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Stabile E, Muiesan ML, Ribichini FL, Sangiorgi G, Taddei S, Versaci F, Villari B, Bacca A, Benedetto D, Fioretti V, Laurenzano E, Scapaticci M, Saia F, Tarantini G, Grassi G, Esposito G. Italian Society of Interventional Cardiology (GISE) and Italian Society of Arterial Hypertension (SIIA) Position Paper on the role of renal denervation in the management of the difficult-to-treat hypertension. Minerva Cardiol Angiol 2024; 72:313-328. [PMID: 38535984 DOI: 10.23736/s2724-5683.23.06433-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/28/2024]
Abstract
Renal denervation (RDN) is a safe and effective strategy for the treatment of difficult to treat hypertension. The blood pressure (BP)-lowering efficacy of RDN is comparable to those of many single antihypertensive medications and it allows to consider the RDN as a valuable option for the treatment of difficult to treat hypertension together with lifestyle modifications and medical therapy. A multidisciplinary team is of pivotal importance from the selection of the patient candidate for the procedure to the post-procedural management. Further studies are needed to investigate the effect of RDN on clinical outcomes and to better identify the predictors of BP response to RDN in order to recognize the patients who are more likely to benefit from the procedure.
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Affiliation(s)
- Eugenio Stabile
- Division of Cardiology, Cardiovascular Department, Azienda Ospedaliera Regionale "San Carlo", Potenza, Italy
| | - Maria L Muiesan
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Flavio L Ribichini
- Division of Cardiovascular Medicine, Department of Medicine, University of Verona, Verona, Italy
| | | | - Stefano Taddei
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | | | - Bruno Villari
- Division of Cardiology, Sacro Cuore di Gesù Hospital, Benevento, Italy
| | - Alessandra Bacca
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Daniela Benedetto
- Division of Cardiology, Tor Vergata University Hospital, Rome, Italy
| | - Vincenzo Fioretti
- Division of Cardiology, Cardiovascular Department, Azienda Ospedaliera Regionale "San Carlo", Potenza, Italy
- Division of Cardiology, Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | | | | | - Francesco Saia
- Cardiology Unit, Cardio-Thoraco-Vascular Department, IRCCS University Hospital of Bologna, Policlinico S. Orsola, Bologna, Italy
| | - Giuseppe Tarantini
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua Medical School, Padua, Italy
| | - Guido Grassi
- Clinica Medica, University of Milano-Bicocca, Milan, Italy
| | - Giovanni Esposito
- Division of Cardiology, Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy -
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Sharp AS, Sanderson A, Hansell N, Reddish K, Miller P, Moss J, Schmieder RE, McCool R. Renal denervation for uncontrolled hypertension: a systematic review and meta-analysis examining multiple subgroups. J Hypertens 2024; 42:1133-1144. [PMID: 38634457 PMCID: PMC11139244 DOI: 10.1097/hjh.0000000000003727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 03/04/2024] [Accepted: 03/12/2024] [Indexed: 04/19/2024]
Abstract
This systematic review and meta-analysis was conducted to assess the randomized controlled trial (RCT) evidence available for renal denervation (RDN) in uncontrolled arterial hypertension. Twenty-five RCTs met the eligibility criteria for the systematic review, and 16 RCTs were included in the meta-analysis. The results of the random effects meta-analysis estimated a mean difference of -8.5 mmHg [95% confidence interval (CI) -13.5 to -3.6] for office SBP, -3.6 mmHg (95% CI -5.2 to -2.0) for 24 h SBP and -3.9 mmHg (95% CI -5.6 to -2.2) for ambulatory daytime SBP in favour of RDN compared with control (medication and/or sham-only) at primary follow-up. Similarly favourable results were observed across a range of prespecified subgroup analyses, including treatment-resistant hypertension. This meta-analysis suggests that the use of RDN in uncontrolled hypertension leads to consistent reductions in blood pressure. Reductions appear to be statistically consistent in the presence or absence of medications and in populations resistant to the use of three medications.
