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Pisano A, Iannone LF, Leo A, Russo E, Coppolino G, Bolignano D. Renal denervation for resistant hypertension. Cochrane Database Syst Rev 2021; 11:CD011499. [PMID: 34806762 PMCID: PMC8607757 DOI: 10.1002/14651858.cd011499.pub3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Resistant hypertension is highly prevalent among the general hypertensive population and the clinical management of this condition remains problematic. Different approaches, including a more intensified antihypertensive therapy, lifestyle modifications or both, have largely failed to improve patients' outcomes and to reduce cardiovascular and renal risk. As renal sympathetic hyperactivity is a major driver of resistant hypertension, in the last decade renal sympathetic ablation (renal denervation) has been proposed as a possible therapeutic alternative to treat this condition. OBJECTIVES We sought to evaluate the short- and long-term effects of renal denervation in individuals with resistant hypertension on clinical end points, including fatal and non-fatal cardiovascular events, all-cause mortality, hospital admissions, quality of life, blood pressure control, left ventricular hypertrophy, cardiovascular and metabolic profile and kidney function, as well as the potential adverse events related to the procedure. SEARCH METHODS For this updated review, the Cochrane Hypertension Information Specialist searched the following databases for randomised controlled trials up to 3 November 2020: Cochrane Hypertension's Specialised Register, CENTRAL (2020, Issue 11), Ovid MEDLINE, and Ovid Embase. The World Health Organization International Clinical Trials Registry Platform (via CENTRAL) and the US National Institutes of Health Ongoing Trials Register ClinicalTrials.gov were searched for ongoing trials. We also contacted authors of relevant papers regarding further published and unpublished work. The searches had no language restrictions. SELECTION CRITERIA We considered randomised controlled trials (RCTs) that compared renal denervation to standard therapy or sham procedure to treat resistant hypertension, without language restriction. DATA COLLECTION AND ANALYSIS Two authors independently extracted data and assessed study risk of bias. We summarised treatment effects on available clinical outcomes and adverse events using random-effects meta-analyses. We assessed heterogeneity in estimated treatment effects using Chi² and I² statistics. We calculated summary treatment estimates as a mean difference (MD) or standardised mean difference (SMD) for continuous outcomes, and a risk ratio (RR) for dichotomous outcomes, together with their 95% confidence intervals (CI). Certainty of evidence has been assessed using the GRADE approach. MAIN RESULTS We found 15 eligible studies (1416 participants). In four studies, renal denervation was compared to sham procedure; in the remaining studies, renal denervation was tested against standard or intensified antihypertensive therapy. Most studies had unclear or high risk of bias for allocation concealment and blinding. When compared to control, there was low-certainty evidence that renal denervation had little or no effect on the risk of myocardial infarction (4 studies, 742 participants; RR 1.31, 95% CI 0.45 to 3.84), ischaemic stroke (5 studies, 892 participants; RR 0.98, 95% CI 0.33 to 2.95), unstable angina (3 studies, 270 participants; RR 0.51, 95% CI 0.09 to 2.89) or hospitalisation (3 studies, 743 participants; RR 1.24, 95% CI 0.50 to 3.11). Based on moderate-certainty evidence, renal denervation may reduce 24-hour ambulatory blood pressure monitoring (ABPM) systolic BP (9 studies, 1045 participants; MD -5.29 mmHg, 95% CI -10.46 to -0.13), ABPM diastolic BP (8 studies, 1004 participants; MD -3.75 mmHg, 95% CI -7.10 to -0.39) and office diastolic BP (8 studies, 1049 participants; MD -4.61 mmHg, 95% CI -8.23 to -0.99). Conversely, this procedure had little or no effect on office systolic BP (10 studies, 1090 participants; MD -5.92 mmHg, 95% CI -12.94 to 1.10). Moderate-certainty evidence suggested that renal denervation may not reduce serum creatinine (5 studies, 721 participants, MD 0.03 mg/dL, 95% CI -0.06 to 0.13) and may not increase the estimated glomerular filtration rate (eGFR) or creatinine clearance (6 studies, 822 participants; MD -2.56 mL/min, 95% CI -7.53 to 2.42). AUTHORS' CONCLUSIONS: In patients with resistant hypertension, there is low-certainty evidence that renal denervation does not improve major cardiovascular outomes and renal function. Conversely, moderate-certainty evidence exists that it may improve 24h ABPM and diastolic office-measured BP. Future trials measuring patient-centred instead of surrogate outcomes, with longer follow-up periods, larger sample size and more standardised procedural methods are necessary to clarify the utility of this procedure in this population.
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Affiliation(s)
- Anna Pisano
- Institute of Clinical Physiology, CNR - Italian National Council of Research, Reggio Calabria, Italy
| | | | - Antonio Leo
- Department of Health Sciences, Magna Graecia University of Catanzaro, Catanzaro, Italy
| | - Emilio Russo
- Department of Health Sciences, Magna Graecia University of Catanzaro, Catanzaro, Italy
| | - Giuseppe Coppolino
- Department of Health Sciences, Magna Graecia University of Catanzaro, Catanzaro, Italy
| | - Davide Bolignano
- Department of Medical and Surgical Sciences, Magna Graecia University of Catanzaro, Catanzaro, Italy
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Kvasnička J, Lambert L, Waldauf P, Zelinka T, Petrák O, Štrauch B, Holaj R, Indra T, Krátká Z, Klímová J, Václavík J, Kociánová E, Nykl I, Jiravský O, Rappová G, Táborský M, Branny M, Widimský J, Rosa J. (Prediction of long-term renal denervation efficacy). COR ET VASA 2019. [DOI: 10.1016/j.crvasa.2018.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Hameed MA, Dasgupta I. Medication adherence and treatment-resistant hypertension: a review. Drugs Context 2019; 8:212560. [PMID: 30774692 PMCID: PMC6365088 DOI: 10.7573/dic.212560] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Revised: 12/28/2018] [Accepted: 01/02/2019] [Indexed: 12/11/2022] Open
Abstract
Nonadherence is a common reason for treatment failure and treatment resistance. No matter how it is defined, it is a major issue in the management of chronic illnesses. There are numerous methods to assess adherence, each with its own strengths and weaknesses; however, no single method is considered the best. Nonadherence is common in patients with hypertension, and it is present in a large proportion of patients with uncontrolled blood pressure taking three or more antihypertensive agents. Availability of procedure-based treatment options for these patients has shed further light on this important issue with development of new methods to assess adherence. There is, however, no consensus on the management of nonadherence, which reflects the complex interplay of factors responsible for it.
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Affiliation(s)
- Mohammed Awais Hameed
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK.,University Hospitals Birmingham NHS Foundation Trust, Birmingham Heartlands Hospital, Birmingham, UK
| | - Indranil Dasgupta
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK.,University Hospitals Birmingham NHS Foundation Trust, Birmingham Heartlands Hospital, Birmingham, UK
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Medication adherence among patients with apparent treatment-resistant hypertension: systematic review and meta-analysis. J Hypertens 2018; 35:2346-2357. [PMID: 28777133 DOI: 10.1097/hjh.0000000000001502] [Citation(s) in RCA: 113] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVES Medication nonadherence is a known behavioural contributor to poor blood pressure (BP) control that puts patients with hypertension at elevated cardiovascular risk. Studies of medication adherence for apparent treatment-resistant hypertension (aTRH) vary significantly with respect to design, methods, and setting, and, as a result, have produced highly variable figures describing the prevalence of nonadherence. This review aimed to describe the prevalence and potential moderators of medication nonadherence estimates for aTRH. METHODS Systematic review and random effects meta-analysis. RESULTS From an initial discovery of 921 studies, we identified 24 studies that measured medication adherence for patients with uncontrolled BP despite being prescribed three or more antihypertensive medications of different classes. By using a random effects model, the pooled prevalence of nonadherence was 31.2% (95% confidence interval = 20.2-44.7, I = 99.50) with nonadherence rates ranging from 3.3 to 86.1%. The strongest contributor to variance in nonadherence rates was the method of adherence assessment used. Studies that relied on self-report measures of adherence and/or pharmacy data reported lower levels of nonadherence than studies using more objective methods, such as liquid chromatography-mass spectrometry in single time-point bioassays or directly observed therapy. CONCLUSION Findings indicate that medication nonadherence is a significant problem among aTRH patients. Identifying the most accurate and clinically feasible adherence assessment methods is necessary to reduce BP and cardiovascular morbidity, facilitate early behavioural intervention, prevent unnecessary diagnostic testing, and limit sometimes unnecessary and expensive BP lowering procedures. REGISTRATION NUMBER CRD42016028121.
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Rodina TA, Mel’nikov ES, Dmitriev AI, Belkov SA, Sokolov AV, Arkhipov VV, Prokof’ev AB. Simultaneous Determination of Metoprolol and Bisoprolol in Human Serum by HPLC-MS/MS for Clinical Drug Monitoring. Pharm Chem J 2018. [DOI: 10.1007/s11094-018-1750-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Gupta P, Patel P, Štrauch B, Lai FY, Akbarov A, Gulsin GS, Beech A, Marešová V, Topham PS, Stanley A, Thurston H, Smith PR, Horne R, Widimský J, Keavney B, Heagerty A, Samani NJ, Williams B, Tomaszewski M. Biochemical Screening for Nonadherence Is Associated With Blood Pressure Reduction and Improvement in Adherence. Hypertension 2017; 70:1042-1048. [PMID: 28847892 PMCID: PMC5642335 DOI: 10.1161/hypertensionaha.117.09631] [Citation(s) in RCA: 112] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Revised: 05/10/2017] [Accepted: 07/17/2017] [Indexed: 12/24/2022]
Abstract
We hypothesized that screening for nonadherence to antihypertensive treatment using liquid chromatography-tandem mass spectrometry-based biochemical analysis of urine/serum has therapeutic applications in nonadherent hypertensive patients. A retrospective analysis of hypertensive patients attending specialist tertiary care centers was conducted in 2 European countries (United Kingdom and Czech Republic). Nonadherence to antihypertensive treatment was diagnosed using biochemical analysis of urine (United Kingdom) or serum (Czech Republic). These results were subsequently discussed with each patient, and data on follow-up clinic blood pressure (BP) measurements were collected from clinical files. Of 238 UK patients who underwent biochemical urine analysis, 73 were nonadherent to antihypertensive treatment. Their initial urinary adherence ratio (the ratio of detected to prescribed antihypertensive medications) increased from 0.33 (0-0.67) to 1 (0.67-1) between the first and the last clinic appointments. The observed increase in the urinary adherence ratio in initially nonadherent UK patients was associated with the improved BP control; by the last clinic appointment, systolic and diastolic BPs were ≈19.5 and 7.5 mm Hg lower than at baseline (P=0.001 and 0.009, respectively). These findings were further corroborated in 93 nonadherent hypertensive patients from Czech Republic-their average systolic and diastolic BPs dropped by ≈32.6 and 17.4 mm Hg, respectively (P<0.001), on appointments after the biochemical analysis. Our data show that nonadherent hypertensive patients respond to liquid chromatography-tandem mass spectrometry-based biochemical analysis with improved adherence and significant BP drop. Such repeated biochemical analyses should be considered as a therapeutic approach in nonadherent hypertensive patients.
