FAU), Erlangen, Germany
| | - Roland E Schmieder
- Department of Nephrology and Hypertension, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nuremberg (FAU), Erlangen, Germany
| | - Dennis Kannenkeril
- Department of Nephrology and Hypertension, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nuremberg (FAU), Erlangen, Germany
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Higashi Y, Kishimoto S. An Extended Follow-Up on Blood Pressure in a Patient With New-Onset Essential Hypertension: Early-Morning Home, Morning Home, and Office Readings. Cureus 2024; 16:e52520. [PMID: 38371123 PMCID: PMC10874287 DOI: 10.7759/cureus.52520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2024] [Indexed: 02/20/2024] Open
Abstract
The patient was a 63-year-old man with a 24-year history of hypertension. During long-term follow-up, when outpatient clinic blood pressure and morning blood pressure are well-regulated, exceptionally elevated early-morning blood pressure does not play a significant role in the development of hypertensive target organ disease or cardiovascular disease.
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Affiliation(s)
- Yukihito Higashi
- Department of Regenerative Medicine, Research Institute for Radiation Biology and Medicine, Hiroshima University, Hiroshima, JPN
| | - Shinji Kishimoto
- Department of Regenerative Medicine, Research Institute for Radiation Biology and Medicine, Hiroshima University, Hiroshima, JPN
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40
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Parvanova A, Reseghetti E, Abbate M, Ruggenenti P. Mechanisms and treatment of obesity-related hypertension-Part 1: Mechanisms. Clin Kidney J 2024; 17:sfad282. [PMID: 38186879 PMCID: PMC10768772 DOI: 10.1093/ckj/sfad282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Indexed: 01/09/2024] Open
Abstract
The prevalence of obesity has tripled over the past five decades. Obesity, especially visceral obesity, is closely related to hypertension, increasing the risk of primary (essential) hypertension by 65%-75%. Hypertension is a major risk factor for cardiovascular disease, the leading cause of death worldwide, and its prevalence is rapidly increasing following the pandemic rise in obesity. Although the causal relationship between obesity and high blood pressure (BP) is well established, the detailed mechanisms for such association are still under research. For more than 30 years sympathetic nervous system (SNS) and kidney sodium reabsorption activation, secondary to insulin resistance and compensatory hyperinsulinemia, have been considered as primary mediators of elevated BP in obesity. However, experimental and clinical data show that severe insulin resistance and hyperinsulinemia can occur in the absence of elevated BP, challenging the causal relationship between insulin resistance and hyperinsulinemia as the key factor linking obesity to hypertension. The purpose of Part 1 of this review is to summarize the available data on recently emerging mechanisms believed to contribute to obesity-related hypertension through increased sodium reabsorption and volume expansion, such as: physical compression of the kidney by perirenal/intrarenal fat and overactivation of the systemic/renal SNS and the renin-angiotensin-aldosterone system. The role of hyperleptinemia, impaired chemoreceptor and baroreceptor reflexes, and increased perivascular fat is also discussed. Specifically targeting these mechanisms may pave the way for a new therapeutic intervention in the treatment of obesity-related hypertension in the context of 'precision medicine' principles, which will be discussed in Part 2.
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Affiliation(s)
- Aneliya Parvanova
- Department of Renal Medicine, Clinical Research Centre for Rare Diseases “Aldo e Cele Daccò”, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Elia Reseghetti
- Unit of Nephrology and Dialysis, Azienda Socio-Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy
| | - Manuela Abbate
- Research Group on Global Health, University of the Balearic Islands, Palma, Spain
- Research Group on Global Health and Lifestyle, Health Research Institutte of the Balearic Islands (IdISBa), Palma, Spain
| | - Piero Ruggenenti
- Department of Renal Medicine, Clinical Research Centre for Rare Diseases “Aldo e Cele Daccò”, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
- Unit of Nephrology and Dialysis, Azienda Socio-Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy
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41
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Liu J, Li Y, Zhang X, Bu P, Du X, Fang L, Feng Y, Guo Y, Han F, Jiang Y, Li Y, Lin J, Liu M, Liu W, Long M, Mu J, Sun N, Wu H, Xie J, Xie J, Xie L, Yu J, Yuan H, Zha Y, Zhang Y, Zhu S, Wang J. Management of nocturnal hypertension: An expert consensus document from Chinese Hypertension League. J Clin Hypertens (Greenwich) 2024; 26:71-83. [PMID: 38126623 PMCID: PMC10795100 DOI: 10.1111/jch.14757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 10/20/2023] [Accepted: 11/20/2023] [Indexed: 12/23/2023]
Abstract
Nocturnal hypertension is highly prevalent among Chinese and Asian populations, which is mainly attributed to high salt intake and high salt sensitivity. Nocturnal hypertension increases the risk of cardiovascular and all-cause mortality, independent of daytime blood pressure (BP). However, it can usually be detected by 24-h ambulatory BP monitoring, rather than routine office or home BP measurement, thus is often underdiagnosed in clinical practice. Currently, no specific guidance is available for the management of nocturnal hypertension in China or worldwide. Experts from the Chinese Hypertension League summarized the epidemiologic and pathophysiologic characteristics and clinical phenotype of nocturnal hypertension and provided consensus recommendations on optimal management of nocturnal hypertension, with the goal of maximally reducing the cardiovascular disease risks. In this consensus document, 24-h ABPM is recommended for screening and diagnosis of nocturnal hypertension, especially in the elderly, patients with diabetes, chronic kidney diseases, obstructive sleep apnea and other conditions prone to high nocturnal BP. Lifestyle modifications including salt intake restriction, exercise, weight loss, sleep improvement, and mental stress relief are recommended. Long-acting antihypertensive medications are preferred for nocturnal and 24-h BP control. Some newly developed agents, renal denervation, and other device-based therapy on nocturnal BP reduction are evaluated.
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Affiliation(s)
- Jing Liu
- Peking University People's HospitalBeijingChina
| | - Yan Li
- Ruijin HospitalShanghai Jiaotong University School of MedicineShanghaiChina
| | - Xinjun Zhang
- West China Hospital of Sichuan UniversityChengduSichuanChina
| | - Peili Bu
- Qilu Hospital of Shandong UniversityJinanShandongChina
| | - Xueping Du
- Yuetan Community Health Service CenterFuxing HospitalCapital Medical UniversityBeijingChina
| | - Lizheng Fang
- Sir Run Run Shaw HospitalZhejiang University School of MedicineHangzhouZhejiangChina
| | - Yingqing Feng
- Guangdong Provincial People's HospitalGuangzhouGuangdongChina
| | - Yifang Guo
- Hebei General HospitalShijiazhuangHebeiChina
| | - Fei Han
- The First Affiliated Hospital of Zhejiang University School of MedicineHangzhouZhejiangChina
| | - Yinong Jiang
- The First Affiliated Hospital of Dalian Medical UniversityDalianChina
| | - Yuming Li
- T International Cardiovascular HospitalTianjinChina
| | - Jinxiu Lin
- The First Affiliated Hospital of Fujian Medical UniversityFuzhouFujianChina
| | - Min Liu
- Henan Province People's HospitalZhengzhouHenanChina
| | - Wei Liu
- Beijing HospitalBeijingChina
| | - Mingzhi Long
- The Second Affiliated Hospital of Nanjing Medical UniversityNanjingJiangsuChina
| | - Jianjun Mu
- The First Affiliated Hospital of Xi'an Jiaotong UniversityXi'anChina
| | | | - Hao Wu
- School of General Practice and Continuing Education, Capital Medical UniversityBeijingChina
| | - Jianhong Xie
- Zhejiang Provincial People's HospitalHangzhouZhejiangChina
| | - Jingyuan Xie
- Ruijin HospitalShanghai Jiaotong University School of MedicineShanghaiChina
| | - Liangdi Xie
- The First Affiliated Hospital of Fujian Medical UniversityFuzhouFujianChina
| | - Jing Yu
- Lanzhou University Second HospitalLanzhouGansuChina
| | - Hong Yuan
- The Third Xiangya Hospital of Central South UniversityChangshaHunanChina
| | - Yan Zha
- Guizhou Provincial People's HospitalGuiyangGuizhouChina
| | - Yuqing Zhang
- Fuwai HospitalChinese Academy of Medical Sciences & Peking Union Medical CollegeBeijingChina
| | - Shanzhu Zhu
- Zhongshan HospitalFudan UniversityShanghaiChina
| | - Jiguang Wang
- Ruijin HospitalShanghai Jiaotong University School of MedicineShanghaiChina
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Rajkumar CA, Foley MJ, Ahmed-Jushuf F, Nowbar AN, Simader FA, Davies JR, O'Kane PD, Haworth P, Routledge H, Kotecha T, Gamma R, Clesham G, Williams R, Din J, Nijjer SS, Curzen N, Ruparelia N, Sinha M, Dungu JN, Ganesananthan S, Khamis R, Mughal L, Kinnaird T, Petraco R, Spratt JC, Sen S, Sehmi J, Collier DJ, Sohaib A, Keeble TR, Cole GD, Howard JP, Francis DP, Shun-Shin MJ, Al-Lamee RK. A Placebo-Controlled Trial of Percutaneous Coronary Intervention for Stable Angina. N Engl J Med 2023; 389:2319-2330. [PMID: 38015442 PMCID: PMC7615400 DOI: 10.1056/nejmoa2310610] [Citation(s) in RCA: 24] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Abstract
BACKGROUND Percutaneous coronary intervention (PCI) is frequently performed to reduce the symptoms of stable angina. Whether PCI relieves angina more than a placebo procedure in patients who are not receiving antianginal medication remains unknown. METHODS We conducted a double-blind, randomized, placebo-controlled trial of PCI in patients with stable angina. Patients stopped all antianginal medications and underwent a 2-week symptom assessment phase before randomization. Patients were then randomly assigned in a 1:1 ratio to undergo PCI or a placebo procedure and were followed for 12 weeks. The primary end point was the angina symptom score, which was calculated daily on the basis of the number of angina episodes that occurred on a given day, the number of antianginal medications prescribed on that day, and clinical events, including the occurrence of unblinding owing to unacceptable angina or acute coronary syndrome or death. Scores range from 0 to 79, with higher scores indicating worse health status with respect to angina. RESULTS A total of 301 patients underwent randomization: 151 to the PCI group and 150 to the placebo group. The mean (±SD) age was 64±9 years, and 79% were men. Ischemia was present in one cardiac territory in 242 patients (80%), in two territories in 52 patients (17%), and in three territories in 7 patients (2%). In the target vessels, the median fractional flow reserve was 0.63 (interquartile range, 0.49 to 0.75), and the median instantaneous wave-free ratio was 0.78 (interquartile range, 0.55 to 0.87). At the 12-week follow-up, the mean angina symptom score was 2.9 in the PCI group and 5.6 in the placebo group (odds ratio, 2.21; 95% confidence interval, 1.41 to 3.47; P<0.001). One patient in the placebo group had unacceptable angina leading to unblinding. Acute coronary syndromes occurred in 4 patients in the PCI group and in 6 patients in the placebo group. CONCLUSIONS Among patients with stable angina who were receiving little or no antianginal medication and had objective evidence of ischemia, PCI resulted in a lower angina symptom score than a placebo procedure, indicating a better health status with respect to angina. (Funded by the National Institute for Health and Care Research Imperial Biomedical Research Centre and others; ORBITA-2 ClinicalTrials.gov number, NCT03742050.).