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Affiliation(s)
| | - Alice Sanderson
- York Health Economics Consortium Ltd, York Science Park, York, UK
| | - Neil Hansell
- York Health Economics Consortium Ltd, York Science Park, York, UK
| | - Katie Reddish
- York Health Economics Consortium Ltd, York Science Park, York, UK
| | - Paul Miller
- York Health Economics Consortium Ltd, York Science Park, York, UK
| | - Joe Moss
- York Health Economics Consortium Ltd, York Science Park, York, UK
| | - Roland E. Schmieder
- Department of Nephrology and Hypertension University Hospital Erlangen, Friedrich Alexander University Erlangen/Nürnberg, Germany
| | - Rachael McCool
- York Health Economics Consortium Ltd, York Science Park, York, UK
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Agwuegbo CC, Antia AU, Shamaki GR, Bob-Manuel T. Controversies related to renal artery denervation and devices. Curr Opin Cardiol 2024; 39:244-250. [PMID: 38567924 DOI: 10.1097/hco.0000000000001146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Abstract
PURPOSE OF REVIEW This review article discusses the controversies, strengths, and limitations of the current literature on renal artery denervation in the management of resistant hypertension, as well as the future directions of this intervention. RECENT FINDINGS There have been conflicting data from the different randomized control trials assessing the efficacy of renal artery denervation in the management of resistant hypertension. SUMMARY Renal artery denervation is achieved by ablating the sympathetic nerves surrounding the renal arteries using endovascular ultrasound, radiofrequency, or alcohol. Our review article highlights that renal artery denervation is generally effective in improving blood pressure in patients with resistant hypertension. The Food and Drug Administration (FDA) has recently approved the ReCor Medical Paradise system, and the Symplicity Spyral RDN systems for renal artery denervation.
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Affiliation(s)
| | | | | | - Tamunoinemi Bob-Manuel
- Division of Cardiovascular Diseases, University of Tennessee Health Science Center, Memphis, Tennessee, USA
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Vukadinović D, Lauder L, Kandzari DE, Bhatt DL, Kirtane A, Edelman ER, Schmieder RE, Azizi M, Böhm M, Mahfoud F. Effects of catheter-based renal denervation in hypertension: a systematic review and meta-analysis. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.06.12.24308869. [PMID: 38946962 PMCID: PMC11213059 DOI: 10.1101/2024.06.12.24308869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/02/2024]
Abstract
Background Several sham-controlled trials have investigated the efficacy and safety of catheter-based renal denervation (RDN) with mixed outcomes. Aim To perform a comprehensive meta-analysis of all randomized, sham-controlled trials investigating RDN with first- and second-generation devices in hypertension. Methods We searched MEDLINE and Cochrane Library for eligible trials. Outcomes included both efficacy (24-hour and office systolic [SBP] and diastolic blood pressure [DBP]) and safety (all-cause death, vascular complication, renal artery stenosis >70%, hypertensive crisis) of RDN. We performed a study-level, pairwise, random-effects meta-analysis of the summary data. Results Ten trials comprising 2,478 patients with hypertension while being either off- or on-treatment were included. Compared with sham, RDN reduced 24-hour and office systolic BP by 4.4 mmHg (95%CI -6.1, -2.7, p<0.00001) and 6.6 mmHg (95%CI -9.7, -3.6, p<0.0001), respectively. The 24-hour and office diastolic BP paralleled these findings (-2.6 mmHg, 95%CI - 3.6, -1.5, p<0.00001; -3.5 mmHg, 95%CI -5.4, -1.6, p=0.0003). There was no difference in 24-hour and office SBP reduction between trials with and without concomitant antihypertensive medication (p for interaction 0.62 and 0.73, respectively). There was no relevant difference concerning vascular complications (OR 1.69, 95%CI 0.57-5.0, p=0.34), renal artery stenosis (OR 1.50, 95%CI 0.06-36.97, p=0.80), hypertensive crisis (OR 0.65, 95%CI 0.30-1.38, p=0.26) and all-cause death (OR 1.76, 95%CI 0.34-9.20, p=0.50) between RDN and sham groups. Change of renal function based on eGFR was comparable between groups (p for interaction 0.84). There was significant heterogeneity between trials. Conclusions RDN safely reduces ambulatory and office SBP/DBP vs. a sham procedure in the presence and absence of antihypertensive medication. Clinical Perspective What is new?Several sham-controlled trials have investigated the efficacy and safety of catheter-based renal denervation (RDN) with mixed outcomes.This comprehensive meta-analysis comprising 2,478 patients shows that irrespective of the utilized method (radiofrequency-, ultrasound-or alcohol-mediated), renal denervation effectively reduced ambulatory and office systolic blood pressure.Renal denervation exhibited no additional risk concerning vascular injury or renal function impairment.What are the clinical implications?This meta-analysis supports current guidelines/consensus statements that renal denervation represents an additive treatment option in carefully selected patients with uncontrolled hypertension.