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Affiliation(s)
- Pankaj Gupta
- From the Department of Metabolic Medicine and Chemical Pathology, University Hospitals of Leicester NHS Trust, United Kingdom (P.G., P.P., G.S.G., P.R.S.); Department of Cardiovascular Sciences, University of Leicester, United Kingdom (P.G., P.P., F.Y.L., G.S.G., N.J.S.); National Institute for Health Research Leicester Cardiovascular Biomedical Research Unit, United Kingdom (P.G., P.P., F.Y.L., N.J.S.); Division of Cardiovascular Sciences, Faculty of Biology, Medicine, and Health, University of Manchester, United Kingdom (P.G., A.A., B.K., A.H., M.T.); 3rd Department of Medicine, Department of Endocrinology and Metabolism, Hypertension Centre (B.S., J.W.) and Institute of Forensic Medicine and Toxicology (V.M.), General University Hospital, Charles University, Prague, Czech Republic; University of Leicester, United Kingdom (A.B.); University Hospitals of Leicester NHS Trust, United Kingdom (P.S.T., A.S., H.T.); Department of Health Psychology, University College of London, United Kingdom (R.H.); Division of Medicine, Central Manchester NHS Foundation Trust, Manchester Academic Health Science Centre, United Kingdom (B.K., A.H., M.T.); Institute of Cardiovascular Science, University College London, United Kingdom (B.W.); and National Institute for Health Research, University College London Hospitals Biomedical Research Centre, United Kingdom (B.W.)
| | - Prashanth Patel
- From the Department of Metabolic Medicine and Chemical Pathology, University Hospitals of Leicester NHS Trust, United Kingdom (P.G., P.P., G.S.G., P.R.S.); Department of Cardiovascular Sciences, University of Leicester, United Kingdom (P.G., P.P., F.Y.L., G.S.G., N.J.S.); National Institute for Health Research Leicester Cardiovascular Biomedical Research Unit, United Kingdom (P.G., P.P., F.Y.L., N.J.S.); Division of Cardiovascular Sciences, Faculty of Biology, Medicine, and Health, University of Manchester, United Kingdom (P.G., A.A., B.K., A.H., M.T.); 3rd Department of Medicine, Department of Endocrinology and Metabolism, Hypertension Centre (B.S., J.W.) and Institute of Forensic Medicine and Toxicology (V.M.), General University Hospital, Charles University, Prague, Czech Republic; University of Leicester, United Kingdom (A.B.); University Hospitals of Leicester NHS Trust, United Kingdom (P.S.T., A.S., H.T.); Department of Health Psychology, University College of London, United Kingdom (R.H.); Division of Medicine, Central Manchester NHS Foundation Trust, Manchester Academic Health Science Centre, United Kingdom (B.K., A.H., M.T.); Institute of Cardiovascular Science, University College London, United Kingdom (B.W.); and National Institute for Health Research, University College London Hospitals Biomedical Research Centre, United Kingdom (B.W.)
| | - Branislav Štrauch
- From the Department of Metabolic Medicine and Chemical Pathology, University Hospitals of Leicester NHS Trust, United Kingdom (P.G., P.P., G.S.G., P.R.S.); Department of Cardiovascular Sciences, University of Leicester, United Kingdom (P.G., P.P., F.Y.L., G.S.G., N.J.S.); National Institute for Health Research Leicester Cardiovascular Biomedical Research Unit, United Kingdom (P.G., P.P., F.Y.L., N.J.S.); Division of Cardiovascular Sciences, Faculty of Biology, Medicine, and Health, University of Manchester, United Kingdom (P.G., A.A., B.K., A.H., M.T.); 3rd Department of Medicine, Department of Endocrinology and Metabolism, Hypertension Centre (B.S., J.W.) and Institute of Forensic Medicine and Toxicology (V.M.), General University Hospital, Charles University, Prague, Czech Republic; University of Leicester, United Kingdom (A.B.); University Hospitals of Leicester NHS Trust, United Kingdom (P.S.T., A.S., H.T.); Department of Health Psychology, University College of London, United Kingdom (R.H.); Division of Medicine, Central Manchester NHS Foundation Trust, Manchester Academic Health Science Centre, United Kingdom (B.K., A.H., M.T.); Institute of Cardiovascular Science, University College London, United Kingdom (B.W.); and National Institute for Health Research, University College London Hospitals Biomedical Research Centre, United Kingdom (B.W.)
| | - Florence Y Lai
- From the Department of Metabolic Medicine and Chemical Pathology, University Hospitals of Leicester NHS Trust, United Kingdom (P.G., P.P., G.S.G., P.R.S.); Department of Cardiovascular Sciences, University of Leicester, United Kingdom (P.G., P.P., F.Y.L., G.S.G., N.J.S.); National Institute for Health Research Leicester Cardiovascular Biomedical Research Unit, United Kingdom (P.G., P.P., F.Y.L., N.J.S.); Division of Cardiovascular Sciences, Faculty of Biology, Medicine, and Health, University of Manchester, United Kingdom (P.G., A.A., B.K., A.H., M.T.); 3rd Department of Medicine, Department of Endocrinology and Metabolism, Hypertension Centre (B.S., J.W.) and Institute of Forensic Medicine and Toxicology (V.M.), General University Hospital, Charles University, Prague, Czech Republic; University of Leicester, United Kingdom (A.B.); University Hospitals of Leicester NHS Trust, United Kingdom (P.S.T., A.S., H.T.); Department of Health Psychology, University College of London, United Kingdom (R.H.); Division of Medicine, Central Manchester NHS Foundation Trust, Manchester Academic Health Science Centre, United Kingdom (B.K., A.H., M.T.); Institute of Cardiovascular Science, University College London, United Kingdom (B.W.); and National Institute for Health Research, University College London Hospitals Biomedical Research Centre, United Kingdom (B.W.)
| | - Artur Akbarov
- From the Department of Metabolic Medicine and Chemical Pathology, University Hospitals of Leicester NHS Trust, United Kingdom (P.G., P.P., G.S.G., P.R.S.); Department of Cardiovascular Sciences, University of Leicester, United Kingdom (P.G., P.P., F.Y.L., G.S.G., N.J.S.); National Institute for Health Research Leicester Cardiovascular Biomedical Research Unit, United Kingdom (P.G., P.P., F.Y.L., N.J.S.); Division of Cardiovascular Sciences, Faculty of Biology, Medicine, and Health, University of Manchester, United Kingdom (P.G., A.A., B.K., A.H., M.T.); 3rd Department of Medicine, Department of Endocrinology and Metabolism, Hypertension Centre (B.S., J.W.) and Institute of Forensic Medicine and Toxicology (V.M.), General University Hospital, Charles University, Prague, Czech Republic; University of Leicester, United Kingdom (A.B.); University Hospitals of Leicester NHS Trust, United Kingdom (P.S.T., A.S., H.T.); Department of Health Psychology, University College of London, United Kingdom (R.H.); Division of Medicine, Central Manchester NHS Foundation Trust, Manchester Academic Health Science Centre, United Kingdom (B.K., A.H., M.T.); Institute of Cardiovascular Science, University College London, United Kingdom (B.W.); and National Institute for Health Research, University College London Hospitals Biomedical Research Centre, United Kingdom (B.W.)
| | - Gaurav S Gulsin
- From the Department of Metabolic Medicine and Chemical Pathology, University Hospitals of Leicester NHS Trust, United Kingdom (P.G., P.P., G.S.G., P.R.S.); Department of Cardiovascular Sciences, University of Leicester, United Kingdom (P.G., P.P., F.Y.L., G.S.G., N.J.S.); National Institute for Health Research Leicester Cardiovascular Biomedical Research Unit, United Kingdom (P.G., P.P., F.Y.L., N.J.S.); Division of Cardiovascular Sciences, Faculty of Biology, Medicine, and Health, University of Manchester, United Kingdom (P.G., A.A., B.K., A.H., M.T.); 3rd Department of Medicine, Department of Endocrinology and Metabolism, Hypertension Centre (B.S., J.W.) and Institute of Forensic Medicine and Toxicology (V.M.), General University Hospital, Charles University, Prague, Czech Republic; University of Leicester, United Kingdom (A.B.); University Hospitals of Leicester NHS Trust, United Kingdom (P.S.T., A.S., H.T.); Department of Health Psychology, University College of London, United Kingdom (R.H.); Division of Medicine, Central Manchester NHS Foundation Trust, Manchester Academic Health Science Centre, United Kingdom (B.K., A.H., M.T.); Institute of Cardiovascular Science, University College London, United Kingdom (B.W.); and National Institute for Health Research, University College London Hospitals Biomedical Research Centre, United Kingdom (B.W.)
| | - Alison Beech
- From the Department of Metabolic Medicine and Chemical Pathology, University Hospitals of Leicester NHS Trust, United Kingdom (P.G., P.P., G.S.G., P.R.S.); Department of Cardiovascular Sciences, University of Leicester, United Kingdom (P.G., P.P., F.Y.L., G.S.G., N.J.S.); National Institute for Health Research Leicester Cardiovascular Biomedical Research Unit, United Kingdom (P.G., P.P., F.Y.L., N.J.S.); Division of Cardiovascular Sciences, Faculty of Biology, Medicine, and Health, University of Manchester, United Kingdom (P.G., A.A., B.K., A.H., M.T.); 3rd Department of Medicine, Department of Endocrinology and Metabolism, Hypertension Centre (B.S., J.W.) and Institute of Forensic Medicine and Toxicology (V.M.), General University Hospital, Charles University, Prague, Czech Republic; University of Leicester, United Kingdom (A.B.); University Hospitals of Leicester NHS Trust, United Kingdom (P.S.T., A.S., H.T.); Department of Health Psychology, University College of London, United Kingdom (R.H.); Division of Medicine, Central Manchester NHS Foundation Trust, Manchester Academic Health Science Centre, United Kingdom (B.K., A.H., M.T.); Institute of Cardiovascular Science, University College London, United Kingdom (B.W.); and National Institute for Health Research, University College London Hospitals Biomedical Research Centre, United Kingdom (B.W.)