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Affiliation(s)
- Christopher A Rajkumar
- From Imperial College London (C.A.R., M.J.F., F.A.-J., F.A.S., S.G., R.K., R.P., G.D.C., J.P.H., D.P.F., M.J.S.-S., R.K.A.-L.), Imperial College Healthcare NHS Trust (C.A.R., M.J.F., F.A.-J., F.A.S., S.S.N., S.G., R.K., R.P., S.S., G.D.C., J.P.H., D.P.F., M.J.S.-S., R.K.A.-L.), Barking Havering and Redbridge University Hospitals NHS Trust (A.N.N., A.S.), Royal Free London NHS Foundation Trust (T. Kotecha), St. George's University Hospitals NHS Foundation Trust (R.W., J.C.S.), St. George's University of London (J.C.S.), Queen Mary University of London (D.J.C., A.S.), and Barts Health NHS Trust (A.S.), London, Essex Cardiothoracic Centre, Mid and South Essex NHS Foundation Trust, Basildon (J.R.D., R.G., G.C., J.N.D., T.R.K.), Anglia Ruskin University, Chelmsford (J.R.D., G.C., T.R.K.), University Hospitals Dorset NHS Foundation Trust, Poole (P.D.O., J.D.), Portsmouth Hospitals University NHS Trust, Portsmouth (P.H.), Worcestershire Acute Hospitals NHS Trust, Worcester (H.R., L.M.), University Hospital Southampton NHS Foundation Trust and the University of Southampton, Southampton (N.C.), Royal Berkshire NHS Foundation Trust, Reading (N.R.), Salisbury NHS Foundation Trust, Salisbury (M.S.), Cardiff and Vale University Health Board, Cardiff (T. Kinnaird), Keele University, Keele (T. Kinnaird), Buckinghamshire Healthcare NHS Trust, Amersham (R.P.), and West Hertfordshire Hospitals NHS Trust, Watford (J.S.) - all in the United Kingdom
| | - Michael J Foley
- From Imperial College London (C.A.R., M.J.F., F.A.-J., F.A.S., S.G., R.K., R.P., G.D.C., J.P.H., D.P.F., M.J.S.-S., R.K.A.-L.), Imperial College Healthcare NHS Trust (C.A.R., M.J.F., F.A.-J., F.A.S., S.S.N., S.G., R.K., R.P., S.S., G.D.C., J.P.H., D.P.F., M.J.S.-S., R.K.A.-L.), Barking Havering and Redbridge University Hospitals NHS Trust (A.N.N., A.S.), Royal Free London NHS Foundation Trust (T. Kotecha), St. George's University Hospitals NHS Foundation Trust (R.W., J.C.S.), St. George's University of London (J.C.S.), Queen Mary University of London (D.J.C., A.S.), and Barts Health NHS Trust (A.S.), London, Essex Cardiothoracic Centre, Mid and South Essex NHS Foundation Trust, Basildon (J.R.D., R.G., G.C., J.N.D., T.R.K.), Anglia Ruskin University, Chelmsford (J.R.D., G.C., T.R.K.), University Hospitals Dorset NHS Foundation Trust, Poole (P.D.O., J.D.), Portsmouth Hospitals University NHS Trust, Portsmouth (P.H.), Worcestershire Acute Hospitals NHS Trust, Worcester (H.R., L.M.), University Hospital Southampton NHS Foundation Trust and the University of Southampton, Southampton (N.C.), Royal Berkshire NHS Foundation Trust, Reading (N.R.), Salisbury NHS Foundation Trust, Salisbury (M.S.), Cardiff and Vale University Health Board, Cardiff (T. Kinnaird), Keele University, Keele (T. Kinnaird), Buckinghamshire Healthcare NHS Trust, Amersham (R.P.), and West Hertfordshire Hospitals NHS Trust, Watford (J.S.) - all in the United Kingdom
| | - Fiyyaz Ahmed-Jushuf
- From Imperial College London (C.A.R., M.J.F., F.A.-J., F.A.S., S.G., R.K., R.P., G.D.C., J.P.H., D.P.F., M.J.S.-S., R.K.A.-L.), Imperial College Healthcare NHS Trust (C.A.R., M.J.F., F.A.-J., F.A.S., S.S.N., S.G., R.K., R.P., S.S., G.D.C., J.P.H., D.P.F., M.J.S.-S., R.K.A.-L.), Barking Havering and Redbridge University Hospitals NHS Trust (A.N.N., A.S.), Royal Free London NHS Foundation Trust (T. Kotecha), St. George's University Hospitals NHS Foundation Trust (R.W., J.C.S.), St. George's University of London (J.C.S.), Queen Mary University of London (D.J.C., A.S.), and Barts Health NHS Trust (A.S.), London, Essex Cardiothoracic Centre, Mid and South Essex NHS Foundation Trust, Basildon (J.R.D., R.G., G.C., J.N.D., T.R.K.), Anglia Ruskin University, Chelmsford (J.R.D., G.C., T.R.K.), University Hospitals Dorset NHS Foundation Trust, Poole (P.D.O., J.D.), Portsmouth Hospitals University NHS Trust, Portsmouth (P.H.), Worcestershire Acute Hospitals NHS Trust, Worcester (H.R., L.M.), University Hospital Southampton NHS Foundation Trust and the University of Southampton, Southampton (N.C.), Royal Berkshire NHS Foundation Trust, Reading (N.R.), Salisbury NHS Foundation Trust, Salisbury (M.S.), Cardiff and Vale University Health Board, Cardiff (T. Kinnaird), Keele University, Keele (T. Kinnaird), Buckinghamshire Healthcare NHS Trust, Amersham (R.P.), and West Hertfordshire Hospitals NHS Trust, Watford (J.S.) - all in the United Kingdom
| | - Alexandra N Nowbar
- From Imperial College London (C.A.R., M.J.F., F.A.-J., F.A.S., S.G., R.K., R.P., G.D.C., J.P.H., D.P.F., M.J.S.-S., R.K.A.-L.), Imperial College Healthcare NHS Trust (C.A.R., M.J.F., F.A.-J., F.A.S., S.S.N., S.G., R.K., R.P., S.S., G.D.C., J.P.H., D.P.F., M.J.S.-S., R.K.A.-L.), Barking Havering and Redbridge University Hospitals NHS Trust (A.N.N., A.S.), Royal Free London NHS Foundation Trust (T. Kotecha), St. George's University Hospitals NHS Foundation Trust (R.W., J.C.S.), St. George's University of London (J.C.S.), Queen Mary University of London (D.J.C., A.S.), and Barts Health NHS Trust (A.S.), London, Essex Cardiothoracic Centre, Mid and South Essex NHS Foundation Trust, Basildon (J.R.D., R.G., G.C., J.N.D., T.R.K.), Anglia Ruskin University, Chelmsford (J.R.D., G.C., T.R.K.), University Hospitals Dorset NHS Foundation Trust, Poole (P.D.O., J.D.), Portsmouth Hospitals University NHS Trust, Portsmouth (P.H.), Worcestershire Acute Hospitals NHS Trust, Worcester (H.R., L.M.), University Hospital Southampton NHS Foundation Trust and the University of Southampton, Southampton (N.C.), Royal Berkshire NHS Foundation Trust, Reading (N.R.), Salisbury NHS Foundation Trust, Salisbury (M.S.), Cardiff and Vale University Health Board, Cardiff (T. Kinnaird), Keele University, Keele (T. Kinnaird), Buckinghamshire Healthcare NHS Trust, Amersham (R.P.), and West Hertfordshire Hospitals NHS Trust, Watford (J.S.) - all in the United Kingdom
| | - Florentina A Simader
- From Imperial College London (C.A.R., M.J.F., F.A.-J., F.A.S., S.G., R.K., R.P., G.D.C., J.P.H., D.P.F., M.J.S.-S., R.K.A.-L.), Imperial College Healthcare NHS Trust (C.A.R., M.J.F., F.A.-J., F.A.S., S.S.N., S.G., R.K., R.P., S.S., G.D.C., J.P.H., D.P.F., M.J.S.-S., R.K.A.-L.), Barking Havering and Redbridge University Hospitals NHS Trust (A.N.N., A.S.), Royal Free London NHS Foundation Trust (T. Kotecha), St. George's University Hospitals NHS Foundation Trust (R.W., J.C.S.), St. George's University of London (J.C.S.), Queen Mary University of London (D.J.C., A.S.), and Barts Health NHS Trust (A.S.), London, Essex Cardiothoracic Centre, Mid and South Essex NHS Foundation Trust, Basildon (J.R.D., R.G., G.C., J.N.D., T.R.K.), Anglia Ruskin University, Chelmsford (J.R.D., G.C., T.R.K.), University Hospitals Dorset NHS Foundation Trust, Poole (P.D.O., J.D.), Portsmouth Hospitals University NHS Trust, Portsmouth (P.H.), Worcestershire Acute Hospitals NHS Trust, Worcester (H.R., L.M.), University Hospital Southampton NHS Foundation Trust and the University of Southampton, Southampton (N.C.), Royal Berkshire NHS Foundation Trust, Reading (N.R.), Salisbury NHS Foundation Trust, Salisbury (M.S.), Cardiff and Vale University Health Board, Cardiff (T. Kinnaird), Keele University, Keele (T. Kinnaird), Buckinghamshire Healthcare NHS Trust, Amersham (R.P.), and West Hertfordshire Hospitals NHS Trust, Watford (J.S.) - all in the United Kingdom
| | - John R Davies
- From Imperial College London (C.A.R., M.J.F., F.A.-J., F.A.S., S.G., R.K., R.P., G.D.C., J.P.H., D.P.F., M.J.S.-S., R.K.A.-L.), Imperial College Healthcare NHS Trust (C.A.R., M.J.F., F.A.-J., F.A.S., S.S.N., S.G., R.K., R.P., S.S., G.D.C., J.P.H., D.P.F., M.J.S.-S., R.K.A.-L.), Barking Havering and Redbridge University Hospitals NHS Trust (A.N.N., A.S.), Royal Free London NHS Foundation Trust (T. Kotecha), St. George's University Hospitals NHS Foundation Trust (R.W., J.C.S.), St. George's University of London (J.C.S.), Queen Mary University of London (D.J.C., A.S.), and Barts Health NHS Trust (A.S.), London, Essex Cardiothoracic Centre, Mid and South Essex NHS Foundation Trust, Basildon (J.R.D., R.G., G.C., J.N.D., T.R.K.), Anglia Ruskin University, Chelmsford (J.R.D., G.C., T.R.K.), University Hospitals Dorset NHS Foundation Trust, Poole (P.D.O., J.D.), Portsmouth Hospitals University NHS Trust, Portsmouth (P.H.), Worcestershire Acute Hospitals NHS Trust, Worcester (H.R., L.M.), University Hospital Southampton NHS Foundation Trust and the University of Southampton, Southampton (N.C.), Royal Berkshire NHS Foundation Trust, Reading (N.R.), Salisbury NHS Foundation Trust, Salisbury (M.S.), Cardiff and Vale University Health Board, Cardiff (T. Kinnaird), Keele University, Keele (T. Kinnaird), Buckinghamshire Healthcare NHS Trust, Amersham (R.P.), and West Hertfordshire Hospitals NHS Trust, Watford (J.S.) - all in the United Kingdom
| | - Peter D O'Kane
- From Imperial College London (C.A.R., M.J.F., F.A.-J., F.A.S., S.G., R.K., R.P., G.D.C., J.P.H., D.P.F., M.J.S.-S., R.K.A.-L.), Imperial College Healthcare NHS Trust (C.A.R., M.J.F., F.A.-J., F.A.S., S.S.N., S.G., R.K., R.P., S.S., G.D.C., J.P.H., D.P.F., M.J.S.-S., R.K.A.-L.), Barking Havering and Redbridge University Hospitals NHS Trust (A.N.N., A.S.), Royal Free London NHS Foundation Trust (T. Kotecha), St. George's University Hospitals NHS Foundation Trust (R.W., J.C.S.), St. George's University of London (J.C.S.), Queen Mary University of London (D.J.C., A.S.), and Barts Health NHS Trust (A.S.), London, Essex Cardiothoracic Centre, Mid and South Essex NHS Foundation Trust, Basildon (J.R.D., R.G., G.C., J.N.D., T.R.K.), Anglia Ruskin University, Chelmsford (J.R.D., G.C., T.R.K.), University Hospitals Dorset NHS Foundation Trust, Poole (P.D.O., J.D.), Portsmouth Hospitals University NHS Trust, Portsmouth (P.H.), Worcestershire Acute Hospitals NHS Trust, Worcester (H.R., L.M.), University Hospital Southampton NHS Foundation Trust and the University of Southampton, Southampton (N.C.), Royal Berkshire NHS Foundation Trust, Reading (N.R.), Salisbury NHS Foundation Trust, Salisbury (M.S.), Cardiff and Vale University Health Board, Cardiff (T. Kinnaird), Keele University, Keele (T. Kinnaird), Buckinghamshire Healthcare NHS Trust, Amersham (R.P.), and West Hertfordshire Hospitals NHS Trust, Watford (J.S.) - all in the United Kingdom