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Vogt A, Plehn A, Atti C, Nussbaum M, Tongers J, Sedding D, Dutzmann J. Left ventricular structure and function following renal sympathetic denervation in patients with HFpEF: an echocardiographic 9-year long-term follow-up. Front Cardiovasc Med 2024; 11:1408547. [PMID: 38919545 PMCID: PMC11196750 DOI: 10.3389/fcvm.2024.1408547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Accepted: 05/23/2024] [Indexed: 06/27/2024] Open
Abstract
Background High blood pressure is a major risk factor for cardiac remodeling and left ventricular hypertrophy, increasing cardiovascular risk and leading to heart failure with preserved ejection fraction (HFpEF). Since renal sympathetic denervation (RDN) reduces blood pressure in the long term, we aimed to investigate the long-term effect of RDN in patients with HFpEF in the present analysis. Methods Patients previously enrolled in a local RDN registry who underwent high-frequency RDN with the use of the Symplicity Flex® renal denervation system between 2011 and 2014 were followed up. The patients were assessed by 24-h ambulatory blood pressure measurement, transthoracic echocardiography, and laboratory tests. We used the echocardiographic and biomarker criteria of the Heart Failure Association (HFA)-PEFF (Pre-test assessment, Echocardiography and Natriuretic Peptide Score, Funkctional testing, and Final aetiology) score to identify patients with HFpEF. Results Echocardiographic assessment was available for 70 patients at a 9-year long-term follow-up. Of these patients, 21 had HFpEF according to the HFA-PEFF score. We found a significant reduction of the HFA-PEFF score from 5.48 ± 0.51 points at baseline to 4.33 ± 1.53 points at the 9-year follow-up (P < 0.01). This decrease was due to a greater reduction in morphological and biomarker subcategories [from 1.95 ± 0.22 to 1.43 ± 0.51 points (P < 0.01) and from 1.52 ± 0.52 to 0.90 ± 0.63 points (P < 0.01), respectively] than in the functional one. Morphologically, there was a reduction in left ventricular hypertrophy and left atrial dilation. Conclusions The present analysis suggests that RDN may lead to a regression of the extent of HFpEF beyond a reduction in blood pressure and thus possibly contribute to an improvement in prognosis. More detailed information will be provided by ongoing randomized sham-controlled trials.
