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Yılmaz F, Keleş M, Bora F. Relationship between the prognostic nutritional index and resistant hypertension in patients with essential hypertension. Clin Exp Hypertens 2022; 44:326-333. [PMID: 35180826 DOI: 10.1080/10641963.2022.2036995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVES Immune system activation plays a role in resistant hypertension (RHTN) pathogenesis. The clinical effect of the prognostic nutritional index (PNI) on patients with RHTN remains unclear. The aim of this study investigated the possible correlation between PNI and RHTN. METHODS In this cross-sectional study, we enrolled 180 adult subjects. In patients were classified into three groups according to their office and ambulatory blood pressure measurements (ABPM): RHTN (n = 60), controlled hypertension (CHTN, n = 60), and normotension-control (NT-C, n = 60). RHTN was defined as BP ≥140/90 mm Hg while taking ≥3 antihypertensive medications or BP <140/90 mm Hg while taking ≥4 medications. The PNI was calculated from the 10 x serum albumin (g/dL) + 0.005 x total lymphocyte count (/μL) formula. RESULTS Office and ABPM were significantly higher in patients with RHTN. Patients in the RHTN (46.1 ± 5.3) had significantly lower PNI than that in the CHTN (54.9 ± 6.7) (P = .032), and PNIs of both hypertensive groups were significantly lower than the NT-C group (P = .019, for both). The ROC curve analysis performed to assess the predictive value of PNI for RHTN and using 50.9 optimal cutoff value of PNI for RHTN gave a sensitivity of 77% and a specificity of 68.5% (AUC = 0.73, 95% CI 0.69-0.96).Multivariate analysis indicated diabetes, 24-h ABPM SBP, CRP, pill burden, and PNI (<51.6) as independent predictors of RHTN. CONCLUSION This study showed that the level of PNI was significantly lower in patients with RHTN compared to patients with CHTN. PNI is independently related to RHTN.
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Affiliation(s)
- Fatih Yılmaz
- Department of Nephrology, Antalya Atatürk State Hospital, Antalya, Turkey
| | - Meryem Keleş
- Department of Nephrology, Ankara City Hospital, Ankara, Turkey
| | - Feyza Bora
- Department of Internal Medicine, Division of Nephrology, Akdeniz University Medicine of Faculty, Antalya, Turkey
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2
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Molcan L. Telemetric data collection should be standard in modern experimental cardiovascular research. Physiol Behav 2021; 242:113620. [PMID: 34637804 DOI: 10.1016/j.physbeh.2021.113620] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 10/05/2021] [Accepted: 10/07/2021] [Indexed: 02/07/2023]
Abstract
Cardiovascular (CV) health is often expressed by changes in heart rate and blood pressure, the physiological record of which may be affected by moving, anaesthesia, handling, time of day and many other factors in rodents. Telemetry measurement minimises these modulations and enables more accurate physiological recording of heart rate and blood pressure than non-invasive methods. Measurement of arterial blood pressure by telemetry requires implanting a catheter tip into the artery. Telemetry enables us to sample physiological parameters with a high frequency continuously for several months. By measuring the pressure in the artery using telemetry, we can visualize pressure changes over a heart cycle as the pressure wave. From the pressure wave, we can subtract systolic, diastolic, mean and pulse pressure. From the beat-to-beat interval (pressure wave) and the RR' interval (electrocardiogram), we can derive the heart rate. From beat-to-beat variability, we can evaluate the autonomic nervous system's activity and spontaneous baroreflex sensitivity and their impact on CV activity. On a long-term scale, circadian variability of CV parameters is evident. Circadian variability is the result of the circadian system's activity, which synchronises and organises many activities in the body, such as autonomic and reflex modulation of the CV system and its response to load over the day. In the presented review, we aimed to discuss telemetry devices, their types, implantation, set-up, limitations, short-term and long-term variability of heart rate and blood pressure in CV research. Data collection by telemetry should be, despite some limitations, standard in modern experimental CV research.
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Affiliation(s)
- Lubos Molcan
- Department of Animal Physiology and Ethology, Faculty of Natural Sciences, Comenius University, Bratislava, Slovakia.