| | - Věra Marešová
- From the Department of Metabolic Medicine and Chemical Pathology, University Hospitals of Leicester NHS Trust, United Kingdom (P.G., P.P., G.S.G., P.R.S.); Department of Cardiovascular Sciences, University of Leicester, United Kingdom (P.G., P.P., F.Y.L., G.S.G., N.J.S.); National Institute for Health Research Leicester Cardiovascular Biomedical Research Unit, United Kingdom (P.G., P.P., F.Y.L., N.J.S.); Division of Cardiovascular Sciences, Faculty of Biology, Medicine, and Health, University of Manchester, United Kingdom (P.G., A.A., B.K., A.H., M.T.); 3rd Department of Medicine, Department of Endocrinology and Metabolism, Hypertension Centre (B.S., J.W.) and Institute of Forensic Medicine and Toxicology (V.M.), General University Hospital, Charles University, Prague, Czech Republic; University of Leicester, United Kingdom (A.B.); University Hospitals of Leicester NHS Trust, United Kingdom (P.S.T., A.S., H.T.); Department of Health Psychology, University College of London, United Kingdom (R.H.); Division of Medicine, Central Manchester NHS Foundation Trust, Manchester Academic Health Science Centre, United Kingdom (B.K., A.H., M.T.); Institute of Cardiovascular Science, University College London, United Kingdom (B.W.); and National Institute for Health Research, University College London Hospitals Biomedical Research Centre, United Kingdom (B.W.)
| | - Peter S Topham
- From the Department of Metabolic Medicine and Chemical Pathology, University Hospitals of Leicester NHS Trust, United Kingdom (P.G., P.P., G.S.G., P.R.S.); Department of Cardiovascular Sciences, University of Leicester, United Kingdom (P.G., P.P., F.Y.L., G.S.G., N.J.S.); National Institute for Health Research Leicester Cardiovascular Biomedical Research Unit, United Kingdom (P.G., P.P., F.Y.L., N.J.S.); Division of Cardiovascular Sciences, Faculty of Biology, Medicine, and Health, University of Manchester, United Kingdom (P.G., A.A., B.K., A.H., M.T.); 3rd Department of Medicine, Department of Endocrinology and Metabolism, Hypertension Centre (B.S., J.W.) and Institute of Forensic Medicine and Toxicology (V.M.), General University Hospital, Charles University, Prague, Czech Republic; University of Leicester, United Kingdom (A.B.); University Hospitals of Leicester NHS Trust, United Kingdom (P.S.T., A.S., H.T.); Department of Health Psychology, University College of London, United Kingdom (R.H.); Division of Medicine, Central Manchester NHS Foundation Trust, Manchester Academic Health Science Centre, United Kingdom (B.K., A.H., M.T.); Institute of Cardiovascular Science, University College London, United Kingdom (B.W.); and National Institute for Health Research, University College London Hospitals Biomedical Research Centre, United Kingdom (B.W.)
| | - Adrian Stanley
- From the Department of Metabolic Medicine and Chemical Pathology, University Hospitals of Leicester NHS Trust, United Kingdom (P.G., P.P., G.S.G., P.R.S.); Department of Cardiovascular Sciences, University of Leicester, United Kingdom (P.G., P.P., F.Y.L., G.S.G., N.J.S.); National Institute for Health Research Leicester Cardiovascular Biomedical Research Unit, United Kingdom (P.G., P.P., F.Y.L., N.J.S.); Division of Cardiovascular Sciences, Faculty of Biology, Medicine, and Health, University of Manchester, United Kingdom (P.G., A.A., B.K., A.H., M.T.); 3rd Department of Medicine, Department of Endocrinology and Metabolism, Hypertension Centre (B.S., J.W.) and Institute of Forensic Medicine and Toxicology (V.M.), General University Hospital, Charles University, Prague, Czech Republic; University of Leicester, United Kingdom (A.B.); University Hospitals of Leicester NHS Trust, United Kingdom (P.S.T., A.S., H.T.); Department of Health Psychology, University College of London, United Kingdom (R.H.); Division of Medicine, Central Manchester NHS Foundation Trust, Manchester Academic Health Science Centre, United Kingdom (B.K., A.H., M.T.); Institute of Cardiovascular Science, University College London, United Kingdom (B.W.); and National Institute for Health Research, University College London Hospitals Biomedical Research Centre, United Kingdom (B.W.)
| | - Herbert Thurston
- From the Department of Metabolic Medicine and Chemical Pathology, University Hospitals of Leicester NHS Trust, United Kingdom (P.G., P.P., G.S.G., P.R.S.); Department of Cardiovascular Sciences, University of Leicester, United Kingdom (P.G., P.P., F.Y.L., G.S.G., N.J.S.); National Institute for Health Research Leicester Cardiovascular Biomedical Research Unit, United Kingdom (P.G., P.P., F.Y.L., N.J.S.); Division of Cardiovascular Sciences, Faculty of Biology, Medicine, and Health, University of Manchester, United Kingdom (P.G., A.A., B.K., A.H., M.T.); 3rd Department of Medicine, Department of Endocrinology and Metabolism, Hypertension Centre (B.S., J.W.) and Institute of Forensic Medicine and Toxicology (V.M.), General University Hospital, Charles University, Prague, Czech Republic; University of Leicester, United Kingdom (A.B.); University Hospitals of Leicester NHS Trust, United Kingdom (P.S.T., A.S., H.T.); Department of Health Psychology, University College of London, United Kingdom (R.H.); Division of Medicine, Central Manchester NHS Foundation Trust, Manchester Academic Health Science Centre, United Kingdom (B.K., A.H., M.T.); Institute of Cardiovascular Science, University College London, United Kingdom (B.W.); and National Institute for Health Research, University College London Hospitals Biomedical Research Centre, United Kingdom (B.W.)
| | - Paul R Smith
- From the Department of Metabolic Medicine and Chemical Pathology, University Hospitals of Leicester NHS Trust, United Kingdom (P.G., P.P., G.S.G., P.R.S.); Department of Cardiovascular Sciences, University of Leicester, United Kingdom (P.G., P.P., F.Y.L., G.S.G., N.J.S.); National Institute for Health Research Leicester Cardiovascular Biomedical Research Unit, United Kingdom (P.G., P.P., F.Y.L., N.J.S.); Division of Cardiovascular Sciences, Faculty of Biology, Medicine, and Health, University of Manchester, United Kingdom (P.G., A.A., B.K., A.H., M.T.); 3rd Department of Medicine, Department of Endocrinology and Metabolism, Hypertension Centre (B.S., J.W.) and Institute of Forensic Medicine and Toxicology (V.M.), General University Hospital, Charles University, Prague, Czech Republic; University of Leicester, United Kingdom (A.B.); University Hospitals of Leicester NHS Trust, United Kingdom (P.S.T., A.S., H.T.); Department of Health Psychology, University College of London, United Kingdom (R.H.); Division of Medicine, Central Manchester NHS Foundation Trust, Manchester Academic Health Science Centre, United Kingdom (B.K., A.H., M.T.); Institute of Cardiovascular Science, University College London, United Kingdom (B.W.); and National Institute for Health Research, University College London Hospitals Biomedical Research Centre, United Kingdom (B.W.)
| | - Robert Horne
- From the Department of Metabolic Medicine and Chemical Pathology, University Hospitals of Leicester NHS Trust, United Kingdom (P.G., P.P., G.S.G., P.R.S.); Department of Cardiovascular Sciences, University of Leicester, United Kingdom (P.G., P.P., F.Y.L., G.S.G., N.J.S.); National Institute for Health Research Leicester Cardiovascular Biomedical Research Unit, United Kingdom (P.G., P.P., F.Y.L., N.J.S.); Division of Cardiovascular Sciences, Faculty of Biology, Medicine, and Health, University of Manchester, United Kingdom (P.G., A.A., B.K., A.H., M.T.); 3rd Department of Medicine, Department of Endocrinology and Metabolism, Hypertension Centre (B.S., J.W.) and Institute of Forensic Medicine and Toxicology (V.M.), General University Hospital, Charles University, Prague, Czech Republic; University of Leicester, United Kingdom (A.B.); University Hospitals of Leicester NHS Trust, United Kingdom (P.S.T., A.S., H.T.); Department of Health Psychology, University College of London, United Kingdom (R.H.); Division of Medicine, Central Manchester NHS Foundation Trust, Manchester Academic Health Science Centre, United Kingdom (B.K., A.H., M.T.); Institute of Cardiovascular Science, University College London, United Kingdom (B.W.); and National Institute for Health Research, University College London Hospitals Biomedical Research Centre, United Kingdom (B.W.)
| | - Jiří Widimský
- From the Department of Metabolic Medicine and Chemical Pathology, University Hospitals of Leicester NHS Trust, United Kingdom (P.G., P.P., G.S.G., P.R.S.); Department of Cardiovascular Sciences, University of Leicester, United Kingdom (P.G., P.P., F.Y.L., G.S.G., N.J.S.); National Institute for Health Research Leicester Cardiovascular Biomedical Research Unit, United Kingdom (P.G., P.P., F.Y.L., N.J.S.); Division of Cardiovascular Sciences, Faculty of Biology, Medicine, and Health, University of Manchester, United Kingdom (P.G., A.A., B.K., A.H., M.T.); 3rd Department of Medicine, Department of Endocrinology and Metabolism, Hypertension Centre (B.S., J.W.) and Institute of Forensic Medicine and Toxicology (V.M.), General University Hospital, Charles University, Prague, Czech Republic; University of Leicester, United Kingdom (A.B.); University Hospitals of Leicester NHS Trust, United Kingdom (P.S.T., A.S., H.T.); Department of Health Psychology, University College of London, United Kingdom (R.H.); Division of Medicine, Central Manchester NHS Foundation Trust, Manchester Academic Health Science Centre, United Kingdom (B.K., A.H., M.T.); Institute of Cardiovascular Science, University College London, United Kingdom (B.W.); and National Institute for Health Research, University College London Hospitals Biomedical Research Centre, United Kingdom (B.W.)