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Affiliation(s)
- Alexander Vogt
- Department of Internal Medicine III, University Hospital Halle (Saale), Halle (Saale), Germany
| | - Alexander Plehn
- Department of Internal Medicine III, University Hospital Halle (Saale), Halle (Saale), Germany
- Praxisklinik Salzatal, Salzatal, Germany
| | - Carlo Atti
- Department of Internal Medicine, Medical University Graz, Graz, Austria
| | - Michael Nussbaum
- Department of Internal Medicine III, University Hospital Halle (Saale), Halle (Saale), Germany
| | - Jörn Tongers
- Department of Internal Medicine III, University Hospital Halle (Saale), Halle (Saale), Germany
| | - Daniel Sedding
- Department of Internal Medicine III, University Hospital Halle (Saale), Halle (Saale), Germany
| | - Jochen Dutzmann
- Department of Internal Medicine III, University Hospital Halle (Saale), Halle (Saale), Germany
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Ogoyama Y, Abe M, Okamura K, Tada K, Katsurada K, Shibata S, Kai H, Rakugi H, Node K, Yokoi H, Kario K, Arima H. Effects of renal denervation on blood pressure in patients with hypertension: a latest systematic review and meta-analysis of randomized sham-controlled trials. Hypertens Res 2024:10.1038/s41440-024-01739-y. [PMID: 38831091 DOI: 10.1038/s41440-024-01739-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Revised: 04/29/2024] [Accepted: 05/13/2024] [Indexed: 06/05/2024]
Abstract
The efficacy of renal denervation (RDN) has been controversial, but recent randomized sham-controlled trials demonstrated significant blood pressure reductions after RDN in patients with hypertension. We conducted a systematic review and updated meta-analysis to evaluate the effects of RDN on ambulatory and office blood pressures in patients with hypertension. Databases were searched up to 15 November 2023 to identify randomized, sham-controlled trials of RDN. The primary endpoint was change in 24 h ambulatory systolic blood pressure (SBP) with RDN versus sham control. The secondary endpoints were changes in 24 h ambulatory diastolic blood pressure, daytime and nighttime blood pressure (BP), office BP, and home BP. A sub-analysis determined outcomes by medication, procedure, and device. From twelve trials, 2222 patients with hypertension were randomized to undergo RDN (n = 1295) or a sham procedure (n = 927). At 2-6 months after treatment, RDN significantly reduced 24 h ambulatory SBP by 2.81 mmHg (95% confidence interval: -4.09, -1.53; p < 0.001) compared with the sham procedure. RDN also reduced daytime SBP by 3.17 mmHg (- 4.75, - 1.58; p < 0.001), nighttime SBP by 3.41 mmHg (- 4.69, - 2.13; p < 0.001), office SBP by 4.95 mmHg (- 6.37, - 3.54; p < 0.001), and home SBP by 4.64 mmHg (- 7.44, - 1.84; p = 0.001) versus the sham control group. There were no significant differences in the magnitude of BP reduction between first- and second-generation trials, between devices, or between with or without medication. These data from randomized sham-controlled trials showed that RDN significantly reduced all blood pressure metrics in medicated or unmedicated patients with hypertension, including resistant/uncontrolled hypertension.
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Affiliation(s)
- Yukako Ogoyama
- Division of Cardiovascular Medicine, Jichi Medical University School of Medicine, Tochigi, Japan
| | - Makiko Abe
- Department of Preventive Medicine and Public Health, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Keisuke Okamura
- Department of Cardiology and Cardiovascular Center, Imamura Hospital, Tosu, Saga, Japan
| | - Kazuhiro Tada
- Division of Nephrology and Rheumatology, Department of Internal Medicine, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Kenichi Katsurada
- Division of Cardiovascular Medicine, Jichi Medical University School of Medicine, Tochigi, Japan
| | - Shigeru Shibata
- Division of Nephrology, Department of Internal Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Hisashi Kai
- Department of Cardiology, Kurume University Medical Center, Fukuoka, Japan
| | - Hiromi Rakugi
- Division of Health Sciences, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Koichi Node
- Department of Cardiovascular Medicine, Saga University, Saga, Japan
| | - Hiroyoshi Yokoi
- Cardiovascular Center, Fukuoka Sanno Hospital, Fukuoka, Japan
| | - Kazuomi Kario
- Division of Cardiovascular Medicine, Jichi Medical University School of Medicine, Tochigi, Japan.
| | - Hisatomi Arima
- Department of Preventive Medicine and Public Health, Faculty of Medicine, Fukuoka University, Fukuoka, Japan.