| | - Peter Haworth
- From Imperial College London (C.A.R., M.J.F., F.A.-J., F.A.S., S.G., R.K., R.P., G.D.C., J.P.H., D.P.F., M.J.S.-S., R.K.A.-L.), Imperial College Healthcare NHS Trust (C.A.R., M.J.F., F.A.-J., F.A.S., S.S.N., S.G., R.K., R.P., S.S., G.D.C., J.P.H., D.P.F., M.J.S.-S., R.K.A.-L.), Barking Havering and Redbridge University Hospitals NHS Trust (A.N.N., A.S.), Royal Free London NHS Foundation Trust (T. Kotecha), St. George's University Hospitals NHS Foundation Trust (R.W., J.C.S.), St. George's University of London (J.C.S.), Queen Mary University of London (D.J.C., A.S.), and Barts Health NHS Trust (A.S.), London, Essex Cardiothoracic Centre, Mid and South Essex NHS Foundation Trust, Basildon (J.R.D., R.G., G.C., J.N.D., T.R.K.), Anglia Ruskin University, Chelmsford (J.R.D., G.C., T.R.K.), University Hospitals Dorset NHS Foundation Trust, Poole (P.D.O., J.D.), Portsmouth Hospitals University NHS Trust, Portsmouth (P.H.), Worcestershire Acute Hospitals NHS Trust, Worcester (H.R., L.M.), University Hospital Southampton NHS Foundation Trust and the University of Southampton, Southampton (N.C.), Royal Berkshire NHS Foundation Trust, Reading (N.R.), Salisbury NHS Foundation Trust, Salisbury (M.S.), Cardiff and Vale University Health Board, Cardiff (T. Kinnaird), Keele University, Keele (T. Kinnaird), Buckinghamshire Healthcare NHS Trust, Amersham (R.P.), and West Hertfordshire Hospitals NHS Trust, Watford (J.S.) - all in the United Kingdom
| | - Helen Routledge
- From Imperial College London (C.A.R., M.J.F., F.A.-J., F.A.S., S.G., R.K., R.P., G.D.C., J.P.H., D.P.F., M.J.S.-S., R.K.A.-L.), Imperial College Healthcare NHS Trust (C.A.R., M.J.F., F.A.-J., F.A.S., S.S.N., S.G., R.K., R.P., S.S., G.D.C., J.P.H., D.P.F., M.J.S.-S., R.K.A.-L.), Barking Havering and Redbridge University Hospitals NHS Trust (A.N.N., A.S.), Royal Free London NHS Foundation Trust (T. Kotecha), St. George's University Hospitals NHS Foundation Trust (R.W., J.C.S.), St. George's University of London (J.C.S.), Queen Mary University of London (D.J.C., A.S.), and Barts Health NHS Trust (A.S.), London, Essex Cardiothoracic Centre, Mid and South Essex NHS Foundation Trust, Basildon (J.R.D., R.G., G.C., J.N.D., T.R.K.), Anglia Ruskin University, Chelmsford (J.R.D., G.C., T.R.K.), University Hospitals Dorset NHS Foundation Trust, Poole (P.D.O., J.D.), Portsmouth Hospitals University NHS Trust, Portsmouth (P.H.), Worcestershire Acute Hospitals NHS Trust, Worcester (H.R., L.M.), University Hospital Southampton NHS Foundation Trust and the University of Southampton, Southampton (N.C.), Royal Berkshire NHS Foundation Trust, Reading (N.R.), Salisbury NHS Foundation Trust, Salisbury (M.S.), Cardiff and Vale University Health Board, Cardiff (T. Kinnaird), Keele University, Keele (T. Kinnaird), Buckinghamshire Healthcare NHS Trust, Amersham (R.P.), and West Hertfordshire Hospitals NHS Trust, Watford (J.S.) - all in the United Kingdom
| | - Tushar Kotecha
- From Imperial College London (C.A.R., M.J.F., F.A.-J., F.A.S., S.G., R.K., R.P., G.D.C., J.P.H., D.P.F., M.J.S.-S., R.K.A.-L.), Imperial College Healthcare NHS Trust (C.A.R., M.J.F., F.A.-J., F.A.S., S.S.N., S.G., R.K., R.P., S.S., G.D.C., J.P.H., D.P.F., M.J.S.-S., R.K.A.-L.), Barking Havering and Redbridge University Hospitals NHS Trust (A.N.N., A.S.), Royal Free London NHS Foundation Trust (T. Kotecha), St. George's University Hospitals NHS Foundation Trust (R.W., J.C.S.), St. George's University of London (J.C.S.), Queen Mary University of London (D.J.C., A.S.), and Barts Health NHS Trust (A.S.), London, Essex Cardiothoracic Centre, Mid and South Essex NHS Foundation Trust, Basildon (J.R.D., R.G., G.C., J.N.D., T.R.K.), Anglia Ruskin University, Chelmsford (J.R.D., G.C., T.R.K.), University Hospitals Dorset NHS Foundation Trust, Poole (P.D.O., J.D.), Portsmouth Hospitals University NHS Trust, Portsmouth (P.H.), Worcestershire Acute Hospitals NHS Trust, Worcester (H.R., L.M.), University Hospital Southampton NHS Foundation Trust and the University of Southampton, Southampton (N.C.), Royal Berkshire NHS Foundation Trust, Reading (N.R.), Salisbury NHS Foundation Trust, Salisbury (M.S.), Cardiff and Vale University Health Board, Cardiff (T. Kinnaird), Keele University, Keele (T. Kinnaird), Buckinghamshire Healthcare NHS Trust, Amersham (R.P.), and West Hertfordshire Hospitals NHS Trust, Watford (J.S.) - all in the United Kingdom
| | - Reto Gamma
- From Imperial College London (C.A.R., M.J.F., F.A.-J., F.A.S., S.G., R.K., R.P., G.D.C., J.P.H., D.P.F., M.J.S.-S., R.K.A.-L.), Imperial College Healthcare NHS Trust (C.A.R., M.J.F., F.A.-J., F.A.S., S.S.N., S.G., R.K., R.P., S.S., G.D.C., J.P.H., D.P.F., M.J.S.-S., R.K.A.-L.), Barking Havering and Redbridge University Hospitals NHS Trust (A.N.N., A.S.), Royal Free London NHS Foundation Trust (T. Kotecha), St. George's University Hospitals NHS Foundation Trust (R.W., J.C.S.), St. George's University of London (J.C.S.), Queen Mary University of London (D.J.C., A.S.), and Barts Health NHS Trust (A.S.), London, Essex Cardiothoracic Centre, Mid and South Essex NHS Foundation Trust, Basildon (J.R.D., R.G., G.C., J.N.D., T.R.K.), Anglia Ruskin University, Chelmsford (J.R.D., G.C., T.R.K.), University Hospitals Dorset NHS Foundation Trust, Poole (P.D.O., J.D.), Portsmouth Hospitals University NHS Trust, Portsmouth (P.H.), Worcestershire Acute Hospitals NHS Trust, Worcester (H.R., L.M.), University Hospital Southampton NHS Foundation Trust and the University of Southampton, Southampton (N.C.), Royal Berkshire NHS Foundation Trust, Reading (N.R.), Salisbury NHS Foundation Trust, Salisbury (M.S.), Cardiff and Vale University Health Board, Cardiff (T. Kinnaird), Keele University, Keele (T. Kinnaird), Buckinghamshire Healthcare NHS Trust, Amersham (R.P.), and West Hertfordshire Hospitals NHS Trust, Watford (J.S.) - all in the United Kingdom
| | - Gerald Clesham
- From Imperial College London (C.A.R., M.J.F., F.A.-J., F.A.S., S.G., R.K., R.P., G.D.C., J.P.H., D.P.F., M.J.S.-S., R.K.A.-L.), Imperial College Healthcare NHS Trust (C.A.R., M.J.F., F.A.-J., F.A.S., S.S.N., S.G., R.K., R.P., S.S., G.D.C., J.P.H., D.P.F., M.J.S.-S., R.K.A.-L.), Barking Havering and Redbridge University Hospitals NHS Trust (A.N.N., A.S.), Royal Free London NHS Foundation Trust (T. Kotecha), St. George's University Hospitals NHS Foundation Trust (R.W., J.C.S.), St. George's University of London (J.C.S.), Queen Mary University of London (D.J.C., A.S.), and Barts Health NHS Trust (A.S.), London, Essex Cardiothoracic Centre, Mid and South Essex NHS Foundation Trust, Basildon (J.R.D., R.G., G.C., J.N.D., T.R.K.), Anglia Ruskin University, Chelmsford (J.R.D., G.C., T.R.K.), University Hospitals Dorset NHS Foundation Trust, Poole (P.D.O., J.D.), Portsmouth Hospitals University NHS Trust, Portsmouth (P.H.), Worcestershire Acute Hospitals NHS Trust, Worcester (H.R., L.M.), University Hospital Southampton NHS Foundation Trust and the University of Southampton, Southampton (N.C.), Royal Berkshire NHS Foundation Trust, Reading (N.R.), Salisbury NHS Foundation Trust, Salisbury (M.S.), Cardiff and Vale University Health Board, Cardiff (T. Kinnaird), Keele University, Keele (T. Kinnaird), Buckinghamshire Healthcare NHS Trust, Amersham (R.P.), and West Hertfordshire Hospitals NHS Trust, Watford (J.S.) - all in the United Kingdom
| | - Rupert Williams
- From Imperial College London (C.A.R., M.J.F., F.A.-J., F.A.S., S.G., R.K., R.P., G.D.C., J.P.H., D.P.F., M.J.S.-S., R.K.A.-L.), Imperial College Healthcare NHS Trust (C.A.R., M.J.F., F.A.-J., F.A.S., S.S.N., S.G., R.K., R.P., S.S., G.D.C., J.P.H., D.P.F., M.J.S.-S., R.K.A.-L.), Barking Havering and Redbridge University Hospitals NHS Trust (A.N.N., A.S.), Royal Free London NHS Foundation Trust (T. Kotecha), St. George's University Hospitals NHS Foundation Trust (R.W., J.C.S.), St. George's University of London (J.C.S.), Queen Mary University of London (D.J.C., A.S.), and Barts Health NHS Trust (A.S.), London, Essex Cardiothoracic Centre, Mid and South Essex NHS Foundation Trust, Basildon (J.R.D., R.G., G.C., J.N.D., T.R.K.), Anglia Ruskin University, Chelmsford (J.R.D., G.C., T.R.K.), University Hospitals Dorset NHS Foundation Trust, Poole (P.D.O., J.D.), Portsmouth Hospitals University NHS Trust, Portsmouth (P.H.), Worcestershire Acute Hospitals NHS Trust, Worcester (H.R., L.M.), University Hospital Southampton NHS Foundation Trust and the University of Southampton, Southampton (N.C.), Royal Berkshire NHS Foundation Trust, Reading (N.R.), Salisbury NHS Foundation Trust, Salisbury (M.S.), Cardiff and Vale University Health Board, Cardiff (T. Kinnaird), Keele University, Keele (T. Kinnaird), Buckinghamshire Healthcare NHS Trust, Amersham (R.P.), and West Hertfordshire Hospitals NHS Trust, Watford (J.S.) - all in the United Kingdom
| | - Jehangir Din