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3
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Kjeldsen SE, Narkiewicz K, Burnier M, Oparil S. The five RADIANCE-HTN and SPYRAL-HTN randomised studies suggest that the BP lowering effect of RDN corresponds to the effect of one antihypertensive drug. Blood Press 2021; 30:327-331. [PMID: 34714185 DOI: 10.1080/08037051.2021.1995975] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Sverre E Kjeldsen
- Departments of Cardiology and Nephrology, University of Oslo, Ullevaal Hospital, Oslo, Norway
| | - Krzysztof Narkiewicz
- Department of Hypertension and Diabetology, Medical University of Gdansk, Gdańsk, Poland
| | - Michel Burnier
- Service of Nephrology and Hypertension, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Suzanne Oparil
- Vascular Biology and Hypertension Program, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
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4
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Prevalence, Characteristics, and Association of Obstructive Sleep Apnea with Blood Pressure Control in Patients with Resistant Hypertension. Ann Am Thorac Soc 2019; 16:1414-1421. [DOI: 10.1513/annalsats.201901-053oc] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
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5
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Factors associated with the changes from a resistant to a refractory phenotype in hypertensive patients: a Pragmatic Longitudinal Study. Hypertens Res 2019; 42:1708-1715. [DOI: 10.1038/s41440-019-0285-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 04/26/2019] [Accepted: 05/15/2019] [Indexed: 12/28/2022]
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6
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Effect of continuous positive airway pressure in patients with true refractory hypertension and sleep apnea. J Hypertens 2019; 37:1269-1275. [DOI: 10.1097/hjh.0000000000002053] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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7
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Kjeldsen SE, Narkiewicz K, Burnier M, Oparil S. Renal denervation achieved by endovascular delivery of ultrasound in RADIANCE-HTN SOLO or by radiofrequency energy in SPYRAL HTN-OFF and SPYRAL-ON lowers blood pressure. Blood Press 2018; 27:185-187. [DOI: 10.1080/08037051.2018.1486178] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Sverre E. Kjeldsen
- Department of Cardiology, University of Oslo, Ullevaal Hospital, Oslo, Norway
| | - Krzysztof Narkiewicz
- Department of Hypertension and Diabetology, Medical University of Gdansk, Gdansk, Poland
| | - Michel Burnier
- Service of Nephrology and Hypertension, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Suzanne Oparil
- Vascular Biology and Hypertension Program, Department of Medicine, University of Alabama at Birmingham, AL, USA
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8
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Kjeldsen SE, Esler MD. Take a blood pressure pill or undergo renal denervation? Lancet 2018; 391:2298-2300. [PMID: 29803587 DOI: 10.1016/s0140-6736(18)31126-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2018] [Accepted: 05/16/2018] [Indexed: 11/28/2022]
Affiliation(s)
- Sverre E Kjeldsen
- Faculty of Medicine, University of Oslo, Oslo, Norway; Section for Cardiovascular and Renal Research and Department of Cardiology, Ullevaal University Hospital, Oslo N-0407, Norway.
| | - Murray D Esler
- Baker Heart and Diabetes Institute, Melbourne, VIC, Australia
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9
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The Use of Precision Medicine to Manage Obstructive Sleep Apnea Treatment in Patients with Resistant Hypertension: Current Evidence and Future Directions. Curr Hypertens Rep 2018; 20:60. [PMID: 29884918 DOI: 10.1007/s11906-018-0853-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW The significant prevalence of resistant hypertension (RH) and the high cardiovascular risk of the population of patients with RH have indicated the necessity to identify its main causes. Among these, obstructive sleep apnea (OSA) is considered the most well-established cause. RECENT FINDINGS In recent years, several studies have shown a beneficial effect of continuous positive airway pressure (CPAP) treatment on blood pressure (BP), but this effect exhibits great variability. The diagnosis and management of OSA in patients with RH suggest a clinical option for a phenotype of patients for whom therapeutic strategies are limited to pharmaceutical therapy and renal denervation. However, the great variability in the CPAP response has increased the necessity to develop instruments to identify patients who could benefit from a treatment that reduces BP. Application of precision medicine to these patients should be considered as a first-line intervention to avoid the prescription of ineffective treatments and excessive consumption of pharmacological drugs that do not ameliorate the cardiovascular risk.
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10
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Kinsara AJ. Ambulatory blood pressure monitoring in daily practice. Indian Heart J 2017; 69:788-789. [PMID: 29174260 PMCID: PMC5717310 DOI: 10.1016/j.ihj.2017.09.223] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Revised: 08/24/2017] [Accepted: 09/29/2017] [Indexed: 11/17/2022] Open
Abstract
Ambulatory blood pressure monitoring is a useful diagnostic tool that still underutilized by community physicians. It is a cost effective, diagnostic and prognostic tool that had been emphasized by the guidelines.