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Sesa-Ashton G, Nolde JM, Muente I, Carnagarin R, Macefield VG, Dawood T, Lambert EA, Lambert GW, Walton A, Esler MD, Schlaich MP. Long-Term Blood Pressure Reductions Following Catheter-Based Renal Denervation: A Systematic Review and Meta-Analysis. Hypertension 2024; 81:e63-e70. [PMID: 38506059 DOI: 10.1161/hypertensionaha.123.22314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 03/05/2024] [Indexed: 03/21/2024]
Abstract
BACKGROUND Renal denervation is a recognized adjunct therapy for hypertension with clinically significant blood pressure (BP)-lowering effects. Long-term follow-up data are critical to ascertain durability of the effect and safety. Aside from the 36-month follow-up data available from randomized control trials, recent cohort analyses extended follow-up out to 10 years. We sought to analyze study-level data and quantify the ambulatory BP reduction of renal denervation across contemporary randomized sham-controlled trials and available long-term follow-up data up to 10 years from observational studies. METHODS A systematic review was performed with data from 4 observational studies with follow-up out to 10 years and 2 randomized controlled trials meeting search and inclusion criteria with follow-up data out to 36 months. Study-level data were extracted and compared statistically. RESULTS In 2 contemporary randomized controlled trials with 36-month follow-up, an average sham-adjusted ambulatory systolic BP reduction of -12.7±4.5 mm Hg from baseline was observed (P=0.05). Likewise, a -14.8±3.4 mm Hg ambulatory systolic BP reduction was found across observational studies with a mean long-term follow-up of 7.7±2.8 years (range, 3.5-9.4 years; P=0.0051). The observed reduction in estimated glomerular filtration rate across the long-term follow-up was in line with the predicted age-related decline. Antihypertensive drug burden was similar at baseline and follow-up. CONCLUSIONS Renal denervation is associated with a significant and clinically meaningful reduction in ambulatory systolic BP in both contemporary randomized sham-controlled trials up to 36 months and observational cohort studies up to 10 years without adverse consequences on renal function.
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Affiliation(s)
- Gianni Sesa-Ashton
- Human Neurotransmitter and Neurovascular Hypertension & Kidney Diseases Laboratories (G.S.-A., E.A.L., G.W.L., M.D.E., M.P.S.), Baker Heart and Diabetes Institute, Melbourne Australia
- Human Autonomic Neurophysiology Laboratory (G.S.-A., V.G.M., T.D.), Baker Heart and Diabetes Institute, Melbourne Australia
- Department of Neuroscience, Monash University, Melbourne Australia (G.S.-A., V.G.M., T.D.)
| | - Janis M Nolde
- Dobney Hypertension Centre, Medical School - Royal Perth Hospital Unit and RPH Research Foundation, The University of Western Australia, Australia (J.M.N., I.M., R.C., M.P.S.)
| | - Ida Muente
- Dobney Hypertension Centre, Medical School - Royal Perth Hospital Unit and RPH Research Foundation, The University of Western Australia, Australia (J.M.N., I.M., R.C., M.P.S.)
| | - Revathy Carnagarin
- Dobney Hypertension Centre, Medical School - Royal Perth Hospital Unit and RPH Research Foundation, The University of Western Australia, Australia (J.M.N., I.M., R.C., M.P.S.)
| | - Vaughan G Macefield
- Human Autonomic Neurophysiology Laboratory (G.S.-A., V.G.M., T.D.), Baker Heart and Diabetes Institute, Melbourne Australia
- Department of Neuroscience, Monash University, Melbourne Australia (G.S.-A., V.G.M., T.D.)
| | - Tye Dawood
- Human Autonomic Neurophysiology Laboratory (G.S.-A., V.G.M., T.D.), Baker Heart and Diabetes Institute, Melbourne Australia
- Department of Neuroscience, Monash University, Melbourne Australia (G.S.-A., V.G.M., T.D.)
| | - Elisabeth A Lambert
- Human Neurotransmitter and Neurovascular Hypertension & Kidney Diseases Laboratories (G.S.-A., E.A.L., G.W.L., M.D.E., M.P.S.), Baker Heart and Diabetes Institute, Melbourne Australia
- Iverson Health Innovation Research Institute & School of Health Sciences, Swinburne University of Technology, Melbourne, Australia (E.A.L., G.W.L.)
| | - Gavin W Lambert
- Human Neurotransmitter and Neurovascular Hypertension & Kidney Diseases Laboratories (G.S.-A., E.A.L., G.W.L., M.D.E., M.P.S.), Baker Heart and Diabetes Institute, Melbourne Australia
- Iverson Health Innovation Research Institute & School of Health Sciences, Swinburne University of Technology, Melbourne, Australia (E.A.L., G.W.L.)