- From Imperial College London (C.A.R., M.J.F., F.A.-J., F.A.S., S.G., R.K., R.P., G.D.C., J.P.H., D.P.F., M.J.S.-S., R.K.A.-L.), Imperial College Healthcare NHS Trust (C.A.R., M.J.F., F.A.-J., F.A.S., S.S.N., S.G., R.K., R.P., S.S., G.D.C., J.P.H., D.P.F., M.J.S.-S., R.K.A.-L.), Barking Havering and Redbridge University Hospitals NHS Trust (A.N.N., A.S.), Royal Free London NHS Foundation Trust (T. Kotecha), St. George's University Hospitals NHS Foundation Trust (R.W., J.C.S.), St. George's University of London (J.C.S.), Queen Mary University of London (D.J.C., A.S.), and Barts Health NHS Trust (A.S.), London, Essex Cardiothoracic Centre, Mid and South Essex NHS Foundation Trust, Basildon (J.R.D., R.G., G.C., J.N.D., T.R.K.), Anglia Ruskin University, Chelmsford (J.R.D., G.C., T.R.K.), University Hospitals Dorset NHS Foundation Trust, Poole (P.D.O., J.D.), Portsmouth Hospitals University NHS Trust, Portsmouth (P.H.), Worcestershire Acute Hospitals NHS Trust, Worcester (H.R., L.M.), University Hospital Southampton NHS Foundation Trust and the University of Southampton, Southampton (N.C.), Royal Berkshire NHS Foundation Trust, Reading (N.R.), Salisbury NHS Foundation Trust, Salisbury (M.S.), Cardiff and Vale University Health Board, Cardiff (T. Kinnaird), Keele University, Keele (T. Kinnaird), Buckinghamshire Healthcare NHS Trust, Amersham (R.P.), and West Hertfordshire Hospitals NHS Trust, Watford (J.S.) - all in the United Kingdom
| | - Sukhjinder S Nijjer
- From Imperial College London (C.A.R., M.J.F., F.A.-J., F.A.S., S.G., R.K., R.P., G.D.C., J.P.H., D.P.F., M.J.S.-S., R.K.A.-L.), Imperial College Healthcare NHS Trust (C.A.R., M.J.F., F.A.-J., F.A.S., S.S.N., S.G., R.K., R.P., S.S., G.D.C., J.P.H., D.P.F., M.J.S.-S., R.K.A.-L.), Barking Havering and Redbridge University Hospitals NHS Trust (A.N.N., A.S.), Royal Free London NHS Foundation Trust (T. Kotecha), St. George's University Hospitals NHS Foundation Trust (R.W., J.C.S.), St. George's University of London (J.C.S.), Queen Mary University of London (D.J.C., A.S.), and Barts Health NHS Trust (A.S.), London, Essex Cardiothoracic Centre, Mid and South Essex NHS Foundation Trust, Basildon (J.R.D., R.G., G.C., J.N.D., T.R.K.), Anglia Ruskin University, Chelmsford (J.R.D., G.C., T.R.K.), University Hospitals Dorset NHS Foundation Trust, Poole (P.D.O., J.D.), Portsmouth Hospitals University NHS Trust, Portsmouth (P.H.), Worcestershire Acute Hospitals NHS Trust, Worcester (H.R., L.M.), University Hospital Southampton NHS Foundation Trust and the University of Southampton, Southampton (N.C.), Royal Berkshire NHS Foundation Trust, Reading (N.R.), Salisbury NHS Foundation Trust, Salisbury (M.S.), Cardiff and Vale University Health Board, Cardiff (T. Kinnaird), Keele University, Keele (T. Kinnaird), Buckinghamshire Healthcare NHS Trust, Amersham (R.P.), and West Hertfordshire Hospitals NHS Trust, Watford (J.S.) - all in the United Kingdom
| | - Nick Curzen
- From Imperial College London (C.A.R., M.J.F., F.A.-J., F.A.S., S.G., R.K., R.P., G.D.C., J.P.H., D.P.F., M.J.S.-S., R.K.A.-L.), Imperial College Healthcare NHS Trust (C.A.R., M.J.F., F.A.-J., F.A.S., S.S.N., S.G., R.K., R.P., S.S., G.D.C., J.P.H., D.P.F., M.J.S.-S., R.K.A.-L.), Barking Havering and Redbridge University Hospitals NHS Trust (A.N.N., A.S.), Royal Free London NHS Foundation Trust (T. Kotecha), St. George's University Hospitals NHS Foundation Trust (R.W., J.C.S.), St. George's University of London (J.C.S.), Queen Mary University of London (D.J.C., A.S.), and Barts Health NHS Trust (A.S.), London, Essex Cardiothoracic Centre, Mid and South Essex NHS Foundation Trust, Basildon (J.R.D., R.G., G.C., J.N.D., T.R.K.), Anglia Ruskin University, Chelmsford (J.R.D., G.C., T.R.K.), University Hospitals Dorset NHS Foundation Trust, Poole (P.D.O., J.D.), Portsmouth Hospitals University NHS Trust, Portsmouth (P.H.), Worcestershire Acute Hospitals NHS Trust, Worcester (H.R., L.M.), University Hospital Southampton NHS Foundation Trust and the University of Southampton, Southampton (N.C.), Royal Berkshire NHS Foundation Trust, Reading (N.R.), Salisbury NHS Foundation Trust, Salisbury (M.S.), Cardiff and Vale University Health Board, Cardiff (T. Kinnaird), Keele University, Keele (T. Kinnaird), Buckinghamshire Healthcare NHS Trust, Amersham (R.P.), and West Hertfordshire Hospitals NHS Trust, Watford (J.S.) - all in the United Kingdom
| | - Neil Ruparelia
- From Imperial College London (C.A.R., M.J.F., F.A.-J., F.A.S., S.G., R.K., R.P., G.D.C., J.P.H., D.P.F., M.J.S.-S., R.K.A.-L.), Imperial College Healthcare NHS Trust (C.A.R., M.J.F., F.A.-J., F.A.S., S.S.N., S.G., R.K., R.P., S.S., G.D.C., J.P.H., D.P.F., M.J.S.-S., R.K.A.-L.), Barking Havering and Redbridge University Hospitals NHS Trust (A.N.N., A.S.), Royal Free London NHS Foundation Trust (T. Kotecha), St. George's University Hospitals NHS Foundation Trust (R.W., J.C.S.), St. George's University of London (J.C.S.), Queen Mary University of London (D.J.C., A.S.), and Barts Health NHS Trust (A.S.), London, Essex Cardiothoracic Centre, Mid and South Essex NHS Foundation Trust, Basildon (J.R.D., R.G., G.C., J.N.D., T.R.K.), Anglia Ruskin University, Chelmsford (J.R.D., G.C., T.R.K.), University Hospitals Dorset NHS Foundation Trust, Poole (P.D.O., J.D.), Portsmouth Hospitals University NHS Trust, Portsmouth (P.H.), Worcestershire Acute Hospitals NHS Trust, Worcester (H.R., L.M.), University Hospital Southampton NHS Foundation Trust and the University of Southampton, Southampton (N.C.), Royal Berkshire NHS Foundation Trust, Reading (N.R.), Salisbury NHS Foundation Trust, Salisbury (M.S.), Cardiff and Vale University Health Board, Cardiff (T. Kinnaird), Keele University, Keele (T. Kinnaird), Buckinghamshire Healthcare NHS Trust, Amersham (R.P.), and West Hertfordshire Hospitals NHS Trust, Watford (J.S.) - all in the United Kingdom
| | - Manas Sinha
- From Imperial College London (C.A.R., M.J.F., F.A.-J., F.A.S., S.G., R.K., R.P., G.D.C., J.P.H., D.P.F., M.J.S.-S., R.K.A.-L.), Imperial College Healthcare NHS Trust (C.A.R., M.J.F., F.A.-J., F.A.S., S.S.N., S.G., R.K., R.P., S.S., G.D.C., J.P.H., D.P.F., M.J.S.-S., R.K.A.-L.), Barking Havering and Redbridge University Hospitals NHS Trust (A.N.N., A.S.), Royal Free London NHS Foundation Trust (T. Kotecha), St. George's University Hospitals NHS Foundation Trust (R.W., J.C.S.), St. George's University of London (J.C.S.), Queen Mary University of London (D.J.C., A.S.), and Barts Health NHS Trust (A.S.), London, Essex Cardiothoracic Centre, Mid and South Essex NHS Foundation Trust, Basildon (J.R.D., R.G., G.C., J.N.D., T.R.K.), Anglia Ruskin University, Chelmsford (J.R.D., G.C., T.R.K.), University Hospitals Dorset NHS Foundation Trust, Poole (P.D.O., J.D.), Portsmouth Hospitals University NHS Trust, Portsmouth (P.H.), Worcestershire Acute Hospitals NHS Trust, Worcester (H.R., L.M.), University Hospital Southampton NHS Foundation Trust and the University of Southampton, Southampton (N.C.), Royal Berkshire NHS Foundation Trust, Reading (N.R.), Salisbury NHS Foundation Trust, Salisbury (M.S.), Cardiff and Vale University Health Board, Cardiff (T. Kinnaird), Keele University, Keele (T. Kinnaird), Buckinghamshire Healthcare NHS Trust, Amersham (R.P.), and West Hertfordshire Hospitals NHS Trust, Watford (J.S.) - all in the United Kingdom
| | - Jason N Dungu
- From Imperial College London (C.A.R., M.J.F., F.A.-J., F.A.S., S.G., R.K., R.P., G.D.C., J.P.H., D.P.F., M.J.S.-S., R.K.A.-L.), Imperial College Healthcare NHS Trust (C.A.R., M.J.F., F.A.-J., F.A.S., S.S.N., S.G., R.K., R.P., S.S., G.D.C., J.P.H., D.P.F., M.J.S.-S., R.K.A.-L.), Barking Havering and Redbridge University Hospitals NHS Trust (A.N.N., A.S.), Royal Free London NHS Foundation Trust (T. Kotecha), St. George's University Hospitals NHS Foundation Trust (R.W., J.C.S.), St. George's University of London (J.C.S.), Queen Mary University of London (D.J.C., A.S.), and Barts Health NHS Trust (A.S.), London, Essex Cardiothoracic Centre, Mid and South Essex NHS Foundation Trust, Basildon (J.R.D., R.G., G.C., J.N.D., T.R.K.), Anglia Ruskin University, Chelmsford (J.R.D., G.C., T.R.K.), University Hospitals Dorset NHS Foundation Trust, Poole (P.D.O., J.D.), Portsmouth Hospitals University NHS Trust, Portsmouth (P.H.), Worcestershire Acute Hospitals NHS Trust, Worcester (H.R., L.M.), University Hospital Southampton NHS Foundation Trust and the University of Southampton, Southampton (N.C.), Royal Berkshire NHS Foundation Trust, Reading (N.R.), Salisbury NHS Foundation Trust, Salisbury (M.S.), Cardiff and Vale University Health Board, Cardiff (T. Kinnaird), Keele University, Keele (T. Kinnaird), Buckinghamshire Healthcare NHS Trust, Amersham (R.P.), and West Hertfordshire Hospitals NHS Trust, Watford (J.S.) - all in the United Kingdom
| | - Sashiananthan Ganesananthan
- From Imperial College London (C.A.R., M.J.F., F.A.-J., F.A.S., S.G., R.K., R.P., G.D.C., J.P.H., D.P.F., M.J.S.-S., R.K.A.-L.), Imperial College Healthcare NHS Trust (C.A.R., M.J.F., F.A.-J., F.A.S., S.S.N., S.G., R.K., R.P., S.S., G.D.C., J.P.H., D.P.F., M.J.S.-S., R.K.A.-L.), Barking Havering and Redbridge University Hospitals NHS Trust (A.N.N., A.S.), Royal Free London NHS Foundation Trust (T. Kotecha), St. George's University Hospitals NHS Foundation Trust (R.W., J.C.S.), St. George's University of London (J.C.S.), Queen Mary University of London (D.J.C., A.S.), and Barts Health NHS Trust (A.S.), London, Essex Cardiothoracic Centre, Mid and South Essex NHS Foundation Trust, Basildon (J.R.D., R.G., G.C., J.N.D., T.R.K.), Anglia Ruskin University, Chelmsford (J.R.D., G.C., T.R.K.), University Hospitals Dorset NHS Foundation Trust, Poole (P.D.O., J.D.), Portsmouth Hospitals University NHS Trust, Portsmouth (P.H.), Worcestershire Acute Hospitals NHS Trust, Worcester (H.R., L.M.), University Hospital Southampton NHS Foundation Trust and the University of Southampton, Southampton (N.C.), Royal Berkshire NHS Foundation Trust, Reading (N.R.), Salisbury NHS Foundation Trust, Salisbury (M.S.), Cardiff and Vale University Health Board, Cardiff (T. Kinnaird), Keele University, Keele (T. Kinnaird), Buckinghamshire Healthcare NHS Trust, Amersham (R.P.), and West Hertfordshire Hospitals NHS Trust, Watford (J.S.) - all in the United Kingdom
| | - Ramzi Khamis