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Affiliation(s)
- Abdulhalim Jamal Kinsara
- King Saud bin Abdulaziz University for Health Sciences, COM-J, King Abdul Aziz Medical City-WR, King Faisal Cardiac Center, Mail Code 6599, P.O. Box 9515, Jeddah 21423, Saudi Arabia.
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11
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12
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Prognostic Importance of Ambulatory Blood Pressure Monitoring in Resistant Hypertension: Is It All that Matters? Curr Hypertens Rep 2016; 18:85. [DOI: 10.1007/s11906-016-0693-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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13
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Taddei S, Maria Bruno R. Resistant Hypertension: A Real Entity Requiring Special Treatment? Eur Cardiol 2016; 11:8-11. [PMID: 30310440 DOI: 10.15420/ecr.2016.11.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Resistant hypertension (RH) was defined many years ago as a clinical situation in which blood pressure remains uncontrolled despite concomitant intake of at least three antihypertensive drugs (one of them preferably being a diuretic) at full doses. This operative definition was aimed at identifying a subset of hypertensive patients requiring a more extensive clinical workup in order to achieve an adequate blood pressure control. An oversimplification of this picture led to consider RH as a separate clinical entity requiring special, expensive treatments, such as renal denervation and baroreceptor activating therapy. In this review we will discuss the utility and the shortcomings of the definition of RH and the possible consequences for treatment.
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Affiliation(s)
| | - Rosa Maria Bruno
- University of Pisa, Pisa, Italy.,Institute of Clinical Physiology - CNR, Pisa, Italy
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14
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Komori T, Eguchi K, Kario K. The measurement of orthostatic blood pressure as a screening tool for masked hypertension with abnormal circadian blood pressure rhythm. Hypertens Res 2016; 39:631-2. [DOI: 10.1038/hr.2016.70] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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15
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Erne P, Sudano I, Resink TJ, Lüscher TF. Interventional therapy for hypertension: Back on track again? Crit Rev Clin Lab Sci 2016; 54:18-25. [PMID: 27282628 DOI: 10.1080/10408363.2016.1194367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Treatment-resistant hypertension, or resistant hypertension, is defined as blood pressure that remains above target despite concurrent use of at least three antihypertensive agents from different classes at optimal doses, one of which should be a diuretic. Important considerations in the diagnosis of treatment-resistant hypertension include the exclusion of pseudoresistance and the evaluation of potential secondary causes of hypertension and of concomitant conditions that maintain high blood pressure. The ability to diagnose true treatment-resistant hypertension is important for selection of patients who may be appropriately treated with an invasive therapy. Currently, there are three interventional approaches to treat resistant hypertension, namely: (1) reduction of the activity of the sympathetic nervous system by renal nerve ablation, (2) stimulation of baroreceptors and (3) creation of a peripheral arterial venous anastomosis. This review focuses on the rationale behind these invasive approaches and the clinical results.