| | - Antony Walton
- Department of Cardiology, Alfred Health, Melbourne, Vic, Australia (A.W., M.D.E.)
| | - Murray D Esler
- Human Neurotransmitter and Neurovascular Hypertension & Kidney Diseases Laboratories (G.S.-A., E.A.L., G.W.L., M.D.E., M.P.S.), Baker Heart and Diabetes Institute, Melbourne Australia
- Department of Cardiology, Alfred Health, Melbourne, Vic, Australia (A.W., M.D.E.)
| | - Markus P Schlaich
- Human Neurotransmitter and Neurovascular Hypertension & Kidney Diseases Laboratories (G.S.-A., E.A.L., G.W.L., M.D.E., M.P.S.), Baker Heart and Diabetes Institute, Melbourne Australia
- Dobney Hypertension Centre, Medical School - Royal Perth Hospital Unit and RPH Research Foundation, The University of Western Australia, Australia (J.M.N., I.M., R.C., M.P.S.)
- Department of Cardiology and Department of Nephrology, Royal Perth Hospital, WA, Australia (M.P.S.)
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Wang J, Yin Y, Lu C, Lu Z, Hu J, Wang Y, Ge J, Jiang H, Yao C, Yan X, Ma W, Qi X, Dang Y, Chen S, Zhu J, Wang D, Ding C, Wang W, Liu J, Wang Y, Li H, Pan Z, Cui K, Li C, Liang X, Chen W, Sobotka PA, Zhang J, Esler M, Sun N, Chen M, Huo Y. Efficacy and safety of sympathetic mapping and ablation of renal nerves for the treatment of hypertension (SMART): 6-month follow-up of a randomised, controlled trial. EClinicalMedicine 2024; 72:102626. [PMID: 38756107 PMCID: PMC11096821 DOI: 10.1016/j.eclinm.2024.102626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Revised: 04/17/2024] [Accepted: 04/17/2024] [Indexed: 05/18/2024] Open
Abstract
Background Previous trials of renal denervation (RDN) have been designed to investigate reduction of blood pressure (BP) as the primary efficacy endpoint using non-selective RDN without intraoperatively verified RDN success. It is an unmet clinical need to map renal nerves, selectively denervate renal sympathetic nerves, provide readouts for the interventionalists and avoid futile RDN. We aimed to examine the safety and efficacy of renal nerve mapping/selective renal denervation (msRDN) in patients with uncontrolled hypertension (HTN) and determine whether antihypertensive drug burden is reduced while office systolic BP (OSBP) is controlled to target level (<140 mmHg). Methods We conducted a randomized, prospective, multicenter, single-blinded, sham-controlled trial. The study combined two efficacy endpoints at 6 months as primary outcomes: The control rate of patients with OSBP <140 mmHg (non-inferior outcome) and change in the composite index of antihypertensive drugs (Drug Index) in the treatment versus Sham group (superior outcome). This design avoids confounding from excess drug-taking in the Sham group. Antihypertensive drug burden was assessed by a composite index constructed as: Class N (number of classes of antihypertensive drugs) × (sum of doses). 15 hospitals in China participated in the study and 220 patients were enrolled in a 1:1 ratio (msRDN vs Sham). The key inclusion criteria included: age (18-65 years old), history of essential HTN (at least 6 months), heart rate (≥70 bpm), OSBP (≥150 mmHg and ≤180 mmHg), ambulatory BP monitoring (ABPM, 24-h SBP ≥130 mmHg or daytime SBP ≥135 mmHg or nighttime SBP ≥120 mmHg), renal artery stenosis (<50%) and renal function (eGFR >45 mL/min/1.73 m2). The catheter with both stimulation and ablation functions was inserted in the distal renal main artery. The RDN site (hot spot) was selected if SBP increased (≥5 mmHg) by intra-renal artery (RA) electrical stimulation; an adequate RDN was confirmed by repeated electronic stimulation if no increase in BP otherwise, a 2nd ablation was performed at the same site. At sites where there was decreased SBP (≥5 mmHg, cold spot) or no BP response (neutral spot) to stimulation, no ablation was performed. The mapping, ablation and confirmation procedure was repeated until the entire renal main artery had been tested then either treated or avoided. After msRDN, patients had to follow a predefined, vigorous drug titration regimen in order to achieve target OSBP (<140 