Renal sympathetic denervation lowers systemic vascular resistance in true treatment-resistant hypertension

Minimal dose resistance training enhances strength without affecting cardiac autonomic modulation in menopausal women: a randomized clinical trial

The proposition of a minimal dose of resistance training (RT) to elicit health benefits, encompassing physiological and psychological aspects, has garnered attention. While empirical investigations have demonstrated the efficacy of low-volume RT protocols in inducing adaptations such as enhanced strength and functional capacity, further exploration of the effects of this paradigm across a broader spectrum of variables is warranted. Thus, this study aimed to investigate the effects of minimal dose RT on strength and functional capacity, cardiac autonomic modulation, and hemodynamic parameters in menopausal women. Twenty-six women were randomly assigned to the training (TG: 63.2 ± 9.3 years) or control group (CG: 59.3 ± 7.6 years). Anthropometric measurements, strength and functional performance tests, cardiac autonomic assessment, and hemodynamic parameters were performed before and after four weeks of intervention. The TG performed the minimum dose RT twice weekly for four weeks (2 sets of 8-12 repetitions in three dynamic exercises, plus three 1-min isometric planks), and the CG had a weekly meeting with lectures and stretching. Two-way ANOVA with repeated measures was applied to each variable. Regarding time comparisons, there was a significant increase for LniRR (F = 4.78; ω2 = 0.046; p = 0.04), one repetition maximum (1RM) bench press (F = 8.06; ω2 = 0,013; p = 0.01), and 1RM leg press (F = 17.3; ω2 = 0,098; p < 0.01). There was a group*time interaction only for the index LnRMSSD (F = 5.11; ω2 = 0.042; p = 0.03), and 1RM bench press (F = 9.52; ω2 = 0,016; p = 0.01). No between-group main effect for any variable was found. The minimal dose RT protocol improved muscle strength, while cardiac autonomic and hemodynamic variables, as well as functional capacity, remained stable over 4 weeks in menopausal women.

Intravascular Renal Denervation Reduces Ambulatory and Office Blood Pressure in Patients with Essential Hypertension: A Meta-Analysis of Randomized Sham-Controlled Trials

BACKGROUND

This meta-analysis was designed to evaluate the antihypertensive efficacy of intravascular renal denervation (RDN) in patients with essential hypertension, especially to determine the magnitude of blood pressure (BP) reduction with RDN therapy using second-generation catheters.

METHODS

PubMed was searched to identify randomized sham-controlled trials from inception through August 2021. The endpoints were changes in 24-h ambulatory BP or office BP. This meta-analysis was performed by calculating the weighted mean difference (WMD) with 95% confidence interval (CI) using the random-effects model when the I2 index was <50%. A fixed-effects model was used when the I2 index was ≥50%.

RESULTS

A total of 1,297 patients were included in 8 randomized, sham-controlled trials in this meta-analysis. Intravascular RDN reduced 24-h ambulatory systolic BP (SBP) -3.02 (WMD, 95% CI: -4.95, -1.10, p < 0.01) and diastolic BP (DBP) -1.66 (WMD, 95% CI: -2.44, -0.88, p < 0.001) mm Hg, respectively. In the studies using first-generation catheters, the WMDs of 24-h ambulatory SBP and DBP changes between intravascular RDN and sham control were -2.67 (95% CI: -5.08, -0.27; p < 0.05; I2 = 0%, p = 0.53) and -0.82 (95% CI: -2.19, 0.56; p > 0.05; I2 = 0%, p = 0.64) mm Hg. In the studies using second-generation catheters, the WMDs of 24-h ambulatory SBP and DBP changes between intravascular RDN and sham control were -3.14 (95% CI: -5.94, -0.33, p < 0.05; I2 = 71%, p = 0.008) and -2.06 (95% CI: -3.02, -1.11, p < 0.001; I2 = 50%, p = 0.09) mm Hg. Intravascular RDN using second-generation catheters reduced office SBP -6.30 (WMD, 95% CI: -7.67, -4.93, p < 0.001; I2 = 43%, p = 0.14) and DBP -3.88 (WMD, 95% CI: -4.44, -3.33, p < 0.001; I2 = 42%, p = 0.14) mm Hg, respectively.

CONCLUSIONS

Intravascular RDN using second-generation catheters reduces ambulatory and office BP in patients with essential hypertension. The selection of appropriate hypertensive patients may be the major challenge for the performance of intravascular RDN in routine clinical practice.

Renal denervation for resistant hypertension

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.