- From Imperial College London (C.A.R., M.J.F., F.A.-J., F.A.S., S.G., R.K., R.P., G.D.C., J.P.H., D.P.F., M.J.S.-S., R.K.A.-L.), Imperial College Healthcare NHS Trust (C.A.R., M.J.F., F.A.-J., F.A.S., S.S.N., S.G., R.K., R.P., S.S., G.D.C., J.P.H., D.P.F., M.J.S.-S., R.K.A.-L.), Barking Havering and Redbridge University Hospitals NHS Trust (A.N.N., A.S.), Royal Free London NHS Foundation Trust (T. Kotecha), St. George's University Hospitals NHS Foundation Trust (R.W., J.C.S.), St. George's University of London (J.C.S.), Queen Mary University of London (D.J.C., A.S.), and Barts Health NHS Trust (A.S.), London, Essex Cardiothoracic Centre, Mid and South Essex NHS Foundation Trust, Basildon (J.R.D., R.G., G.C., J.N.D., T.R.K.), Anglia Ruskin University, Chelmsford (J.R.D., G.C., T.R.K.), University Hospitals Dorset NHS Foundation Trust, Poole (P.D.O., J.D.), Portsmouth Hospitals University NHS Trust, Portsmouth (P.H.), Worcestershire Acute Hospitals NHS Trust, Worcester (H.R., L.M.), University Hospital Southampton NHS Foundation Trust and the University of Southampton, Southampton (N.C.), Royal Berkshire NHS Foundation Trust, Reading (N.R.), Salisbury NHS Foundation Trust, Salisbury (M.S.), Cardiff and Vale University Health Board, Cardiff (T. Kinnaird), Keele University, Keele (T. Kinnaird), Buckinghamshire Healthcare NHS Trust, Amersham (R.P.), and West Hertfordshire Hospitals NHS Trust, Watford (J.S.) - all in the United Kingdom
| | - Lal Mughal
- From Imperial College London (C.A.R., M.J.F., F.A.-J., F.A.S., S.G., R.K., R.P., G.D.C., J.P.H., D.P.F., M.J.S.-S., R.K.A.-L.), Imperial College Healthcare NHS Trust (C.A.R., M.J.F., F.A.-J., F.A.S., S.S.N., S.G., R.K., R.P., S.S., G.D.C., J.P.H., D.P.F., M.J.S.-S., R.K.A.-L.), Barking Havering and Redbridge University Hospitals NHS Trust (A.N.N., A.S.), Royal Free London NHS Foundation Trust (T. Kotecha), St. George's University Hospitals NHS Foundation Trust (R.W., J.C.S.), St. George's University of London (J.C.S.), Queen Mary University of London (D.J.C., A.S.), and Barts Health NHS Trust (A.S.), London, Essex Cardiothoracic Centre, Mid and South Essex NHS Foundation Trust, Basildon (J.R.D., R.G., G.C., J.N.D., T.R.K.), Anglia Ruskin University, Chelmsford (J.R.D., G.C., T.R.K.), University Hospitals Dorset NHS Foundation Trust, Poole (P.D.O., J.D.), Portsmouth Hospitals University NHS Trust, Portsmouth (P.H.), Worcestershire Acute Hospitals NHS Trust, Worcester (H.R., L.M.), University Hospital Southampton NHS Foundation Trust and the University of Southampton, Southampton (N.C.), Royal Berkshire NHS Foundation Trust, Reading (N.R.), Salisbury NHS Foundation Trust, Salisbury (M.S.), Cardiff and Vale University Health Board, Cardiff (T. Kinnaird), Keele University, Keele (T. Kinnaird), Buckinghamshire Healthcare NHS Trust, Amersham (R.P.), and West Hertfordshire Hospitals NHS Trust, Watford (J.S.) - all in the United Kingdom
| | - Tim Kinnaird
- From Imperial College London (C.A.R., M.J.F., F.A.-J., F.A.S., S.G., R.K., R.P., G.D.C., J.P.H., D.P.F., M.J.S.-S., R.K.A.-L.), Imperial College Healthcare NHS Trust (C.A.R., M.J.F., F.A.-J., F.A.S., S.S.N., S.G., R.K., R.P., S.S., G.D.C., J.P.H., D.P.F., M.J.S.-S., R.K.A.-L.), Barking Havering and Redbridge University Hospitals NHS Trust (A.N.N., A.S.), Royal Free London NHS Foundation Trust (T. Kotecha), St. George's University Hospitals NHS Foundation Trust (R.W., J.C.S.), St. George's University of London (J.C.S.), Queen Mary University of London (D.J.C., A.S.), and Barts Health NHS Trust (A.S.), London, Essex Cardiothoracic Centre, Mid and South Essex NHS Foundation Trust, Basildon (J.R.D., R.G., G.C., J.N.D., T.R.K.), Anglia Ruskin University, Chelmsford (J.R.D., G.C., T.R.K.), University Hospitals Dorset NHS Foundation Trust, Poole (P.D.O., J.D.), Portsmouth Hospitals University NHS Trust, Portsmouth (P.H.), Worcestershire Acute Hospitals NHS Trust, Worcester (H.R., L.M.), University Hospital Southampton NHS Foundation Trust and the University of Southampton, Southampton (N.C.), Royal Berkshire NHS Foundation Trust, Reading (N.R.), Salisbury NHS Foundation Trust, Salisbury (M.S.), Cardiff and Vale University Health Board, Cardiff (T. Kinnaird), Keele University, Keele (T. Kinnaird), Buckinghamshire Healthcare NHS Trust, Amersham (R.P.), and West Hertfordshire Hospitals NHS Trust, Watford (J.S.) - all in the United Kingdom
| | - Ricardo Petraco
- From Imperial College London (C.A.R., M.J.F., F.A.-J., F.A.S., S.G., R.K., R.P., G.D.C., J.P.H., D.P.F., M.J.S.-S., R.K.A.-L.), Imperial College Healthcare NHS Trust (C.A.R., M.J.F., F.A.-J., F.A.S., S.S.N., S.G., R.K., R.P., S.S., G.D.C., J.P.H., D.P.F., M.J.S.-S., R.K.A.-L.), Barking Havering and Redbridge University Hospitals NHS Trust (A.N.N., A.S.), Royal Free London NHS Foundation Trust (T. Kotecha), St. George's University Hospitals NHS Foundation Trust (R.W., J.C.S.), St. George's University of London (J.C.S.), Queen Mary University of London (D.J.C., A.S.), and Barts Health NHS Trust (A.S.), London, Essex Cardiothoracic Centre, Mid and South Essex NHS Foundation Trust, Basildon (J.R.D., R.G., G.C., J.N.D., T.R.K.), Anglia Ruskin University, Chelmsford (J.R.D., G.C., T.R.K.), University Hospitals Dorset NHS Foundation Trust, Poole (P.D.O., J.D.), Portsmouth Hospitals University NHS Trust, Portsmouth (P.H.), Worcestershire Acute Hospitals NHS Trust, Worcester (H.R., L.M.), University Hospital Southampton NHS Foundation Trust and the University of Southampton, Southampton (N.C.), Royal Berkshire NHS Foundation Trust, Reading (N.R.), Salisbury NHS Foundation Trust, Salisbury (M.S.), Cardiff and Vale University Health Board, Cardiff (T. Kinnaird), Keele University, Keele (T. Kinnaird), Buckinghamshire Healthcare NHS Trust, Amersham (R.P.), and West Hertfordshire Hospitals NHS Trust, Watford (J.S.) - all in the United Kingdom
| | - James C Spratt
- From Imperial College London (C.A.R., M.J.F., F.A.-J., F.A.S., S.G., R.K., R.P., G.D.C., J.P.H., D.P.F., M.J.S.-S., R.K.A.-L.), Imperial College Healthcare NHS Trust (C.A.R., M.J.F., F.A.-J., F.A.S., S.S.N., S.G., R.K., R.P., S.S., G.D.C., J.P.H., D.P.F., M.J.S.-S., R.K.A.-L.), Barking Havering and Redbridge University Hospitals NHS Trust (A.N.N., A.S.), Royal Free London NHS Foundation Trust (T. Kotecha), St. George's University Hospitals NHS Foundation Trust (R.W., J.C.S.), St. George's University of London (J.C.S.), Queen Mary University of London (D.J.C., A.S.), and Barts Health NHS Trust (A.S.), London, Essex Cardiothoracic Centre, Mid and South Essex NHS Foundation Trust, Basildon (J.R.D., R.G., G.C., J.N.D., T.R.K.), Anglia Ruskin University, Chelmsford (J.R.D., G.C., T.R.K.), University Hospitals Dorset NHS Foundation Trust, Poole (P.D.O., J.D.), Portsmouth Hospitals University NHS Trust, Portsmouth (P.H.), Worcestershire Acute Hospitals NHS Trust, Worcester (H.R., L.M.), University Hospital Southampton NHS Foundation Trust and the University of Southampton, Southampton (N.C.), Royal Berkshire NHS Foundation Trust, Reading (N.R.), Salisbury NHS Foundation Trust, Salisbury (M.S.), Cardiff and Vale University Health Board, Cardiff (T. Kinnaird), Keele University, Keele (T. Kinnaird), Buckinghamshire Healthcare NHS Trust, Amersham (R.P.), and West Hertfordshire Hospitals NHS Trust, Watford (J.S.) - all in the United Kingdom
| | - Sayan Sen
- From Imperial College London (C.A.R., M.J.F., F.A.-J., F.A.S., S.G., R.K., R.P., G.D.C., J.P.H., D.P.F., M.J.S.-S., R.K.A.-L.), Imperial College Healthcare NHS Trust (C.A.R., M.J.F., F.A.-J., F.A.S., S.S.N., S.G., R.K., R.P., S.S., G.D.C., J.P.H., D.P.F., M.J.S.-S., R.K.A.-L.), Barking Havering and Redbridge University Hospitals NHS Trust (A.N.N., A.S.), Royal Free London NHS Foundation Trust (T. Kotecha), St. George's University Hospitals NHS Foundation Trust (R.W., J.C.S.), St. George's University of London (J.C.S.), Queen Mary University of London (D.J.C., A.S.), and Barts Health NHS Trust (A.S.), London, Essex Cardiothoracic Centre, Mid and South Essex NHS Foundation Trust, Basildon (J.R.D., R.G., G.C., J.N.D., T.R.K.), Anglia Ruskin University, Chelmsford (J.R.D., G.C., T.R.K.), University Hospitals Dorset NHS Foundation Trust, Poole (P.D.O., J.D.), Portsmouth Hospitals University NHS Trust, Portsmouth (P.H.), Worcestershire Acute Hospitals NHS Trust, Worcester (H.R., L.M.), University Hospital Southampton NHS Foundation Trust and the University of Southampton, Southampton (N.C.), Royal Berkshire NHS Foundation Trust, Reading (N.R.), Salisbury NHS Foundation Trust, Salisbury (M.S.), Cardiff and Vale University Health Board, Cardiff (T. Kinnaird), Keele University, Keele (T. Kinnaird), Buckinghamshire Healthcare NHS Trust, Amersham (R.P.), and West Hertfordshire Hospitals NHS Trust, Watford (J.S.) - all in the United Kingdom
| | - Joban Sehmi
- From Imperial College London (C.A.R., M.J.F., F.A.-J., F.A.S., S.G., R.K., R.P., G.D.C., J.P.H., D.P.F., M.J.S.-S., R.K.A.-L.), Imperial College Healthcare NHS Trust (C.A.R., M.J.F., F.A.-J., F.A.S., S.S.N., S.G., R.K., R.P., S.S., G.D.C., J.P.H., D.P.F., M.J.S.-S., R.K.A.-L.), Barking Havering and Redbridge University Hospitals NHS Trust (A.N.N., A.S.), Royal Free London NHS Foundation Trust (T. Kotecha), St. George's University Hospitals NHS Foundation Trust (R.W., J.C.S.), St. George's University of London (J.C.S.), Queen Mary University of London (D.J.C., A.S.), and Barts Health NHS Trust (A.S.), London, Essex Cardiothoracic Centre, Mid and South Essex NHS Foundation Trust, Basildon (J.R.D., R.G., G.C., J.N.D., T.R.K.), Anglia Ruskin University, Chelmsford (J.R.D., G.C., T.R.K.), University Hospitals Dorset NHS Foundation Trust, Poole (P.D.O., J.D.), Portsmouth Hospitals University NHS Trust, Portsmouth (P.H.), Worcestershire Acute Hospitals NHS Trust, Worcester (H.R., L.M.), University Hospital Southampton NHS Foundation Trust and the University of Southampton, Southampton (N.C.), Royal Berkshire NHS Foundation Trust, Reading (N.R.), Salisbury NHS Foundation Trust, Salisbury (M.S.), Cardiff and Vale University Health Board, Cardiff (T. Kinnaird), Keele University, Keele (T. Kinnaird), Buckinghamshire Healthcare NHS Trust, Amersham (R.P.), and West Hertfordshire Hospitals NHS Trust, Watford (J.S.) - all in the United Kingdom