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Affiliation(s)
- Paul Erne
- a Department of Biomedicine , Basel University Hospital , Basel , Switzerland and
| | - Isabella Sudano
- b Cardiology, University Heart Center, University Hospital Zurich , Zurich , Switzerland
| | - Therese J Resink
- a Department of Biomedicine , Basel University Hospital , Basel , Switzerland and
| | - Thomas F Lüscher
- b Cardiology, University Heart Center, University Hospital Zurich , Zurich , Switzerland
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16
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Kishi T. What is the benefit of renal denervation? Hypertens Res 2016; 39:201-2. [PMID: 26763847 DOI: 10.1038/hr.2015.150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Takuya Kishi
- Collaborative Research Institute of Innovation for Cardiovascular Diseases, Kyushu University Center for Disruptive Cardiovascular Medicine, Fukuoka, Japan
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17
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Renal Denervation for Treatment of Hypertension: a Second Start and New Challenges. Curr Hypertens Rep 2016; 18:6. [DOI: 10.1007/s11906-015-0610-9] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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18
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Hamrahian SM, Falkner B. Hypertension in Chronic Kidney Disease. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2016; 956:307-325. [PMID: 27873228 DOI: 10.1007/5584_2016_84] [Citation(s) in RCA: 97] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Hypertension, a global public health problem, is currently the leading factor in the global burden of disease. It is the major modifiable risk factor for heart disease, stroke and kidney failure. Chronic kidney disease (CKD) is both a common cause of hypertension and CKD is also a complication of uncontrolled hypertension. The interaction between hypertension and CKD is complex and increases the risk of adverse cardiovascular and cerebrovascular outcomes. This is particularly significant in the setting of resistant hypertension commonly seen in patient with CKD. The pathophysiology of CKD associated hypertension is multi-factorial with different mechanisms contributing to hypertension. These pathogenic mechanisms include sodium dysregulation, increased sympathetic nervous system and alterations in renin angiotensin aldosterone system activity. Standardized blood pressure (BP) measurement is essential in establishing the diagnosis and management of hypertension in CKD. Use of ambulatory blood pressure monitoring provides an additional assessment of diurnal variation in BP commonly seen in CKD patients. The optimal BP target in the treatment of hypertension in general and CKD population remains a matter of debate and controversial despite recent guidelines and clinical trial data. Medical therapy of patients with CKD associated hypertension can be difficult and challenging. Additional evaluation by a hypertension specialist may be required in the setting of treatment resistant hypertension by excluding pseudo-resistance and treatable secondary causes. Treatment with a combination of antihypertensive drugs, including appropriate diuretic choice, based on estimated glomerular filtration rate, is a key component of hypertension management in CKD patients. In addition to drug treatment non-pharmacological approaches including life style modification, most important of which is dietary salt restriction, should be included in the management of hypertension in CKD patients.
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Affiliation(s)
- Seyed Mehrdad Hamrahian
- Division of Nephrology, Department of Medicine, Sidney Kimmel School of Medicine, Thomas Jefferson University, 833 Chestnut Street, Suite 700, Philadelphia, PA, 19107, USA.
| | - Bonita Falkner
- Division of Nephrology, Department of Medicine, Sidney Kimmel School of Medicine, Thomas Jefferson University, 833 Chestnut Street, Suite 700, Philadelphia, PA, 19107, USA
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Fatemi O, Goa C, Faselis C, Kokkinos P, Papademetriou V. Improvement in All-Cause Mortality With Blood Pressure Control in a Group of US Veterans With Drug-Resistant Hypertension. J Clin Hypertens (Greenwich) 2015; 18:33-9. [DOI: 10.1111/jch.12672] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Revised: 07/01/2015] [Accepted: 07/05/2015] [Indexed: 01/13/2023]
Affiliation(s)
- Omid Fatemi
- George Washington University Hospital; Washington DC
- Georgetown University Hospital; Washington DC
- Veterans Affairs Medical Center; Washington DC
- Washington Hospital Center; Washington DC
| | - Cristobal Goa
- Georgetown University Hospital; Washington DC
- Veterans Affairs Medical Center; Washington DC
- Washington Hospital Center; Washington DC
| | - Charles Faselis
- Veterans Affairs Medical Center; Washington DC
- George Washington University School of Medicine; Washington DC
| | - Peter Kokkinos
- Veterans Affairs Medical Center; Washington DC
- George Washington University School of Medicine; Washington DC
- Georgetown University School of Medicine; Washington DC
| | - Vasilios Papademetriou
- Georgetown University Hospital; Washington DC
- Washington DC VA Medical Center; Washington DC
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20
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Rimoldi SF, Messerli FH, Bangalore S, Scherrer U. Resistant hypertension: what the cardiologist needs to know. Eur Heart J 2015; 36:2686-95. [PMID: 26261296 DOI: 10.1093/eurheartj/ehv392] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Accepted: 07/27/2015] [Indexed: 12/23/2022] Open
Abstract
Treatment-resistant hypertension (TRH) affects between 3 and 30% of hypertensive patients, and its presence is associated with increased cardiovascular morbidity and mortality. Until recently, the interest on these patients has been limited, because providing care for them is difficult and often frustrating. However, the arrival of new treatment options [i.e. catheter-based renal denervation (RDN) and baroreceptor stimulation] has revitalized the interest in this topic. The very promising results of the initial uncontrolled studies on the blood pressure (BP)-lowering effect of RDN in TRH seemed to suggest that this intervention might represent an easy solution for a complex problem. However, subsequently, data from controlled studies have tempered the enthusiasm of the medical community (and the industry). Conversely, these new studies emphasized some seminal aspects on this topic: (i) the key role of 24 h ambulatory BP and arterial stiffness measurement to identify 'true' resistant patients; (ii) the high prevalence of secondary hypertension among this population; and (iii) the difficulty to identify those patients who may profit from device-based interventions. Accordingly, for those patients with documented TRH, the guidelines suggest to refer them to a hypertension specialist/centre in order to perform adequate work-up and treatment strategies. The aim of this review is to provide guidance for the cardiologist on how to identify patients with TRH and elucidate the prevailing underlying pathophysiological mechanism(s), to define a strategy for the identification of patients with TRH who may benefit from device-based interventions and discuss results and limitations of these interventions, and finally to briefly summarize the different drug-based treatment strategies.