| | - Bernard Keavney
- From the Department of Metabolic Medicine and Chemical Pathology, University Hospitals of Leicester NHS Trust, United Kingdom (P.G., P.P., G.S.G., P.R.S.); Department of Cardiovascular Sciences, University of Leicester, United Kingdom (P.G., P.P., F.Y.L., G.S.G., N.J.S.); National Institute for Health Research Leicester Cardiovascular Biomedical Research Unit, United Kingdom (P.G., P.P., F.Y.L., N.J.S.); Division of Cardiovascular Sciences, Faculty of Biology, Medicine, and Health, University of Manchester, United Kingdom (P.G., A.A., B.K., A.H., M.T.); 3rd Department of Medicine, Department of Endocrinology and Metabolism, Hypertension Centre (B.S., J.W.) and Institute of Forensic Medicine and Toxicology (V.M.), General University Hospital, Charles University, Prague, Czech Republic; University of Leicester, United Kingdom (A.B.); University Hospitals of Leicester NHS Trust, United Kingdom (P.S.T., A.S., H.T.); Department of Health Psychology, University College of London, United Kingdom (R.H.); Division of Medicine, Central Manchester NHS Foundation Trust, Manchester Academic Health Science Centre, United Kingdom (B.K., A.H., M.T.); Institute of Cardiovascular Science, University College London, United Kingdom (B.W.); and National Institute for Health Research, University College London Hospitals Biomedical Research Centre, United Kingdom (B.W.)
| | - Anthony Heagerty
- From the Department of Metabolic Medicine and Chemical Pathology, University Hospitals of Leicester NHS Trust, United Kingdom (P.G., P.P., G.S.G., P.R.S.); Department of Cardiovascular Sciences, University of Leicester, United Kingdom (P.G., P.P., F.Y.L., G.S.G., N.J.S.); National Institute for Health Research Leicester Cardiovascular Biomedical Research Unit, United Kingdom (P.G., P.P., F.Y.L., N.J.S.); Division of Cardiovascular Sciences, Faculty of Biology, Medicine, and Health, University of Manchester, United Kingdom (P.G., A.A., B.K., A.H., M.T.); 3rd Department of Medicine, Department of Endocrinology and Metabolism, Hypertension Centre (B.S., J.W.) and Institute of Forensic Medicine and Toxicology (V.M.), General University Hospital, Charles University, Prague, Czech Republic; University of Leicester, United Kingdom (A.B.); University Hospitals of Leicester NHS Trust, United Kingdom (P.S.T., A.S., H.T.); Department of Health Psychology, University College of London, United Kingdom (R.H.); Division of Medicine, Central Manchester NHS Foundation Trust, Manchester Academic Health Science Centre, United Kingdom (B.K., A.H., M.T.); Institute of Cardiovascular Science, University College London, United Kingdom (B.W.); and National Institute for Health Research, University College London Hospitals Biomedical Research Centre, United Kingdom (B.W.)
| | - Nilesh J Samani
- From the Department of Metabolic Medicine and Chemical Pathology, University Hospitals of Leicester NHS Trust, United Kingdom (P.G., P.P., G.S.G., P.R.S.); Department of Cardiovascular Sciences, University of Leicester, United Kingdom (P.G., P.P., F.Y.L., G.S.G., N.J.S.); National Institute for Health Research Leicester Cardiovascular Biomedical Research Unit, United Kingdom (P.G., P.P., F.Y.L., N.J.S.); Division of Cardiovascular Sciences, Faculty of Biology, Medicine, and Health, University of Manchester, United Kingdom (P.G., A.A., B.K., A.H., M.T.); 3rd Department of Medicine, Department of Endocrinology and Metabolism, Hypertension Centre (B.S., J.W.) and Institute of Forensic Medicine and Toxicology (V.M.), General University Hospital, Charles University, Prague, Czech Republic; University of Leicester, United Kingdom (A.B.); University Hospitals of Leicester NHS Trust, United Kingdom (P.S.T., A.S., H.T.); Department of Health Psychology, University College of London, United Kingdom (R.H.); Division of Medicine, Central Manchester NHS Foundation Trust, Manchester Academic Health Science Centre, United Kingdom (B.K., A.H., M.T.); Institute of Cardiovascular Science, University College London, United Kingdom (B.W.); and National Institute for Health Research, University College London Hospitals Biomedical Research Centre, United Kingdom (B.W.)
| | - Bryan Williams
- From the Department of Metabolic Medicine and Chemical Pathology, University Hospitals of Leicester NHS Trust, United Kingdom (P.G., P.P., G.S.G., P.R.S.); Department of Cardiovascular Sciences, University of Leicester, United Kingdom (P.G., P.P., F.Y.L., G.S.G., N.J.S.); National Institute for Health Research Leicester Cardiovascular Biomedical Research Unit, United Kingdom (P.G., P.P., F.Y.L., N.J.S.); Division of Cardiovascular Sciences, Faculty of Biology, Medicine, and Health, University of Manchester, United Kingdom (P.G., A.A., B.K., A.H., M.T.); 3rd Department of Medicine, Department of Endocrinology and Metabolism, Hypertension Centre (B.S., J.W.) and Institute of Forensic Medicine and Toxicology (V.M.), General University Hospital, Charles University, Prague, Czech Republic; University of Leicester, United Kingdom (A.B.); University Hospitals of Leicester NHS Trust, United Kingdom (P.S.T., A.S., H.T.); Department of Health Psychology, University College of London, United Kingdom (R.H.); Division of Medicine, Central Manchester NHS Foundation Trust, Manchester Academic Health Science Centre, United Kingdom (B.K., A.H., M.T.); Institute of Cardiovascular Science, University College London, United Kingdom (B.W.); and National Institute for Health Research, University College London Hospitals Biomedical Research Centre, United Kingdom (B.W.)
| | - Maciej Tomaszewski
- From the Department of Metabolic Medicine and Chemical Pathology, University Hospitals of Leicester NHS Trust, United Kingdom (P.G., P.P., G.S.G., P.R.S.); Department of Cardiovascular Sciences, University of Leicester, United Kingdom (P.G., P.P., F.Y.L., G.S.G., N.J.S.); National Institute for Health Research Leicester Cardiovascular Biomedical Research Unit, United Kingdom (P.G., P.P., F.Y.L., N.J.S.); Division of Cardiovascular Sciences, Faculty of Biology, Medicine, and Health, University of Manchester, United Kingdom (P.G., A.A., B.K., A.H., M.T.); 3rd Department of Medicine, Department of Endocrinology and Metabolism, Hypertension Centre (B.S., J.W.) and Institute of Forensic Medicine and Toxicology (V.M.), General University Hospital, Charles University, Prague, Czech Republic; University of Leicester, United Kingdom (A.B.); University Hospitals of Leicester NHS Trust, United Kingdom (P.S.T., A.S., H.T.); Department of Health Psychology, University College of London, United Kingdom (R.H.); Division of Medicine, Central Manchester NHS Foundation Trust, Manchester Academic Health Science Centre, United Kingdom (B.K., A.H., M.T.); Institute of Cardiovascular Science, University College London, United Kingdom (B.W.); and National Institute for Health Research, University College London Hospitals Biomedical Research Centre, United Kingdom (B.W.).
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Renal denervation in comparison with intensified pharmacotherapy in true resistant hypertension. J Hypertens 2017; 35:1093-1099. [DOI: 10.1097/hjh.0000000000001257] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
BACKGROUND Resistant hypertension is highly prevalent among the general hypertensive population and the clinical management of this condition remains problematic. Different approaches, including a more intensified antihypertensive therapy, lifestyle modifications, or both, have largely failed to improve patients' outcomes and to reduce cardiovascular and renal risk. As renal sympathetic hyperactivity is a major driver of resistant hypertension, renal sympathetic ablation (renal denervation) has been recently proposed as a possible therapeutic alternative to treat this condition. OBJECTIVES We sought to evaluate the short- and long-term effects of renal denervation in individuals with resistant hypertension on clinical end points, including fatal and non-fatal cardiovascular events, all-cause mortality, hospital admissions, quality of life, blood pressure control, left ventricular hypertrophy, cardiovascular and metabolic profile, and kidney function, as well as the potential adverse events related to the procedure. SEARCH METHODS We searched the following databases to 17 February 2016 using relevant search terms: the Cochrane Hypertension Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE and ClinicalTrials.gov SELECTION CRITERIA: We considered randomised controlled trials (RCTs) that compared renal denervation to standard therapy or sham procedure to treat resistant hypertension, without language restriction. DATA COLLECTION AND ANALYSIS Two authors independently extracted data and assessed study risks of bias. We summarised treatment effects on available clinical outcomes and adverse events using random-effects meta-analyses. We assessed heterogeneity in estimated treatment effects using Chi² and I² statistics. We calculated summary treatment estimates as a mean difference (MD) or standardised mean difference (SMD) for continuous outcomes, and a risk ratio (RR) for dichotomous outcomes, together with their 95% confidence intervals (CI). MAIN RESULTS We found 12 eligible studies (1149 participants). In four studies, renal denervation was compared to sham procedure; one study compared a proximal ablation to a complete renal artery denervation; in the remaining, renal denervation was tested against standard or intensified antihypertensive therapy.None of the included trials was designed to look at hard clinical end points as primary outcomes.When compared to control, there was low quality evidence that renal denervation did not reduce the risk of myocardial infarction (4 studies, 742 participants; RR 1.31, 95% CI 0.45 to 3.84), ischaemic stroke (4 studies, 823 participants; RR 1.15, 95% CI 0.36 to 3.72), or unstable angina (2 studies, 201 participants; RR 0.63, 95% CI 0.08 to 5.06), and moderate quality evidence that it had no effect on 24-hour ambulatory blood pressure monitoring (ABPM) systolic BP (5 studies, 797 participants; MD 0.28 mmHg, 95% CI -3.74 to 4.29), diastolic BP (4 studies, 756 participants; MD 0.93 mmHg, 95% CI -4.50 to 6.36), office measured systolic BP (6 studies, 886 participants; MD -4.08 mmHg, 95% CI -15.26 to 7.11), or diastolic BP (5 studies, 845 participants; MD -1.30 mmHg, 95% CI -7.30 to 4.69). Furthermore, low quality evidence suggested that this procedure produced no effect on either serum creatinine (3 studies, 736 participants, MD 0.01 mg/dL; 95% CI -0.12 to 0.14), estimated glomerular filtration rate (eGFR), or creatinine clearance (4 studies, 837 participants; MD -2.09 mL/min, 95% CI -8.12 to 3.95). Based on low-quality evidence, renal denervation significantly increased bradycardia episodes compared to control (3 studies, 220 participants; RR 6.63, 95% CI 1.19 to 36.84), while the risk of other adverse events was comparable or not assessable.Data were sparse or absent for all cause mortality, hospitalisation, fatal cardiovascular events, quality of life, atrial fibrillation episodes, left ventricular hypertrophy, sleep apnoea severity, need for renal replacement therapy, and metabolic profile.The quality of the evidence was low for cardiovascular outcomes and adverse events and moderate for lack of effect on blood pressure and renal function. AUTHORS' CONCLUSIONS In patients with resistant hypertension, there is low quality evidence that renal denervation does not change major cardiovascular events, and renal function. There was moderate quality evidence that it does not change blood pressure and and low quality evidence that it caused an increaseof bradycardia episodes. Future trials measuring patient-centred instead of surrogate outcomes, with longer follow-up periods, larger sample size and more standardized procedural methods are necessary to clarify the utility of this procedure in this population.