| | - David J Collier
- From Imperial College London (C.A.R., M.J.F., F.A.-J., F.A.S., S.G., R.K., R.P., G.D.C., J.P.H., D.P.F., M.J.S.-S., R.K.A.-L.), Imperial College Healthcare NHS Trust (C.A.R., M.J.F., F.A.-J., F.A.S., S.S.N., S.G., R.K., R.P., S.S., G.D.C., J.P.H., D.P.F., M.J.S.-S., R.K.A.-L.), Barking Havering and Redbridge University Hospitals NHS Trust (A.N.N., A.S.), Royal Free London NHS Foundation Trust (T. Kotecha), St. George's University Hospitals NHS Foundation Trust (R.W., J.C.S.), St. George's University of London (J.C.S.), Queen Mary University of London (D.J.C., A.S.), and Barts Health NHS Trust (A.S.), London, Essex Cardiothoracic Centre, Mid and South Essex NHS Foundation Trust, Basildon (J.R.D., R.G., G.C., J.N.D., T.R.K.), Anglia Ruskin University, Chelmsford (J.R.D., G.C., T.R.K.), University Hospitals Dorset NHS Foundation Trust, Poole (P.D.O., J.D.), Portsmouth Hospitals University NHS Trust, Portsmouth (P.H.), Worcestershire Acute Hospitals NHS Trust, Worcester (H.R., L.M.), University Hospital Southampton NHS Foundation Trust and the University of Southampton, Southampton (N.C.), Royal Berkshire NHS Foundation Trust, Reading (N.R.), Salisbury NHS Foundation Trust, Salisbury (M.S.), Cardiff and Vale University Health Board, Cardiff (T. Kinnaird), Keele University, Keele (T. Kinnaird), Buckinghamshire Healthcare NHS Trust, Amersham (R.P.), and West Hertfordshire Hospitals NHS Trust, Watford (J.S.) - all in the United Kingdom
| | - Afzal Sohaib
- From Imperial College London (C.A.R., M.J.F., F.A.-J., F.A.S., S.G., R.K., R.P., G.D.C., J.P.H., D.P.F., M.J.S.-S., R.K.A.-L.), Imperial College Healthcare NHS Trust (C.A.R., M.J.F., F.A.-J., F.A.S., S.S.N., S.G., R.K., R.P., S.S., G.D.C., J.P.H., D.P.F., M.J.S.-S., R.K.A.-L.), Barking Havering and Redbridge University Hospitals NHS Trust (A.N.N., A.S.), Royal Free London NHS Foundation Trust (T. Kotecha), St. George's University Hospitals NHS Foundation Trust (R.W., J.C.S.), St. George's University of London (J.C.S.), Queen Mary University of London (D.J.C., A.S.), and Barts Health NHS Trust (A.S.), London, Essex Cardiothoracic Centre, Mid and South Essex NHS Foundation Trust, Basildon (J.R.D., R.G., G.C., J.N.D., T.R.K.), Anglia Ruskin University, Chelmsford (J.R.D., G.C., T.R.K.), University Hospitals Dorset NHS Foundation Trust, Poole (P.D.O., J.D.), Portsmouth Hospitals University NHS Trust, Portsmouth (P.H.), Worcestershire Acute Hospitals NHS Trust, Worcester (H.R., L.M.), University Hospital Southampton NHS Foundation Trust and the University of Southampton, Southampton (N.C.), Royal Berkshire NHS Foundation Trust, Reading (N.R.), Salisbury NHS Foundation Trust, Salisbury (M.S.), Cardiff and Vale University Health Board, Cardiff (T. Kinnaird), Keele University, Keele (T. Kinnaird), Buckinghamshire Healthcare NHS Trust, Amersham (R.P.), and West Hertfordshire Hospitals NHS Trust, Watford (J.S.) - all in the United Kingdom
| | - Thomas R Keeble
- From Imperial College London (C.A.R., M.J.F., F.A.-J., F.A.S., S.G., R.K., R.P., G.D.C., J.P.H., D.P.F., M.J.S.-S., R.K.A.-L.), Imperial College Healthcare NHS Trust (C.A.R., M.J.F., F.A.-J., F.A.S., S.S.N., S.G., R.K., R.P., S.S., G.D.C., J.P.H., D.P.F., M.J.S.-S., R.K.A.-L.), Barking Havering and Redbridge University Hospitals NHS Trust (A.N.N., A.S.), Royal Free London NHS Foundation Trust (T. Kotecha), St. George's University Hospitals NHS Foundation Trust (R.W., J.C.S.), St. George's University of London (J.C.S.), Queen Mary University of London (D.J.C., A.S.), and Barts Health NHS Trust (A.S.), London, Essex Cardiothoracic Centre, Mid and South Essex NHS Foundation Trust, Basildon (J.R.D., R.G., G.C., J.N.D., T.R.K.), Anglia Ruskin University, Chelmsford (J.R.D., G.C., T.R.K.), University Hospitals Dorset NHS Foundation Trust, Poole (P.D.O., J.D.), Portsmouth Hospitals University NHS Trust, Portsmouth (P.H.), Worcestershire Acute Hospitals NHS Trust, Worcester (H.R., L.M.), University Hospital Southampton NHS Foundation Trust and the University of Southampton, Southampton (N.C.), Royal Berkshire NHS Foundation Trust, Reading (N.R.), Salisbury NHS Foundation Trust, Salisbury (M.S.), Cardiff and Vale University Health Board, Cardiff (T. Kinnaird), Keele University, Keele (T. Kinnaird), Buckinghamshire Healthcare NHS Trust, Amersham (R.P.), and West Hertfordshire Hospitals NHS Trust, Watford (J.S.) - all in the United Kingdom
| | - Graham D Cole
- From Imperial College London (C.A.R., M.J.F., F.A.-J., F.A.S., S.G., R.K., R.P., G.D.C., J.P.H., D.P.F., M.J.S.-S., R.K.A.-L.), Imperial College Healthcare NHS Trust (C.A.R., M.J.F., F.A.-J., F.A.S., S.S.N., S.G., R.K., R.P., S.S., G.D.C., J.P.H., D.P.F., M.J.S.-S., R.K.A.-L.), Barking Havering and Redbridge University Hospitals NHS Trust (A.N.N., A.S.), Royal Free London NHS Foundation Trust (T. Kotecha), St. George's University Hospitals NHS Foundation Trust (R.W., J.C.S.), St. George's University of London (J.C.S.), Queen Mary University of London (D.J.C., A.S.), and Barts Health NHS Trust (A.S.), London, Essex Cardiothoracic Centre, Mid and South Essex NHS Foundation Trust, Basildon (J.R.D., R.G., G.C., J.N.D., T.R.K.), Anglia Ruskin University, Chelmsford (J.R.D., G.C., T.R.K.), University Hospitals Dorset NHS Foundation Trust, Poole (P.D.O., J.D.), Portsmouth Hospitals University NHS Trust, Portsmouth (P.H.), Worcestershire Acute Hospitals NHS Trust, Worcester (H.R., L.M.), University Hospital Southampton NHS Foundation Trust and the University of Southampton, Southampton (N.C.), Royal Berkshire NHS Foundation Trust, Reading (N.R.), Salisbury NHS Foundation Trust, Salisbury (M.S.), Cardiff and Vale University Health Board, Cardiff (T. Kinnaird), Keele University, Keele (T. Kinnaird), Buckinghamshire Healthcare NHS Trust, Amersham (R.P.), and West Hertfordshire Hospitals NHS Trust, Watford (J.S.) - all in the United Kingdom
| | - James P Howard
- From Imperial College London (C.A.R., M.J.F., F.A.-J., F.A.S., S.G., R.K., R.P., G.D.C., J.P.H., D.P.F., M.J.S.-S., R.K.A.-L.), Imperial College Healthcare NHS Trust (C.A.R., M.J.F., F.A.-J., F.A.S., S.S.N., S.G., R.K., R.P., S.S., G.D.C., J.P.H., D.P.F., M.J.S.-S., R.K.A.-L.), Barking Havering and Redbridge University Hospitals NHS Trust (A.N.N., A.S.), Royal Free London NHS Foundation Trust (T. Kotecha), St. George's University Hospitals NHS Foundation Trust (R.W., J.C.S.), St. George's University of London (J.C.S.), Queen Mary University of London (D.J.C., A.S.), and Barts Health NHS Trust (A.S.), London, Essex Cardiothoracic Centre, Mid and South Essex NHS Foundation Trust, Basildon (J.R.D., R.G., G.C., J.N.D., T.R.K.), Anglia Ruskin University, Chelmsford (J.R.D., G.C., T.R.K.), University Hospitals Dorset NHS Foundation Trust, Poole (P.D.O., J.D.), Portsmouth Hospitals University NHS Trust, Portsmouth (P.H.), Worcestershire Acute Hospitals NHS Trust, Worcester (H.R., L.M.), University Hospital Southampton NHS Foundation Trust and the University of Southampton, Southampton (N.C.), Royal Berkshire NHS Foundation Trust, Reading (N.R.), Salisbury NHS Foundation Trust, Salisbury (M.S.), Cardiff and Vale University Health Board, Cardiff (T. Kinnaird), Keele University, Keele (T. Kinnaird), Buckinghamshire Healthcare NHS Trust, Amersham (R.P.), and West Hertfordshire Hospitals NHS Trust, Watford (J.S.) - all in the United Kingdom
| | - Darrel P Francis
- From Imperial College London (C.A.R., M.J.F., F.A.-J., F.A.S., S.G., R.K., R.P., G.D.C., J.P.H., D.P.F., M.J.S.-S., R.K.A.-L.), Imperial College Healthcare NHS Trust (C.A.R., M.J.F., F.A.-J., F.A.S., S.S.N., S.G., R.K., R.P., S.S., G.D.C., J.P.H., D.P.F., M.J.S.-S., R.K.A.-L.), Barking Havering and Redbridge University Hospitals NHS Trust (A.N.N., A.S.), Royal Free London NHS Foundation Trust (T. Kotecha), St. George's University Hospitals NHS Foundation Trust (R.W., J.C.S.), St. George's University of London (J.C.S.), Queen Mary University of London (D.J.C., A.S.), and Barts Health NHS Trust (A.S.), London, Essex Cardiothoracic Centre, Mid and South Essex NHS Foundation Trust, Basildon (J.R.D., R.G., G.C., J.N.D., T.R.K.), Anglia Ruskin University, Chelmsford (J.R.D., G.C., T.R.K.), University Hospitals Dorset NHS Foundation Trust, Poole (P.D.O., J.D.), Portsmouth Hospitals University NHS Trust, Portsmouth (P.H.), Worcestershire Acute Hospitals NHS Trust, Worcester (H.R., L.M.), University Hospital Southampton NHS Foundation Trust and the University of Southampton, Southampton (N.C.), Royal Berkshire NHS Foundation Trust, Reading (N.R.), Salisbury NHS Foundation Trust, Salisbury (M.S.), Cardiff and Vale University Health Board, Cardiff (T. Kinnaird), Keele University, Keele (T. Kinnaird), Buckinghamshire Healthcare NHS Trust, Amersham (R.P.), and West Hertfordshire Hospitals NHS Trust, Watford (J.S.) - all in the United Kingdom
| | - Matthew J Shun-Shin