mmHg). Drug adherence was monitored by liquid chromatography-tandem mass spectrometry analysis using urine. This study is registered with ClinicalTrials.gov (NCT02761811) and 5-year follow-up is ongoing. Findings Between July 8, 2016 and February 23, 2022, 611 patients were consented, 220 patients were enrolled in the study who received standardized antihypertensive drug treatments (at least two drugs) for at least 28 days, presented OSBP ≥150 mmHg and ≤180 mmHg and met all inclusion and exclusion criteria. In left RA and right RA, mapped sites were 8.2 (3.0) and 8.0 (2.7), hot/ablated sites were 3.7 (1.4) and 4.0 (1.6), cold spots were 2.4 (2.6) and 2.0 (2.2), neutral spots were 2.0 (2.1) and 2.0 (2.1), respectively. Hot, cold and neutral spots was 48.0%, 27.5% and 24.4% of total mapped sites, respectively. At 6 M, the Control Rate of OSBP was comparable between msRDN and Sham group (95.4% vs 92.8%, p = 0.429), achieved non-inferiority margin -10% (2.69%; 95% CI -4.11%, 9.83%, p < 0.001 for non-inferiority); the change in Drug Index was significantly lower in msRDN group compared to Sham group (4.37 (6.65) vs 7.61 (10.31), p = 0.010) and superior to Sham group (-3.25; 95% CI -5.56, -0.94, p = 0.003), indicating msRDN patients need significantly fewer drugs to control OSBP <140 mmHg. 24-hour ambulatory SBP decreased from 146.8 (13.9) mmHg by 10.8 (14.1) mmHg, and from 149.8 (12.8) mmHg by 10.0 (14.0) mmHg in msRDN and Sham groups, respectively (p < 0.001 from Baseline; p > 0.05 between groups). Safety profiles were comparable between msRDN and Sham groups, demonstrating the safety and efficacy of renal mapping/selective RDN to treat uncontrolled HTN. Interpretation The msRDN therapy achieved the goals of reducing the drug burden of HTN patients and controlling OSBP <140 mmHg, with only approximately four targeted ablations per renal main artery, much lower than in previous trials. Funding SyMap Medical (Suzhou), LTD, Suzhou, China.
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Affiliation(s)
- Jie Wang
- The First Affiliated Hospital with Nanjing Medical University, Nanjing, 210029, China
- Division of Cardiology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, NY, 10032, USA
| | - Yuehui Yin
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China
| | - Chengzhi Lu
- Department of Cardiology, Tianjin First Central Hospital, Tianjin, 300190, China
| | - Zhibing Lu
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, 430060, China
- Department of Cardiology, Zhongnan Hospital, Wuhan University, Wuhan, 430071, China
| | - Jialu Hu
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai, 200032, China
| | - Yue Wang
- The First Affiliated Hospital with Nanjing Medical University, Nanjing, 210029, China
| | - Junbo Ge
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai, 200032, China
| | - Hong Jiang
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, 430060, China
| | - Chen Yao
- Peking University Health Science Center, Beijing, 100034, China
| | - Xiaoyan Yan
- Peking University Health Science Center, Beijing, 100034, China
| | - Wei Ma
- Department of Cardiology, Peking University First Hospital, Beijing, 100034, China
| | - Xiaoyong Qi
- Department of Cardiology, Hebei General Hospital, Shijiazhuang, 050057, China
| | - Yi Dang
- Department of Cardiology, Hebei General Hospital, Shijiazhuang, 050057, China
| | - Shaoliang Chen
- Department of Cardiology, Nanjing First Hospital, Nanjing, 210012, China
| | - Jiancheng Zhu
- Department of Cardiology, Nanjing First Hospital, Nanjing, 210012, China
| | - Dongmei Wang
- Department of Cardiology, Norman Bethune International Peace Hospital, Shijiazhuang, 050082, China
| | - Chao Ding
- Department of Cardiology, Norman Bethune International Peace Hospital, Shijiazhuang, 050082, China
| | - Weimin Wang
- Department of Cardiology, Peking University People's Hospital, Beijing, 100044, China
| | - Jian Liu
- Department of Cardiology, Peking University People's Hospital, Beijing, 100044, China
| | - Yanbin Wang