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Affiliation(s)
- Giuseppe Coppolino
- "Pugliese‐Ciaccio" General HospitalNephrology and Dialysis UnitViale pio XCatanzaroCatanzaroItaly88100
| | - Anna Pisano
- CNR ‐ Italian National Council of ResearchInstitute of Clinical PhysiologyCNR‐IFC Via Vallone Petrara c/o Ospedali RiunitiReggio CalabriaItaly89100
| | - Laura Rivoli
- University "Magna Graecia"Department of Medical and Surgical Sciences, Nephrology and Dialysis UnitViale EuropaCatanzaroItaly88100
| | - Davide Bolignano
- CNR ‐ Italian National Council of ResearchInstitute of Clinical PhysiologyCNR‐IFC Via Vallone Petrara c/o Ospedali RiunitiReggio CalabriaItaly89100
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Renal Denervation. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2016. [PMID: 27815927 DOI: 10.1007/5584_2016_148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register]
Abstract
Sympathetic nervous system over-activity is closely linked with elevation of systemic blood pressure. Both animal and human studies suggest renal sympathetic nerves play an important role in this respect. Historically, modulation of sympathetic activity has been used to treat hypertension. More recently, catheter based renal sympathetic denervation was introduced for the management of treatment resistant hypertension. Sound physiological principles and surgical precedent underpin renal denervation as a therapy for treatment of resistant hypertension. Encouraging results of early studies led to a widespread adoption of the procedure for management of this condition. Subsequently a sham controlled randomised controlled study failed to confirm the benefit of renal denervation leading to a halt in its use in most countries in the world. However, critical analysis of the sham-controlled study indicates a number of flaws. A number of lessons have been learnt from this and other studies which need to be applied in future trials to ascertain the actual role of renal denervation in the management of treatment resistant hypertension before further implementation. This chapter deals with all these issues in detail.
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Rosa J, Zelinka T, Petrák O, Štrauch B, Holaj R, Widimský J. Should All Patients with Resistant Hypertension Receive Spironolactone? Curr Hypertens Rep 2016; 18:81. [PMID: 27787836 DOI: 10.1007/s11906-016-0690-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
- Ján Rosa
- 3rd Department of Medicine, Center for Hypertension, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic.
- Cardiocenter, University Hospital Královské Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic.
| | - Tomáš Zelinka
- 3rd Department of Medicine, Center for Hypertension, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Ondřej Petrák
- 3rd Department of Medicine, Center for Hypertension, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Branislav Štrauch
- 3rd Department of Medicine, Center for Hypertension, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Robert Holaj
- 3rd Department of Medicine, Center for Hypertension, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Jiří Widimský
- 3rd Department of Medicine, Center for Hypertension, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic
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Rosa J, Widimský P, Waldauf P, Lambert L, Zelinka T, Táborský M, Branny M, Toušek P, Petrák O, Čurila K, Bednář F, Holaj R, Štrauch B, Václavík J, Nykl I, Krátká Z, Kociánová E, Jiravský O, Rappová G, Indra T, Widimský J. Role of Adding Spironolactone and Renal Denervation in True Resistant Hypertension: One-Year Outcomes of Randomized PRAGUE-15 Study. Hypertension 2015; 67:397-403. [PMID: 26693818 DOI: 10.1161/hypertensionaha.115.06526] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Accepted: 11/09/2015] [Indexed: 01/28/2023]
Abstract
This randomized, multicenter study compared the relative efficacy of renal denervation (RDN) versus pharmacotherapy alone in patients with true resistant hypertension and assessed the effect of spironolactone addition. We present here the 12-month data. A total of 106 patients with true resistant hypertension were enrolled in this study: 52 patients were randomized to RDN and 54 patients to the spironolactone addition, with baseline systolic blood pressure of 159±17 and 155±17 mm Hg and average number of drugs 5.1 and 5.4, respectively. Twelve-month results are available in 101 patients. The intention-to-treat analysis found a comparable mean 24-hour systolic blood pressure decline of 6.4 mm Hg, P=0.001 in RDN versus 8.2 mm Hg, P=0.002 in the pharmacotherapy group. Per-protocol analysis revealed a significant difference of 24-hour systolic blood pressure decline between complete RDN (6.3 mm Hg, P=0.004) and the subgroup where spironolactone was added, and this continued within the 12 months (15 mm Hg, P= 0.003). Renal artery computed tomography angiograms before and after 1 year post-RDN did not reveal any relevant changes. This study shows that over a period of 12 months, RDN is safe, with no serious side effects and no major changes in the renal arteries. RDN in the settings of true resistant hypertension with confirmed compliance is not superior to intensified pharmacological treatment. Spironolactone addition (if tolerated) seems to be more effective in blood pressure reduction.
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Affiliation(s)
- Ján Rosa
- From the 3rd Department of Medicine, Center for Hypertension, General University Hospital and First Faculty of Medicine (J.R., T.Z., O.P., R.H., B.Š., Z.K., T.I., J.W. Jr), Cardiocentre, University Hospital Královské Vinohrady and Third Faculty of Medicine (J.R., P. Widimský, P. Toušek, K.Č., F.B.), Department of Anesthesiology, University Hospital Královské Vinohrady and Third Faculty of Medicine (P. Waldauf), and Department of Radiology, General University Hospital and First Faculty of Medicine (L.L.), Charles University, Prague, Czech Republic; Department of Internal Medicine I, University Hospital Olomouc, Czech Republic (M.T., J.V., E.K.); and Cardiocentre, Nemocnice Podlesí, Třinec, Czech Republic (M.B., I.N., O.J., G.R.).
| | - Petr Widimský
- From the 3rd Department of Medicine, Center for Hypertension, General University Hospital and First Faculty of Medicine (J.R., T.Z., O.P., R.H., B.Š., Z.K., T.I., J.W. Jr), Cardiocentre, University Hospital Královské Vinohrady and Third Faculty of Medicine (J.R., P. Widimský, P. Toušek, K.Č., F.B.), Department of Anesthesiology, University Hospital Královské Vinohrady and Third Faculty of Medicine (P. Waldauf), and Department of Radiology, General University Hospital and First Faculty of Medicine (L.L.), Charles University, Prague, Czech Republic; Department of Internal Medicine I, University Hospital Olomouc, Czech Republic (M.T., J.V., E.K.); and Cardiocentre, Nemocnice Podlesí, Třinec, Czech Republic (M.B., I.N., O.J., G.R.)
| | - Petr Waldauf
- From the 3rd Department of Medicine, Center for Hypertension, General University Hospital and First Faculty of Medicine (J.R., T.Z., O.P., R.H., B.Š., Z.K., T.I., J.W. Jr), Cardiocentre, University Hospital Královské Vinohrady and Third Faculty of Medicine (J.R., P. Widimský, P. Toušek, K.Č., F.B.), Department of Anesthesiology, University Hospital Královské Vinohrady and Third Faculty of Medicine (P. Waldauf), and Department of Radiology, General University Hospital and First Faculty of Medicine (L.L.), Charles University, Prague, Czech Republic; Department of Internal Medicine I, University Hospital Olomouc, Czech Republic (M.T., J.V., E.K.); and Cardiocentre, Nemocnice Podlesí, Třinec, Czech Republic (M.B., I.N., O.J., G.R.)
| | - Lukáš Lambert
- From the 3rd Department of Medicine, Center for Hypertension, General University Hospital and First Faculty of Medicine (J.R., T.Z., O.P., R.H., B.Š., Z.K., T.I., J.W. Jr), Cardiocentre, University Hospital Královské Vinohrady and Third Faculty of Medicine (J.R., P. Widimský, P. Toušek, K.Č., F.B.), Department of Anesthesiology, University Hospital Královské Vinohrady and Third Faculty of Medicine (P. Waldauf), and Department of Radiology, General University Hospital and First Faculty of Medicine (L.L.), Charles University, Prague, Czech Republic; Department of Internal Medicine I, University Hospital Olomouc, Czech Republic (M.T., J.V., E.K.); and Cardiocentre, Nemocnice Podlesí, Třinec, Czech Republic (M.B., I.N., O.J., G.R.)
| | - Tomáš Zelinka
- From the 3rd Department of Medicine, Center for Hypertension, General University Hospital and First Faculty of Medicine (J.R., T.Z., O.P., R.H., B.Š., Z.K., T.I., J.W. Jr), Cardiocentre, University Hospital Královské Vinohrady and Third Faculty of Medicine (J.R., P. Widimský, P. Toušek, K.Č., F.B.), Department of Anesthesiology, University Hospital Královské Vinohrady and Third Faculty of Medicine (P. Waldauf), and Department of Radiology, General University Hospital and First Faculty of Medicine (L.L.), Charles University, Prague, Czech Republic; Department of Internal Medicine I, University Hospital Olomouc, Czech Republic (M.T., J.V., E.K.); and Cardiocentre, Nemocnice Podlesí, Třinec, Czech Republic (M.B., I.N., O.J., G.R.)
| | - Miloš Táborský
- From the 3rd Department of Medicine, Center for Hypertension, General University Hospital and First Faculty of Medicine (J.R., T.Z., O.P., R.H., B.Š., Z.K., T.I., J.W. Jr), Cardiocentre, University Hospital Královské Vinohrady and Third Faculty of Medicine (J.R., P. Widimský, P. Toušek, K.Č., F.B.), Department of Anesthesiology, University Hospital Královské Vinohrady and Third Faculty of Medicine (P. Waldauf), and Department of Radiology, General University Hospital and First Faculty of Medicine (L.L.), Charles University, Prague, Czech Republic; Department of Internal Medicine I, University Hospital Olomouc, Czech Republic (M.T., J.V., E.K.); and Cardiocentre, Nemocnice Podlesí, Třinec, Czech Republic (M.B., I.N., O.J., G.R.)