- From Imperial College London (C.A.R., M.J.F., F.A.-J., F.A.S., S.G., R.K., R.P., G.D.C., J.P.H., D.P.F., M.J.S.-S., R.K.A.-L.), Imperial College Healthcare NHS Trust (C.A.R., M.J.F., F.A.-J., F.A.S., S.S.N., S.G., R.K., R.P., S.S., G.D.C., J.P.H., D.P.F., M.J.S.-S., R.K.A.-L.), Barking Havering and Redbridge University Hospitals NHS Trust (A.N.N., A.S.), Royal Free London NHS Foundation Trust (T. Kotecha), St. George's University Hospitals NHS Foundation Trust (R.W., J.C.S.), St. George's University of London (J.C.S.), Queen Mary University of London (D.J.C., A.S.), and Barts Health NHS Trust (A.S.), London, Essex Cardiothoracic Centre, Mid and South Essex NHS Foundation Trust, Basildon (J.R.D., R.G., G.C., J.N.D., T.R.K.), Anglia Ruskin University, Chelmsford (J.R.D., G.C., T.R.K.), University Hospitals Dorset NHS Foundation Trust, Poole (P.D.O., J.D.), Portsmouth Hospitals University NHS Trust, Portsmouth (P.H.), Worcestershire Acute Hospitals NHS Trust, Worcester (H.R., L.M.), University Hospital Southampton NHS Foundation Trust and the University of Southampton, Southampton (N.C.), Royal Berkshire NHS Foundation Trust, Reading (N.R.), Salisbury NHS Foundation Trust, Salisbury (M.S.), Cardiff and Vale University Health Board, Cardiff (T. Kinnaird), Keele University, Keele (T. Kinnaird), Buckinghamshire Healthcare NHS Trust, Amersham (R.P.), and West Hertfordshire Hospitals NHS Trust, Watford (J.S.) - all in the United Kingdom
| | - Rasha K Al-Lamee
- From Imperial College London (C.A.R., M.J.F., F.A.-J., F.A.S., S.G., R.K., R.P., G.D.C., J.P.H., D.P.F., M.J.S.-S., R.K.A.-L.), Imperial College Healthcare NHS Trust (C.A.R., M.J.F., F.A.-J., F.A.S., S.S.N., S.G., R.K., R.P., S.S., G.D.C., J.P.H., D.P.F., M.J.S.-S., R.K.A.-L.), Barking Havering and Redbridge University Hospitals NHS Trust (A.N.N., A.S.), Royal Free London NHS Foundation Trust (T. Kotecha), St. George's University Hospitals NHS Foundation Trust (R.W., J.C.S.), St. George's University of London (J.C.S.), Queen Mary University of London (D.J.C., A.S.), and Barts Health NHS Trust (A.S.), London, Essex Cardiothoracic Centre, Mid and South Essex NHS Foundation Trust, Basildon (J.R.D., R.G., G.C., J.N.D., T.R.K.), Anglia Ruskin University, Chelmsford (J.R.D., G.C., T.R.K.), University Hospitals Dorset NHS Foundation Trust, Poole (P.D.O., J.D.), Portsmouth Hospitals University NHS Trust, Portsmouth (P.H.), Worcestershire Acute Hospitals NHS Trust, Worcester (H.R., L.M.), University Hospital Southampton NHS Foundation Trust and the University of Southampton, Southampton (N.C.), Royal Berkshire NHS Foundation Trust, Reading (N.R.), Salisbury NHS Foundation Trust, Salisbury (M.S.), Cardiff and Vale University Health Board, Cardiff (T. Kinnaird), Keele University, Keele (T. Kinnaird), Buckinghamshire Healthcare NHS Trust, Amersham (R.P.), and West Hertfordshire Hospitals NHS Trust, Watford (J.S.) - all in the United Kingdom
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Jelaković B, Perkov D, Barišić K, Bukal N, Gellineo L, Jelaković A, Josipović J, Prkačin I, Željković Vrkić T, Živko M. Renal Denervation in the Treatment of Resistant Hypertension and Difficult-to-Control Hypertension - Consensus Document of the Croatian Hypertension League - Croatian Society of Hypertension, Croatian Cardiac Society, Croatian Endovascular Initiative, Croatian Society for Diabetes and Metabolic Diseases, Croatian Renal Association, and Croatian Society of Family Physicians of the Croatian Medical Association. Vasc Health Risk Manag 2023; 19:805-826. [PMID: 38108022 PMCID: PMC10724019 DOI: 10.2147/vhrm.s422773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 11/21/2023] [Indexed: 12/19/2023] Open
Abstract
Renal denervation (RDN) as a method of treating arterial hypertension (AH) was introduced in Croatia in 2012. A multidisciplinary team and a network of hospitals that diagnose and treat patients with severe forms of AH were established, and a very strict diagnostic-treatment algorithm was prepared. At monthly meetings patients with truly resistant hypertension who were candidates for RDN were discussed. According to the 2021 ESH position statement and 2023 ESH guidelines, RDN is considered an alternative and additional, not a competitive method of treating patients with various forms of AH which must be performed by following a structured procedure and the patient's preference should be considered. In view of the changes in the global scientific community, the Croatian Hypertension League brings this consensus document on RDN conducted with radiofrequency-based catheter, the only currently available method in Croatia. In this document, exclusion and inclusion criteria are shown, as well as three groups of patients in whom RDN could be considered. The new diagnostic-treatment algorithm is prepared and follow-up procedure is explained. In Croatia, RDN is reimbursed by the national insurance company, thus pharmacoeconomic analyses is also shown. Criteria required by an individual centre to be approved of RDN are listed, and plans for prospective research on RDN in Croatia, including the Croatian registry for RDN, are discussed.
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Affiliation(s)
- Bojan Jelaković
- School of Medicine University of Zagreb, Zagreb, Croatia
- Department of Nephrology, Hypertension, Dialysis and Transplantation, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Dražen Perkov
- Department of Diagnostic and Interventional Radiology, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Klara Barišić
- Department of Nephrology, Hypertension, Dialysis and Transplantation, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Nikolina Bukal
- Department of Internal Medicine, Nephrology and Pulmonology, General Hospital “Dr. J. Benčević”, Slavonski Brod, Croatia
| | - Lana Gellineo
- Department of Nephrology, Hypertension, Dialysis and Transplantation, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Ana Jelaković
- Department of Nephrology, Hypertension, Dialysis and Transplantation, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Josipa Josipović
- Croatian Catholic University, Zagreb, Croatia
- Department of Nephrology and Dialysis, University Hospital Centre Sestre Milosrdnice, Zagreb, Croatia
| | - Ingrid Prkačin
- Department for Emergency Medicine, Clinical Hospital Merkur, Zagreb, Croatia
| | | | - Marijana Živko
- Department of Nephrology, Hypertension, Dialysis and Transplantation, University Hospital Centre Zagreb, Zagreb, Croatia
| | - On the behalf of Task force for the Resistant Hypertension and Renal Denervation of the Croatian Hypertension League
- School of Medicine University of Zagreb, Zagreb, Croatia
- Department of Nephrology, Hypertension, Dialysis and Transplantation, University Hospital Centre Zagreb, Zagreb, Croatia
- Department of Diagnostic and Interventional Radiology, University Hospital Centre Zagreb, Zagreb, Croatia
- Department of Internal Medicine, Nephrology and Pulmonology, General Hospital “Dr. J. Benčević”, Slavonski Brod, Croatia
- Croatian Catholic University, Zagreb, Croatia
- Department of Nephrology and Dialysis, University Hospital Centre Sestre Milosrdnice, Zagreb, Croatia
- Department for Emergency Medicine, Clinical Hospital Merkur, Zagreb, Croatia
- Institute for Cardiovascular Prevention and Rehabilitation, Zagreb, Croatia
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Hu X, Zhou H, Chen W, Li D, Du H, Xia T, Yin Y. Current problems in renal denervation and a hope to break the stage. Hypertens Res 2023; 46:2654-2660. [PMID: 37500716 DOI: 10.1038/s41440-023-01380-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 05/28/2023] [Accepted: 06/29/2023] [Indexed: 07/29/2023]
Abstract
Renal denervation (RDN) is currently confronted with the considerable heterogeneity of different post-procedural blood pressure responses. The challenges predominantly arise from not only the lack of selection of appropriate responders but also the absence of detection for the successful endpoints of intervention. In this paper, we summarize the significant characteristics of potentially appropriate hypertensive patients and propose a hopeful way to improve the accuracy of RDN, that is, the application of three-dimensional reconstruction technology combined with electrical renal nerve stimulation to guide the radiofrequency catheter ablation, which may promote the development of selective and accurate RDN in real-world clinical practice. This paper focuses on two current critical concerns of renal denervation (RDN): appropriate patient selection and the improvement in the accuracy of selective RDN. A hopeful way of accurate RDN may be the combination of 3D electroanatomic mapping systems for the renal artery with modified renal nerve stimulation (RNS) techniques and technology for appropriate hypertensive candidates.
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Affiliation(s)
- Xinyu Hu
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, No. 288 Tianwen Avenue, Nan'an District, Chongqing, China
- Department of Cardiology, Chongqing University Fuling Hospital, Chongqing, China
| | - Hao Zhou
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, No. 288 Tianwen Avenue, Nan'an District, Chongqing, China
- Chongqing Cardiac Arrhythmias Therapeutic Service Center, Chongqing, China
| | - Weijie Chen
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, No. 288 Tianwen Avenue, Nan'an District, Chongqing, China
- Chongqing Cardiac Arrhythmias Therapeutic Service Center, Chongqing, China
| | - Dan Li
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, No. 288 Tianwen Avenue, Nan'an District, Chongqing, China
- Chongqing Cardiac Arrhythmias Therapeutic Service Center, Chongqing, China
| | - Huaan Du
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, No. 288 Tianwen Avenue, Nan'an District, Chongqing, China
- Chongqing Cardiac Arrhythmias Therapeutic Service Center, Chongqing, China
| | - Tianli Xia
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, No. 288 Tianwen Avenue, Nan'an District, Chongqing, China
- Chongqing Cardiac Arrhythmias Therapeutic Service Center, Chongqing, China
| | - Yuehui Yin
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, No. 288 Tianwen Avenue, Nan'an District, Chongqing, China.
- Chongqing Cardiac Arrhythmias Therapeutic Service Center, Chongqing, China.
- Chongqing Key Laboratory of Arrhythmias, Chongqing, China.