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Affiliation(s)
- Stefano F Rimoldi
- Department of Cardiology and Clinical Research, University Hospital, Bern, Switzerland
| | - Franz H Messerli
- Department of Cardiology and Clinical Research, University Hospital, Bern, Switzerland Division of Cardiology, St Luke's-Roosevelt Hospital Center, New York, NY, USA
| | - Sripal Bangalore
- Division of Cardiology, St Luke's-Roosevelt Hospital Center, New York, NY, USA
| | - Urs Scherrer
- Department of Cardiology and Clinical Research, University Hospital, Bern, Switzerland Facultad de Ciencias, Departamento de Biología, Universidad de Tarapacá, Arica, Chile
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The Setback of Renal Denervation Should Not Backfire on Sympathetic Overactivity in Hypertension ∗. J Am Coll Cardiol 2015; 65:1322-1323. [DOI: 10.1016/j.jacc.2015.01.038] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Accepted: 01/25/2015] [Indexed: 11/30/2022]
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22
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Design of renal denervation studies not confounded by antihypertensive drugs. ACTA ACUST UNITED AC 2015; 9:337-40. [PMID: 25863572 DOI: 10.1016/j.jash.2015.02.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Revised: 02/18/2015] [Accepted: 02/19/2015] [Indexed: 12/14/2022]
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Abstract
After three years of excessive confidence, overoptimistic expectations and performance of 15 to 20,000 renal denervation procedures in Europe, the failure of a single well-designed US trial—Symplicity HTN-3—to meet its primary efficacy endpoint has cast doubt on renal denervation as a whole. The use of a sound methodology, including randomisation and blinded endpoint assessment was enough to see the typical 25–30 mmHg systolic blood pressure decrease observed after renal denervation melt down to less than 3 mmHg, the rest being likely explained by Hawthorne and placebo effects, attenuation of white coat effect, regression to the mean and other physician and patient-related biases. The modest blood pressure benefit directly assignable to renal denervation should be balanced with unresolved safety issues, such as potentially increased risk of renal artery stenosis after the procedure (more than ten cases reported up to now, most of them in 2014), unclear long-term impact on renal function and lack of morbidity–mortality data. Accordingly, there is no doubt that renal denervation is not ready for clinical use. Still, renal denervation is supported by a strong rationale and is occasionally followed by major blood pressure responses in at-risk patients who may otherwise have remained uncontrolled. Upcoming research programmes should focus on identification of those few patients with truly resistant hypertension who may derive a substantial benefit from the technique, within the context of well-designed randomised trials and independent registries. While electrical stimulation of baroreceptors and other interventional treatments of hypertension are already “knocking at the door”, the premature and uncontrolled dissemination of renal denervation should remain an example of what should not be done, and trigger radical changes in evaluation processes of new devices by national and European health authorities.
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Fadl Elmula FEM, Larstorp AC, Kjeldsen SE, Persu A, Jin Y, Staessen JA. Renal sympathetic denervation after Symplicity HTN-3 and therapeutic drug monitoring in severe hypertension. Front Physiol 2015; 6:9. [PMID: 25709581 PMCID: PMC4321349 DOI: 10.3389/fphys.2015.00009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2014] [Accepted: 01/08/2015] [Indexed: 12/01/2022] Open
Abstract
Renal sympathetic denervation (RDN) has been and is still proposed as a new treatment modality in patients with apparently treatment resistant hypertension (TRH), a condition defined as persistent blood pressure elevation despite prescription of at least 3 antihypertensive drugs including a diuretic. However, the large fall in blood pressure after RDN reported in the first randomized study, Symplicity HTN-2 and multiple observational studies has not been confirmed in five subsequent prospective randomized studies and may be largely explained by non-specific effects such as improvement of drug adherence in initially poorly adherent patients (the Hawthorne effect), placebo effect and regression to the mean. The overall blood-pressure lowering effect of RDN seems rather limited and the characteristics of true responders are largely unknown. Accordingly, RDN is not ready for clinical practice. In most patients with apparently TRH, drug monitoring and improvement of drug adherence may prove more effective and cost-beneficial to achieve blood pressure control. In the meantime, research should aim at identifying characteristics of those patients with truly TRH who may respond to RDN.