| | - Marian Branny
- From the 3rd Department of Medicine, Center for Hypertension, General University Hospital and First Faculty of Medicine (J.R., T.Z., O.P., R.H., B.Š., Z.K., T.I., J.W. Jr), Cardiocentre, University Hospital Královské Vinohrady and Third Faculty of Medicine (J.R., P. Widimský, P. Toušek, K.Č., F.B.), Department of Anesthesiology, University Hospital Královské Vinohrady and Third Faculty of Medicine (P. Waldauf), and Department of Radiology, General University Hospital and First Faculty of Medicine (L.L.), Charles University, Prague, Czech Republic; Department of Internal Medicine I, University Hospital Olomouc, Czech Republic (M.T., J.V., E.K.); and Cardiocentre, Nemocnice Podlesí, Třinec, Czech Republic (M.B., I.N., O.J., G.R.)
| | - Petr Toušek
- From the 3rd Department of Medicine, Center for Hypertension, General University Hospital and First Faculty of Medicine (J.R., T.Z., O.P., R.H., B.Š., Z.K., T.I., J.W. Jr), Cardiocentre, University Hospital Královské Vinohrady and Third Faculty of Medicine (J.R., P. Widimský, P. Toušek, K.Č., F.B.), Department of Anesthesiology, University Hospital Královské Vinohrady and Third Faculty of Medicine (P. Waldauf), and Department of Radiology, General University Hospital and First Faculty of Medicine (L.L.), Charles University, Prague, Czech Republic; Department of Internal Medicine I, University Hospital Olomouc, Czech Republic (M.T., J.V., E.K.); and Cardiocentre, Nemocnice Podlesí, Třinec, Czech Republic (M.B., I.N., O.J., G.R.)
| | - Ondřej Petrák
- From the 3rd Department of Medicine, Center for Hypertension, General University Hospital and First Faculty of Medicine (J.R., T.Z., O.P., R.H., B.Š., Z.K., T.I., J.W. Jr), Cardiocentre, University Hospital Královské Vinohrady and Third Faculty of Medicine (J.R., P. Widimský, P. Toušek, K.Č., F.B.), Department of Anesthesiology, University Hospital Královské Vinohrady and Third Faculty of Medicine (P. Waldauf), and Department of Radiology, General University Hospital and First Faculty of Medicine (L.L.), Charles University, Prague, Czech Republic; Department of Internal Medicine I, University Hospital Olomouc, Czech Republic (M.T., J.V., E.K.); and Cardiocentre, Nemocnice Podlesí, Třinec, Czech Republic (M.B., I.N., O.J., G.R.)
| | - Karol Čurila
- From the 3rd Department of Medicine, Center for Hypertension, General University Hospital and First Faculty of Medicine (J.R., T.Z., O.P., R.H., B.Š., Z.K., T.I., J.W. Jr), Cardiocentre, University Hospital Královské Vinohrady and Third Faculty of Medicine (J.R., P. Widimský, P. Toušek, K.Č., F.B.), Department of Anesthesiology, University Hospital Královské Vinohrady and Third Faculty of Medicine (P. Waldauf), and Department of Radiology, General University Hospital and First Faculty of Medicine (L.L.), Charles University, Prague, Czech Republic; Department of Internal Medicine I, University Hospital Olomouc, Czech Republic (M.T., J.V., E.K.); and Cardiocentre, Nemocnice Podlesí, Třinec, Czech Republic (M.B., I.N., O.J., G.R.)
| | - František Bednář
- From the 3rd Department of Medicine, Center for Hypertension, General University Hospital and First Faculty of Medicine (J.R., T.Z., O.P., R.H., B.Š., Z.K., T.I., J.W. Jr), Cardiocentre, University Hospital Královské Vinohrady and Third Faculty of Medicine (J.R., P. Widimský, P. Toušek, K.Č., F.B.), Department of Anesthesiology, University Hospital Královské Vinohrady and Third Faculty of Medicine (P. Waldauf), and Department of Radiology, General University Hospital and First Faculty of Medicine (L.L.), Charles University, Prague, Czech Republic; Department of Internal Medicine I, University Hospital Olomouc, Czech Republic (M.T., J.V., E.K.); and Cardiocentre, Nemocnice Podlesí, Třinec, Czech Republic (M.B., I.N., O.J., G.R.)
| | - Robert Holaj
- From the 3rd Department of Medicine, Center for Hypertension, General University Hospital and First Faculty of Medicine (J.R., T.Z., O.P., R.H., B.Š., Z.K., T.I., J.W. Jr), Cardiocentre, University Hospital Královské Vinohrady and Third Faculty of Medicine (J.R., P. Widimský, P. Toušek, K.Č., F.B.), Department of Anesthesiology, University Hospital Královské Vinohrady and Third Faculty of Medicine (P. Waldauf), and Department of Radiology, General University Hospital and First Faculty of Medicine (L.L.), Charles University, Prague, Czech Republic; Department of Internal Medicine I, University Hospital Olomouc, Czech Republic (M.T., J.V., E.K.); and Cardiocentre, Nemocnice Podlesí, Třinec, Czech Republic (M.B., I.N., O.J., G.R.)
| | - Branislav Štrauch
- From the 3rd Department of Medicine, Center for Hypertension, General University Hospital and First Faculty of Medicine (J.R., T.Z., O.P., R.H., B.Š., Z.K., T.I., J.W. Jr), Cardiocentre, University Hospital Královské Vinohrady and Third Faculty of Medicine (J.R., P. Widimský, P. Toušek, K.Č., F.B.), Department of Anesthesiology, University Hospital Královské Vinohrady and Third Faculty of Medicine (P. Waldauf), and Department of Radiology, General University Hospital and First Faculty of Medicine (L.L.), Charles University, Prague, Czech Republic; Department of Internal Medicine I, University Hospital Olomouc, Czech Republic (M.T., J.V., E.K.); and Cardiocentre, Nemocnice Podlesí, Třinec, Czech Republic (M.B., I.N., O.J., G.R.)
| | - Jan Václavík
- From the 3rd Department of Medicine, Center for Hypertension, General University Hospital and First Faculty of Medicine (J.R., T.Z., O.P., R.H., B.Š., Z.K., T.I., J.W. Jr), Cardiocentre, University Hospital Královské Vinohrady and Third Faculty of Medicine (J.R., P. Widimský, P. Toušek, K.Č., F.B.), Department of Anesthesiology, University Hospital Královské Vinohrady and Third Faculty of Medicine (P. Waldauf), and Department of Radiology, General University Hospital and First Faculty of Medicine (L.L.), Charles University, Prague, Czech Republic; Department of Internal Medicine I, University Hospital Olomouc, Czech Republic (M.T., J.V., E.K.); and Cardiocentre, Nemocnice Podlesí, Třinec, Czech Republic (M.B., I.N., O.J., G.R.)
| | - Igor Nykl
- From the 3rd Department of Medicine, Center for Hypertension, General University Hospital and First Faculty of Medicine (J.R., T.Z., O.P., R.H., B.Š., Z.K., T.I., J.W. Jr), Cardiocentre, University Hospital Královské Vinohrady and Third Faculty of Medicine (J.R., P. Widimský, P. Toušek, K.Č., F.B.), Department of Anesthesiology, University Hospital Královské Vinohrady and Third Faculty of Medicine (P. Waldauf), and Department of Radiology, General University Hospital and First Faculty of Medicine (L.L.), Charles University, Prague, Czech Republic; Department of Internal Medicine I, University Hospital Olomouc, Czech Republic (M.T., J.V., E.K.); and Cardiocentre, Nemocnice Podlesí, Třinec, Czech Republic (M.B., I.N., O.J., G.R.)
| | - Zuzana Krátká
- From the 3rd Department of Medicine, Center for Hypertension, General University Hospital and First Faculty of Medicine (J.R., T.Z., O.P., R.H., B.Š., Z.K., T.I., J.W. Jr), Cardiocentre, University Hospital Královské Vinohrady and Third Faculty of Medicine (J.R., P. Widimský, P. Toušek, K.Č., F.B.), Department of Anesthesiology, University Hospital Královské Vinohrady and Third Faculty of Medicine (P. Waldauf), and Department of Radiology, General University Hospital and First Faculty of Medicine (L.L.), Charles University, Prague, Czech Republic; Department of Internal Medicine I, University Hospital Olomouc, Czech Republic (M.T., J.V., E.K.); and Cardiocentre, Nemocnice Podlesí, Třinec, Czech Republic (M.B., I.N., O.J., G.R.)
| | - Eva Kociánová
- From the 3rd Department of Medicine, Center for Hypertension, General University Hospital and First Faculty of Medicine (J.R., T.Z., O.P., R.H., B.Š., Z.K., T.I., J.W. Jr), Cardiocentre, University Hospital Královské Vinohrady and Third Faculty of Medicine (J.R., P. Widimský, P. Toušek, K.Č., F.B.), Department of Anesthesiology, University Hospital Královské Vinohrady and Third Faculty of Medicine (P. Waldauf), and Department of Radiology, General University Hospital and First Faculty of Medicine (L.L.), Charles University, Prague, Czech Republic; Department of Internal Medicine I, University Hospital Olomouc, Czech Republic (M.T., J.V., E.K.); and Cardiocentre, Nemocnice Podlesí, Třinec, Czech Republic (M.B., I.N., O.J., G.R.)
| | - Otakar Jiravský
- From the 3rd Department of Medicine, Center for Hypertension, General University Hospital and First Faculty of Medicine (J.R., T.Z., O.P., R.H., B.Š., Z.K., T.I., J.W. Jr), Cardiocentre, University Hospital Královské Vinohrady and Third Faculty of Medicine (J.R., P. Widimský, P. Toušek, K.Č., F.B.), Department of Anesthesiology, University Hospital Královské Vinohrady and Third Faculty of Medicine (P. Waldauf), and Department of Radiology, General University Hospital and First Faculty of Medicine (L.L.), Charles University, Prague, Czech Republic; Department of Internal Medicine I, University Hospital Olomouc, Czech Republic (M.T., J.V., E.K.); and Cardiocentre, Nemocnice Podlesí, Třinec, Czech Republic (M.B., I.N., O.J., G.R.)