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45
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Persu A, Stoenoiu MS, Maes F, Kreutz R, Mancia G, Kjeldsen SE. Late outcomes of renal denervation are more favourable than early ones: facts or fancies? Clin Kidney J 2023; 16:2357-2364. [PMID: 38046011 PMCID: PMC10689164 DOI: 10.1093/ckj/sfad231] [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: 04/23/2023] [Indexed: 12/05/2023] Open
Abstract
Following second-generation randomized trials, there is evidence that renal denervation (RDN) decreases blood pressure (BP), although to a lesser extent than suggested in the initial controlled and observational studies. The recent publication of the 36-month follow-up of the Symplicity HTN-3 trial has raised expectations, suggesting increasing, late benefits of the procedure, despite initially negative results. These findings come after those obtained at 36 months in the sham-controlled trial SPYRAL HTN-ON MED and in the Global Symplicity Registry. However, they are susceptible to biases inherent in observational studies (after unblinding for sham-control) and non-random, substantial attrition of treatment groups at 36 months, and used interpolation of missing BPs. More importantly, in SPYRAL HTN-ON MED and Symplicity HTN-3, long-term BP changes in patients from the initial RDN group were compared with those in a heterogeneous control group, including both control patients who did not benefit from RDN and patients who eventually crossed over to RDN. In crossover patients, the last BP before RDN was imputed to subsequent follow-up. In Symplicity HTN-3, this particular approach led to the claim of increasing long-term benefits of RDN. However, comparison of BP changes in patients from the RDN group and control patients who did not undergo RDN, without imputation of BPs from crossover patients, does not support this view. The good news is that despite the suggestion of sympathetic nerve regrowth after RDN in some animal models, there is no strong signal in favour of a decreasing effect of RDN over time, up to 24 or even 36 months. Still, current data do not support a long-term increase in the effect of RDN and the durability of RDN-related BP reduction remains to be formally demonstrated.
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Affiliation(s)
- Alexandre Persu
- Division of Cardiology, Cliniques Universitaires Saint-Luc Université Catholique de Louvain, Brussels, Belgium
- Pole of Cardiovascular Research, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
| | - Maria S Stoenoiu
- Department of Internal Medicine, Rheumatology, Cliniques Universitaires Saint-Luc, Institut de Recherche Expérimentale et Clinique, Université catholique de Louvain, Brussels, Belgium
| | - Frédéric Maes
- Division of Cardiology, Cliniques Universitaires Saint-Luc Université Catholique de Louvain, Brussels, Belgium
- Pole of Cardiovascular Research, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
| | - Reinhold Kreutz
- Charité – Universitätsmedizin Berlin, Institute of Clinical Pharmacology and Toxicology, Berlin, Germany
| | | | - Sverre E Kjeldsen
- Institute of Clinical Medicine, University of Oslo, Departments of Cardiology and Nephrology, Ullevaal Hospital, Oslo, Norway
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46
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Lobo MD, Rull G, Saxena M, Kapil V. Selecting patients for interventional procedures to treat hypertension. Blood Press 2023; 32:2248276. [PMID: 37665430 DOI: 10.1080/08037051.2023.2248276] [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: 06/20/2023] [Revised: 08/08/2023] [Accepted: 08/10/2023] [Indexed: 09/05/2023]
Abstract
Purpose: Interventional approaches to treat hypertension are an emerging option that may be suitable for patients whose BP control cannot be achieved with lifestyle and/or pharmacotherapy and possibly for those who do not wish to take drug therapy.Materials and Methods: Interventional strategies include renal denervation with radiofrequency, ultrasound and alcohol-mediated platforms as well as baroreflex activation therapy and cardiac neuromodulation therapy. Presently renal denervation is the most advanced of the therapeutic options and is currently being commercialised in the EU.Results: It is apparent that RDN is effective in both unmedicated patients and patients with more severe hypertension including those with resistant hypertension.Conclusion: However, at present there is no evidence for the use of RDN in patients with secondary forms of hypertension and thus evaluation to rule these out is necessary before proceeding with a procedure. Furthermore, there are numerous pitfalls in the diagnosis and management of secondary hypertension which need to be taken into consideration. Finally, prior to performing an intervention it is appropriate to document presence/absence of hypertension-mediated organ damage.
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Affiliation(s)
- Melvin D Lobo
- William Harvey Research Institute, Barts NIHR Biomedical Research Centre, Queen Mary University of London, London, UK
| | - Gurvinder Rull
- William Harvey Research Institute, Barts NIHR Biomedical Research Centre, Queen Mary University of London, London, UK
| | - Manish Saxena
- William Harvey Research Institute, Barts NIHR Biomedical Research Centre, Queen Mary University of London, London, UK
| | - Vikas Kapil
- William Harvey Research Institute, Barts NIHR Biomedical Research Centre, Queen Mary University of London, London, UK
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47
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Zeijen VJM, Theuns DA, Feyz L, Saville KA, Bhagwandien R, Kardys I, Van Mieghem NM, Daemen J. Long-term safety and efficacy of renal sympathetic denervation in atrial fibrillation: 3-year results of the AFFORD study. Clin Res Cardiol 2023; 112:1766-1777. [PMID: 37231258 PMCID: PMC10697905 DOI: 10.1007/s00392-023-02222-3] [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: 04/04/2023] [Accepted: 05/02/2023] [Indexed: 05/27/2023]
Abstract
BACKGROUND Atrial fibrillation (AF) is the most common sustained arrhythmia which has been associated with increased sympathetic nervous system activity and hypertension. Recent evidence indicated that renal sympathetic denervation (RDN) could safely contribute to an improvement in AF burden. OBJECTIVE To investigate the long-term safety and efficacy of radiofrequency RDN in hypertensive patients with symptomatic AF. METHODS This pilot study included patients with symptomatic paroxysmal or persistent AF (European Hearth Rhythm Association class ≥ II) despite optimal medical therapy, office systolic blood pressure (BP) ≥ 140 mmHg and ≥ 2 antihypertensive drugs. AF burden was measured using an implantable cardiac monitor (ICM), implanted 3 months prior to RDN. ICM interrogation and 24-h ambulatory BP monitoring were performed at baseline and at 3/6/12/24/36 months post RDN. The primary efficacy outcome was daily AF burden. Statistical analyses were performed using Poisson and negative binomial models. RESULTS A total of 20 patients with a median age [25th-75th percentiles] of 66.2 [61.2-70.8] years (55% female) were included. At baseline, office BP ± standard deviation (SD) was 153.8/87.5 ± 15.2/10.4 mmHg, while mean 24-h ambulatory BP was 129.5/77.3 ± 15.5/9.3 mmHg. Baseline daily AF burden was 1.4 [0.0-10.9] minutes/day and throughout a 3-year follow-up period, no significant change was observed (- 15.4%/year; 95% confidence interval (CI) - 50.2%, + 43.7%; p = 0.54). The number of defined daily doses of antiarrhythmic drugs and antihypertensive drugs remained stable over time, while mean 24-h ambulatory systolic BP decreased with - 2.2 (95% CI - 3.9, - 0.6; p = 0.01) mmHg/year. CONCLUSIONS In patients with hypertension and symptomatic AF, stand-alone RDN reduced BP but did not significantly reduce AF burden up until 3 years of follow-up.
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Affiliation(s)
- Victor J M Zeijen
- Department of Cardiology, Thorax Center, Erasmus University Medical Center, Room Rg-628, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Dominic A Theuns
- Department of Cardiology, Thorax Center, Erasmus University Medical Center, Room Rg-628, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Lida Feyz
- Department of Cardiology, Thorax Center, Erasmus University Medical Center, Room Rg-628, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Kari A Saville
- Department of Cardiology, Thorax Center, Erasmus University Medical Center, Room Rg-628, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Rohit Bhagwandien
- Department of Cardiology, Thorax Center, Erasmus University Medical Center, Room Rg-628, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Isabella Kardys
- Department of Cardiology, Thorax Center, Erasmus University Medical Center, Room Rg-628, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Nicolas M Van Mieghem
- Department of Cardiology, Thorax Center, Erasmus University Medical Center, Room Rg-628, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Joost Daemen
- Department of Cardiology, Thorax Center, Erasmus University Medical Center, Room Rg-628, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands.
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48
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Creegan D, McEvoy JW. Selected highlights in the updated treatment of hypertension. Trends Cardiovasc Med 2023:S1050-1738(23)00097-X. [PMID: 37981201 DOI: 10.1016/j.tcm.2023.11.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 10/30/2023] [Accepted: 11/11/2023] [Indexed: 11/21/2023]
Abstract
Hypertension remains the leading international risk factor for cardiovascular disease and premature death but, despite effective treatments, hypertension remains significantly underdiagnosed and undertreated. In the present review paper, we provide a selected update on recent developments of interest in the management of hypertension. We focus on summarizing four topics that we believe are worth highlighting to a clinical audience: (1) the evidence and strong motivation for new lower systolic BP treatment targets; (2) new studies reporting on the efficacy of renal denervation in the management of hypertension; (3) interesting new data to inform the great salt debate; and (4), perhaps most importantly, pioneering new work highlighting the huge potential of multi-disciplinary care in the management of hypertension.
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Affiliation(s)
- Daniel Creegan
- University Hospital Galway and SAOLTA University Health Care Group, Galway, Ireland; School of Medicine, University of Galway, Ireland
| | - John W McEvoy
- University Hospital Galway and SAOLTA University Health Care Group, Galway, Ireland; School of Medicine, University of Galway, Ireland; National Institute for Prevention and Cardiovascular Health, Moyola Lane, Galway, H91 FF68, Ireland; Johns Hopkins University School of Medicine and Bloomberg School of Public Health, Baltimore, MD, USA.
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49
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Kiuchi MG, Carnagarin R, Schultz C, Shetty S, Ward NC, Santos CE, Schlaich MP. Update on advanced interventional neuromodulatory approaches to lower blood pressure. Heart 2023; 109:1734-1740. [PMID: 37353317 DOI: 10.1136/heartjnl-2022-321499] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 06/01/2023] [Indexed: 06/25/2023] Open
Abstract
Herein, we review interventional peripheral neuromodulatory approaches to reduce blood pressure (BP), specifically focusing on catheter-based renal denervation (RDN), as well as the latest data from recent clinical trials underpinning its clinical use. Given the apparent failure of established lifestyle measures and pharmacologic BP-lowering approaches to improve hypertension (HTN) control rates, the past decade has seen remarkable scientific efforts to explore the utility of interventional strategies for BP management. Experimental studies and human clinical trials have demonstrated the crucial role of the sympathetic nervous system in the development and mainenance of HTN - consequently, most recent interventional technologies aimed primarily at modulating neural pathways. Advanced approaches that were rigorously tested in human studies include RDN, endovascular baroreflex amplification, baroreflex activation therapy and cardiac neuromodulation stimulation.Amongst these, RDN is by far the most established technology. With recent robust evidence from clinical trials and real-world data showing the safety and efficacy of both ultrasound and radiofrequency-based approaches, a recent clinical consensus statement of the European Society of Cardiology Council on Hypertension and the European Association of Percutaneous Cardiovascular Interventions concludes that RDN represents an ancillary therapeutic option in patients with uncontrolled resistant HTN confirmed by ambulatory blood pressure measurement and in spite of attention to lifestyle changes and optimised pharmacological treatment. Furthermore, RDN could alos be considered for patienst unlikley to adhere to or tolerate long-term antihypertensive drug treatment. Very recent data indicate long-term safety and efficacy up to 10 years. Appropriate implementation of RDN into clinical practice is now warranted.For all other interventions additional data from adequately designed human studies are required to establish their safety and clinical utility for potential future use in routine practice.
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Affiliation(s)
- Marcio Galindo Kiuchi
- Dobney Hypertension Centre, Medical School, The University of Western Australia, Perth, Western Australia, Australia
| | - Revathy Carnagarin
- Dobney Hypertension Centre, Medical School, The University of Western Australia, Perth, Western Australia, Australia
| | - Carl Schultz
- Department of Cardiology, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Sharad Shetty
- Department of Cardiology, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - Natalie C Ward
- Dobney Hypertension Centre, Medical School, The University of Western Australia, Perth, Western Australia, Australia
| | | | - Markus P Schlaich
- Dobney Hypertension Centre, Medical School, The University of Western Australia, Perth, Western Australia, Australia
- Department of Cardiology, Royal Perth Hospital, Perth, Western Australia, Australia
- Department of Nephrology, Royal Perth Hospital, Perth, Western Australia, Australia
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50
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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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