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Affiliation(s)
- Fadl Elmula M Fadl Elmula
- Departments of Cardiology and Internal Medicine, Oslo University Hospital Ullevaal, Norway ; Faculty of Medicine, University of Oslo Oslo, Norway
| | - Anne C Larstorp
- Departments of Cardiology and Internal Medicine, Oslo University Hospital Ullevaal, Norway ; Faculty of Medicine, University of Oslo Oslo, Norway
| | - Sverre E Kjeldsen
- Departments of Cardiology and Internal Medicine, Oslo University Hospital Ullevaal, Norway ; Faculty of Medicine, University of Oslo Oslo, Norway
| | - Alexandre Persu
- Pole of Cardiovascular Research, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain Brussels, Belgium ; Division of Cardiology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain Brussels, Belgium
| | - Yu Jin
- Studies Coordinating Centre, Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven Department of Cardiovascular Sciences, University of Leuven Leuven, Belgium
| | - Jan A Staessen
- Studies Coordinating Centre, Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven Department of Cardiovascular Sciences, University of Leuven Leuven, Belgium ; VitaK Development and Research, Maastricht University Maastricht, Netherlands
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Kjeldsen SE, Fadl Elmula FEM, Os I, Persu A, Jin Y, Staessen JA. Renal sympathetic denervation after Symplicity HTN-3 and therapeutic drug monitoring in patients with resistant hypertension to improve patients' adherence. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2015; 1:48-56. [DOI: 10.1093/ehjcvp/pvu009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/07/2014] [Accepted: 09/27/2014] [Indexed: 12/26/2022]
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Persu A, Fadl Elmula FEM, Jin Y, Os I, Kjeldsen SE, Staessen JA. Renal Denervation After Symplicity HTN-3 - Back to Basics. Review of the Evidence. Eur Cardiol 2014; 9:110-114. [PMID: 30310496 PMCID: PMC6159409 DOI: 10.15420/ecr.2014.9.2.110] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2014] [Accepted: 11/09/2014] [Indexed: 12/31/2022] Open
Abstract
Renal sympathetic denervation (RDN) has been proposed as a new treatment modality in patients with apparent treatment resistant hypertension, a condition defined as office blood pressure elevation despite prescription of at least three antihypertensive drugs including a diuretic. However, the impressive fall in blood pressure reported after RDN in Symplicity HTN-2, the first randomised study, and multiple observational studies has not been confirmed in the US sham-controlled trial Symplicity HTN-3 and four subsequent prospective randomised studies, all published or presented in 2014. The blood pressure reduction documented in earlier studies may be largely due to non-specific effects such as improvement of drug adherence in initially poorly adherent patients (Hawthorne effect), placebo effect and regression to the mean. The overall blood pressure lowering effect of RDN seems rather limited and the characteristics of true responders remain largely unknown. Accordingly, RDN is not ready for clinical practice. In most patients with apparent drug-resistant hypertension, drug monitoring and subsequent improvement of drug adherence may prove more effective and cost-beneficial to achieve blood pressure control. In the meantime, research should aim at identifying characteristics of those few patients adherent to drug treatment and with true resistant hypertension who may respond to RDN.
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Affiliation(s)
- Alexandre Persu
- Pole of Cardiovascular Research, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
- Division of Cardiology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Fadl Elmula M Fadl Elmula
- Departments of General Internal Medicine, Cardiology and Nephrology, Ullevaal University Hospital
- Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Yu Jin
- Studies Coordinating Centre, Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - Ingrid Os
- Departments of General Internal Medicine, Cardiology and Nephrology, Ullevaal University Hospital
- Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Sverre E Kjeldsen
- Departments of General Internal Medicine, Cardiology and Nephrology, Ullevaal University Hospital
- Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Jan A Staessen
- Studies Coordinating Centre, Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
- Vitak Development and Research, Maastricht University, Maastricht, The Netherlands
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