| | - Gabriela Rappová
- From the 3rd Department of Medicine, Center for Hypertension, General University Hospital and First Faculty of Medicine (J.R., T.Z., O.P., R.H., B.Š., Z.K., T.I., J.W. Jr), Cardiocentre, University Hospital Královské Vinohrady and Third Faculty of Medicine (J.R., P. Widimský, P. Toušek, K.Č., F.B.), Department of Anesthesiology, University Hospital Královské Vinohrady and Third Faculty of Medicine (P. Waldauf), and Department of Radiology, General University Hospital and First Faculty of Medicine (L.L.), Charles University, Prague, Czech Republic; Department of Internal Medicine I, University Hospital Olomouc, Czech Republic (M.T., J.V., E.K.); and Cardiocentre, Nemocnice Podlesí, Třinec, Czech Republic (M.B., I.N., O.J., G.R.)
| | - Tomáš Indra
- From the 3rd Department of Medicine, Center for Hypertension, General University Hospital and First Faculty of Medicine (J.R., T.Z., O.P., R.H., B.Š., Z.K., T.I., J.W. Jr), Cardiocentre, University Hospital Královské Vinohrady and Third Faculty of Medicine (J.R., P. Widimský, P. Toušek, K.Č., F.B.), Department of Anesthesiology, University Hospital Královské Vinohrady and Third Faculty of Medicine (P. Waldauf), and Department of Radiology, General University Hospital and First Faculty of Medicine (L.L.), Charles University, Prague, Czech Republic; Department of Internal Medicine I, University Hospital Olomouc, Czech Republic (M.T., J.V., E.K.); and Cardiocentre, Nemocnice Podlesí, Třinec, Czech Republic (M.B., I.N., O.J., G.R.)
| | - Jiří Widimský
- From the 3rd Department of Medicine, Center for Hypertension, General University Hospital and First Faculty of Medicine (J.R., T.Z., O.P., R.H., B.Š., Z.K., T.I., J.W. Jr), Cardiocentre, University Hospital Královské Vinohrady and Third Faculty of Medicine (J.R., P. Widimský, P. Toušek, K.Č., F.B.), Department of Anesthesiology, University Hospital Královské Vinohrady and Third Faculty of Medicine (P. Waldauf), and Department of Radiology, General University Hospital and First Faculty of Medicine (L.L.), Charles University, Prague, Czech Republic; Department of Internal Medicine I, University Hospital Olomouc, Czech Republic (M.T., J.V., E.K.); and Cardiocentre, Nemocnice Podlesí, Třinec, Czech Republic (M.B., I.N., O.J., G.R.)
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12
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Screening for non-adherence to antihypertensive treatment as a part of the diagnostic pathway to renal denervation. J Hum Hypertens 2015; 30:368-73. [PMID: 26446393 PMCID: PMC4856755 DOI: 10.1038/jhh.2015.103] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Revised: 07/21/2015] [Accepted: 08/07/2015] [Indexed: 01/12/2023]
Abstract
Renal denervation is a potential therapeutic option for resistant hypertension. A thorough clinical assessment to exclude reversible/spurious causes of resistance to antihypertensive therapy is required prior to this procedure. The extent to which non-adherence to antihypertensive treatment contributes to apparent resistance to antihypertensive therapy in patients considered for renal denervation is not known. Patients (n=34) referred for renal denervation entered the evaluation pathway that included screening for adherence to antihypertensive treatment by high-performance liquid chromatography-tandem mass spectrometry-based urine analysis. Biochemical non-adherence to antihypertensive treatment was the most common cause of non-eligibility for renal denervation-23.5% of patients were either partially or completely non-adherent to prescribed antihypertensive treatment. About 5.9% of those referred for renal denervation had admitted non-adherence prior to performing the screening test. Suboptimal pharmacological treatment of hypertension and 'white-coat effect' accounted for apparently resistant hypertension in a further 17.7 and 5.9% of patients, respectively. Taken together, these three causes of pseudo-resistant hypertension accounted for 52.9% of patients referred for renal denervation. Only 14.7% of referred patients were ultimately deemed eligible for renal denervation. Without biochemical screening for therapeutic non-adherence, the eligibility rate for renal denervation would have been 38.2%. Non-adherence to antihypertensive treatment and other forms of therapeutic pseudo-resistance are by far the most common reason of 'resistant hypertension' in patients referred for renal denervation. We suggest that inclusion of biochemical screening for non-adherence to antihypertensive treatment may be helpful in evaluation of patients with 'resistant hypertension' prior to consideration of renal denervation.
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13
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Fadl Elmula FEM, Jin Y, Yang WY, Thijs L, Lu YC, Larstorp AC, Persu A, Sapoval M, Rosa J, Widimský P, Jacobs L, Renkin J, Petrák O, Chatellier G, Shimada K, Widimský J, Kario K, Azizi M, Kjeldsen SE, Staessen JA. Meta-analysis of randomized controlled trials of renal denervation in treatment-resistant hypertension. Blood Press 2015; 24:263-74. [DOI: 10.3109/08037051.2015.1058595] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Fadl Elmula M. Fadl Elmula
- Departments of Cardiology, Internal Medicine and Medical Biochemistry, Oslo University Hospital, Ullevaal, Oslo, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Yu Jin
- Studies Coordinating Centre, Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven, Leuven, Belgium
| | - Wen-Yi Yang
- Studies Coordinating Centre, Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven, Leuven, Belgium
| | - Lutgarde Thijs
- Studies Coordinating Centre, Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven, Leuven, Belgium
| | - Yi-Chao Lu
- Studies Coordinating Centre, Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven, Leuven, Belgium
| | - Anne C. Larstorp
- Departments of Cardiology, Internal Medicine and Medical Biochemistry, Oslo University Hospital, Ullevaal, Oslo, Norway
| | - Alexandre Persu
- Pole of Cardiovascular Research, Institut de Recherche Expérimentale et Clinique
- Division of Cardiology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Marc Sapoval
- Universit Paris-Descartes and H pital Europ en Georges Pompidou, Assistance Publique H pitaux de Paris, Paris, France
| | - Ján Rosa
- Centre for Hypertension, Third Department of Medicine, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic
- Cardiocentre, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Petr Widimský
- Cardiocentre, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Lotte Jacobs
- Studies Coordinating Centre, Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven, Leuven, Belgium
| | - Jean Renkin
- Pole of Cardiovascular Research, Institut de Recherche Expérimentale et Clinique
- Division of Cardiology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Ondřej Petrák
- Centre for Hypertension, Third Department of Medicine, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Gilles Chatellier
- Universit Paris-Descartes and H pital Europ en Georges Pompidou, Assistance Publique H pitaux de Paris, Paris, France
- INSERM CIC1418, Paris, France
| | - Kazuyuki Shimada
- Department of Cardiovascular Medicine, Jichi Medical University School of Medicine, Tochigi, Japan
| | - Jiři Widimský
- Centre for Hypertension, Third Department of Medicine, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Kazuomi Kario
- Department of Cardiovascular Medicine, Jichi Medical University School of Medicine, Tochigi, Japan
| | - Michel Azizi
- Universit Paris-Descartes and H pital Europ en Georges Pompidou, Assistance Publique H pitaux de Paris, Paris, France
- INSERM CIC1418, Paris, France
| | - Sverre E. Kjeldsen
- Departments of Cardiology, Internal Medicine and Medical Biochemistry, Oslo University Hospital, Ullevaal, Oslo, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Jan A. Staessen
- Studies Coordinating Centre, Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven, Leuven, Belgium
- R&D Group VitaK, Maastricht University, Maastricht, The Netherlands
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14
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An update of the expert consensus statement of the Czech Hypertension Society on renal denervation in resistant hypertension. COR ET VASA 2015. [DOI: 10.1016/j.crvasa.2015.01.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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15
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Combination antihypertensive therapy in clinical practice. The analysis of 1254 consecutive patients with uncontrolled hypertension. J Hum Hypertens 2015; 30:35-9. [PMID: 25833703 DOI: 10.1038/jhh.2015.24] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2014] [Revised: 02/01/2015] [Accepted: 02/17/2015] [Indexed: 11/08/2022]
Abstract
The aim of the study was to analyze the clinical use of different types of combination therapy in a large sample of consecutive patients with uncontrolled hypertension referred to Hypertension Centre. We performed a retrospective analysis of combination antihypertensive therapy in 1254 consecutive patients with uncontrolled hypertension receiving at least triple-combination antihypertensive therapy. Among the most prescribed antihypertensive classes were renin-angiotensin blockers (96.8%), calcium channel blockers (82.5%), diuretics (82.0%), beta-blockers (73.0%), centrally acting drugs (56.0%) and urapidil (24.1%). Least prescribed were spironolactone (22.2%) and alpha-1-blockers (17.1%). Thiazide/thiazide-like diuretics were underdosed in more than two-thirds of patients. Furosemide was prescribed in 14.3% of patients treated with diuretics, while only indicated in 3.9%. Inappropriate combination therapy was found in 40.4% of patients. Controversial dual and higher blockade of renin-angiotensin system occurred in 25.2%. Incorrect use of a combination of two antihypertensive drugs with the similar mechanism of action was found in 28.1%, most commonly a combination of two drugs with central mechanism (13.5%). In conclusion, use of controversial or incorrect combinations of drugs in uncontrolled hypertension is common. Diuretics are frequently underdosed and spironolactone remains neglected in general practice. The improper combination of antihypertensive drugs may contribute to uncontrolled hypertension.
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Persu A, Jin Y, Fadl Elmula FEM, Renkin J, Høieggen A, Kjeldsen SE, Staessen JA. Renal denervation in treatment-resistant hypertension: a reappraisal. Curr Opin Pharmacol 2015; 21:48-52. [DOI: 10.1016/j.coph.2014.12.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Revised: 12/11/2014] [Accepted: 12/21/2014] [Indexed: 11/30/2022]
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17
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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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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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19
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Rosa J, Widimský P, Toušek P, Petrák O, Čurila K, Waldauf P, Bednář F, Zelinka T, Holaj R, Štrauch B, Šomlóová Z, Táborský M, Václavík J, Kociánová E, Branny M, Nykl I, Jiravský O, Widimský J. Randomized comparison of renal denervation versus intensified pharmacotherapy including spironolactone in true-resistant hypertension: six-month results from the Prague-15 study. Hypertension 2014; 65:407-13. [PMID: 25421981 DOI: 10.1161/hypertensionaha.114.04019] [Citation(s) in RCA: 156] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
This prospective, randomized, open-label multicenter trial evaluated the efficacy of catheter-based renal denervation (Symplicity, Medtronic) versus intensified pharmacological treatment including spironolactone (if tolerated) in patients with true-resistant hypertension. This was confirmed by 24-hour ambulatory blood pressure monitoring after excluding secondary hypertension and confirmation of adherence to therapy by measurement of plasma antihypertensive drug levels before enrollment. One-hundred six patients were randomized to renal denervation (n=52), or intensified pharmacological treatment (n=54) with baseline systolic blood pressure of 159±17 and 155±17 mm Hg and average number of drugs 5.1 and 5.4, respectively. A significant reduction in 24-hour average systolic blood pressure after 6 months (-8.6 [95% cofidence interval: -11.8, -5.3] mm Hg; P<0.001 in renal denervation versus -8.1 [95% cofidence interval: -12.7, -3.4] mm Hg; P=0.001 in pharmacological group) was observed, which was comparable in both groups. Similarly, a significant reduction in systolic office blood pressure (-12.4 [95% cofidence interval: -17.0, -7.8] mm Hg; P<0.001 in renal denervation versus -14.3 [95% cofidence interval: -19.7, -8.9] mm Hg; P<0.001 in pharmacological group) was present. Between-group differences in change were not significant. The average number of antihypertensive drugs used after 6 months was significantly higher in the pharmacological group (+0.3 drugs; P<0.001). A significant increase in serum creatinine and a parallel decrease of creatinine clearance were observed in the pharmacological group; between-group difference were borderline significant. The 6-month results of this study confirmed the safety of renal denervation. In conclusion, renal denervation achieved reduction of blood pressure comparable with intensified pharmacotherapy.
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Affiliation(s)
- Ján Rosa
- From the 3rd Department of Medicine, Centre for Hypertension, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., O.P., T.Z., R.H., B.Š., Z.Š., J.W.); Cardiocentre, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., P.W., P.T., K.Č., F.B.); Department of Anesthesiology, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (P.W.); Department of Internal Medicine I, University Hospital Olomouc, Czech Republic (M.T., J.V., E.K.); and Cardiocentre, Nemocnice Podlesí, Třinec, Czech Republic (M.B., I.N., O.J.).
| | - Petr Widimský
- From the 3rd Department of Medicine, Centre for Hypertension, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., O.P., T.Z., R.H., B.Š., Z.Š., J.W.); Cardiocentre, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., P.W., P.T., K.Č., F.B.); Department of Anesthesiology, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (P.W.); Department of Internal Medicine I, University Hospital Olomouc, Czech Republic (M.T., J.V., E.K.); and Cardiocentre, Nemocnice Podlesí, Třinec, Czech Republic (M.B., I.N., O.J.)
| | - Petr Toušek
- From the 3rd Department of Medicine, Centre for Hypertension, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., O.P., T.Z., R.H., B.Š., Z.Š., J.W.); Cardiocentre, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., P.W., P.T., K.Č., F.B.); Department of Anesthesiology, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (P.W.); Department of Internal Medicine I, University Hospital Olomouc, Czech Republic (M.T., J.V., E.K.); and Cardiocentre, Nemocnice Podlesí, Třinec, Czech Republic (M.B., I.N., O.J.)
| | - Ondřej Petrák
- From the 3rd Department of Medicine, Centre for Hypertension, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., O.P., T.Z., R.H., B.Š., Z.Š., J.W.); Cardiocentre, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., P.W., P.T., K.Č., F.B.); Department of Anesthesiology, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (P.W.); Department of Internal Medicine I, University Hospital Olomouc, Czech Republic (M.T., J.V., E.K.); and Cardiocentre, Nemocnice Podlesí, Třinec, Czech Republic (M.B., I.N., O.J.)
| | - Karol Čurila
- From the 3rd Department of Medicine, Centre for Hypertension, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., O.P., T.Z., R.H., B.Š., Z.Š., J.W.); Cardiocentre, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., P.W., P.T., K.Č., F.B.); Department of Anesthesiology, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (P.W.); Department of Internal Medicine I, University Hospital Olomouc, Czech Republic (M.T., J.V., E.K.); and Cardiocentre, Nemocnice Podlesí, Třinec, Czech Republic (M.B., I.N., O.J.)
| | - Petr Waldauf
- From the 3rd Department of Medicine, Centre for Hypertension, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., O.P., T.Z., R.H., B.Š., Z.Š., J.W.); Cardiocentre, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., P.W., P.T., K.Č., F.B.); Department of Anesthesiology, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (P.W.); Department of Internal Medicine I, University Hospital Olomouc, Czech Republic (M.T., J.V., E.K.); and Cardiocentre, Nemocnice Podlesí, Třinec, Czech Republic (M.B., I.N., O.J.)
| | - František Bednář
- From the 3rd Department of Medicine, Centre for Hypertension, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., O.P., T.Z., R.H., B.Š., Z.Š., J.W.); Cardiocentre, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., P.W., P.T., K.Č., F.B.); Department of Anesthesiology, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (P.W.); Department of Internal Medicine I, University Hospital Olomouc, Czech Republic (M.T., J.V., E.K.); and Cardiocentre, Nemocnice Podlesí, Třinec, Czech Republic (M.B., I.N., O.J.)
| | - Tomáš Zelinka
- From the 3rd Department of Medicine, Centre for Hypertension, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., O.P., T.Z., R.H., B.Š., Z.Š., J.W.); Cardiocentre, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., P.W., P.T., K.Č., F.B.); Department of Anesthesiology, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (P.W.); Department of Internal Medicine I, University Hospital Olomouc, Czech Republic (M.T., J.V., E.K.); and Cardiocentre, Nemocnice Podlesí, Třinec, Czech Republic (M.B., I.N., O.J.)
| | - Robert Holaj
- From the 3rd Department of Medicine, Centre for Hypertension, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., O.P., T.Z., R.H., B.Š., Z.Š., J.W.); Cardiocentre, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., P.W., P.T., K.Č., F.B.); Department of Anesthesiology, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (P.W.); Department of Internal Medicine I, University Hospital Olomouc, Czech Republic (M.T., J.V., E.K.); and Cardiocentre, Nemocnice Podlesí, Třinec, Czech Republic (M.B., I.N., O.J.)
| | - Branislav Štrauch
- From the 3rd Department of Medicine, Centre for Hypertension, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., O.P., T.Z., R.H., B.Š., Z.Š., J.W.); Cardiocentre, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., P.W., P.T., K.Č., F.B.); Department of Anesthesiology, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (P.W.); Department of Internal Medicine I, University Hospital Olomouc, Czech Republic (M.T., J.V., E.K.); and Cardiocentre, Nemocnice Podlesí, Třinec, Czech Republic (M.B., I.N., O.J.)
| | - Zuzana Šomlóová
- From the 3rd Department of Medicine, Centre for Hypertension, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., O.P., T.Z., R.H., B.Š., Z.Š., J.W.); Cardiocentre, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., P.W., P.T., K.Č., F.B.); Department of Anesthesiology, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (P.W.); Department of Internal Medicine I, University Hospital Olomouc, Czech Republic (M.T., J.V., E.K.); and Cardiocentre, Nemocnice Podlesí, Třinec, Czech Republic (M.B., I.N., O.J.)
| | - Miloš Táborský
- From the 3rd Department of Medicine, Centre for Hypertension, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., O.P., T.Z., R.H., B.Š., Z.Š., J.W.); Cardiocentre, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., P.W., P.T., K.Č., F.B.); Department of Anesthesiology, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (P.W.); Department of Internal Medicine I, University Hospital Olomouc, Czech Republic (M.T., J.V., E.K.); and Cardiocentre, Nemocnice Podlesí, Třinec, Czech Republic (M.B., I.N., O.J.)
| | - Jan Václavík
- From the 3rd Department of Medicine, Centre for Hypertension, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., O.P., T.Z., R.H., B.Š., Z.Š., J.W.); Cardiocentre, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., P.W., P.T., K.Č., F.B.); Department of Anesthesiology, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (P.W.); Department of Internal Medicine I, University Hospital Olomouc, Czech Republic (M.T., J.V., E.K.); and Cardiocentre, Nemocnice Podlesí, Třinec, Czech Republic (M.B., I.N., O.J.)
| | - Eva Kociánová
- From the 3rd Department of Medicine, Centre for Hypertension, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., O.P., T.Z., R.H., B.Š., Z.Š., J.W.); Cardiocentre, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., P.W., P.T., K.Č., F.B.); Department of Anesthesiology, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (P.W.); Department of Internal Medicine I, University Hospital Olomouc, Czech Republic (M.T., J.V., E.K.); and Cardiocentre, Nemocnice Podlesí, Třinec, Czech Republic (M.B., I.N., O.J.)
| | - Marian Branny
- From the 3rd Department of Medicine, Centre for Hypertension, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., O.P., T.Z., R.H., B.Š., Z.Š., J.W.); Cardiocentre, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., P.W., P.T., K.Č., F.B.); Department of Anesthesiology, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (P.W.); Department of Internal Medicine I, University Hospital Olomouc, Czech Republic (M.T., J.V., E.K.); and Cardiocentre, Nemocnice Podlesí, Třinec, Czech Republic (M.B., I.N., O.J.)
| | - Igor Nykl
- From the 3rd Department of Medicine, Centre for Hypertension, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., O.P., T.Z., R.H., B.Š., Z.Š., J.W.); Cardiocentre, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., P.W., P.T., K.Č., F.B.); Department of Anesthesiology, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (P.W.); Department of Internal Medicine I, University Hospital Olomouc, Czech Republic (M.T., J.V., E.K.); and Cardiocentre, Nemocnice Podlesí, Třinec, Czech Republic (M.B., I.N., O.J.)
| | - Otakar Jiravský
- From the 3rd Department of Medicine, Centre for Hypertension, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., O.P., T.Z., R.H., B.Š., Z.Š., J.W.); Cardiocentre, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., P.W., P.T., K.Č., F.B.); Department of Anesthesiology, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (P.W.); Department of Internal Medicine I, University Hospital Olomouc, Czech Republic (M.T., J.V., E.K.); and Cardiocentre, Nemocnice Podlesí, Třinec, Czech Republic (M.B., I.N., O.J.)
| | - Jiří Widimský
- From the 3rd Department of Medicine, Centre for Hypertension, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., O.P., T.Z., R.H., B.Š., Z.Š., J.W.); Cardiocentre, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., P.W., P.T., K.Č., F.B.); Department of Anesthesiology, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (P.W.); Department of Internal Medicine I, University Hospital Olomouc, Czech Republic (M.T., J.V., E.K.); and Cardiocentre, Nemocnice Podlesí, Třinec, Czech Republic (M.B., I.N., O.J.)
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