- Department of Cardiology, Taiyuan Central Hospital, Taiyuan, 030009, China
| | - Hui Li
- Department of Cardiology, Daqing Oilfield General Hospital, Daqing, 163458, China
| | - Zhenhua Pan
- Department of Cardiology, Daqing Oilfield General Hospital, Daqing, 163458, China
| | - Kaijun Cui
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, 332001, China
| | - Chengzong Li
- Department of Cardiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, 221002, China
| | - Xinjian Liang
- Department of Cardiology, Shenzhen People's Hospital, Shenzhen, Guangdong, 430060, China
| | - Weijie Chen
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China
| | - Paul A. Sobotka
- Department of Cardiology, The Ohio State University College of Medicine, Columbus, OH, 43210, USA
| | | | - Murray Esler
- Baker IDI Heart and Diabetes Institute, Melbourne, Australia
| | - Ningling Sun
- Department of Hypertension, Heart Center, Peking University People's Hospital, Beijing, 100044, China
| | - Minglong Chen
- Department of Cardiology, The First Affiliated Hospital with Nanjing Medical University, Nanjing, 210029, China
| | - Yong Huo
- Department of Cardiology, Peking University First Hospital, Beijing, 100034, China
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9
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Esler MD, Osborn JW, Schlaich MP. Sympathetic Pathophysiology in Hypertension Origins: The Path to Renal Denervation. Hypertension 2024; 81:1194-1205. [PMID: 38557153 DOI: 10.1161/hypertensionaha.123.21715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
The importance of the sympathetic nervous system in essential hypertension has been recognized in 2 eras. The first was in early decades of the 20th century, through to the 1960s. Here, the sympathetic nervous system was identified as a target for the treatment of hypertension, and an extensive range of antiadrenergic therapies were developed. Then, after a period of lapsed interest, in a second era from 1985 on, the development of precise measures of human sympathetic nerve firing and transmitter release allowed demonstration of the importance of neural mechanisms in the initiation and maintenance of the arterial blood pressure elevation in hypertension. This led to the development of a device treatment of hypertension, catheter-based renal denervation, which we will discuss.
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Affiliation(s)
- Murray D Esler
- Human Neurotransmitter Laboratory, Baker Heart and Diabetes Institute, Melbourne, VIC, Australia (M.D.E., M.P.S.)
| | - John W Osborn
- Department of Surgery, Medical School, University of Minnesota, Minneapolis (J.W.O.)
| | - Markus P Schlaich
- Human Neurotransmitter Laboratory, Baker Heart and Diabetes Institute, Melbourne, VIC, Australia (M.D.E., M.P.S.)
- Dobney Hypertension Centre, Medical School, Royal Perth Hospital Unit and RPH Research Foundation, The University of Western Australia (M.P.S.)
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10
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Sarafidis P, Schmieder R, Burnier M, Persu A, Januszewicz A, Halimi JM, Arici M, Ortiz A, Wanner C, Mancia G, Kreutz R. A European Renal Association (ERA) synopsis for nephrology practice of the 2023 European Society of Hypertension (ESH) Guidelines for the Management of Arterial Hypertension. Nephrol Dial Transplant 2024; 39:929-943. [PMID: 38365947 PMCID: PMC11139525 DOI: 10.1093/ndt/gfae041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2023] [Indexed: 02/18/2024] Open
Abstract
In June 2023, the European Society of Hypertension (ESH) presented and published the new 2023 ESH Guidelines for the Management of Arterial Hypertension, a document that was endorsed by the European Renal Association (ERA). Following the evolution of evidence in recent years, several novel recommendations relevant to the management of hypertension in patients with chronic kidney disease (CKD) appeared in these Guidelines. These include recommendations for target office blood pressure (BP) <130/80 mmHg in most and against target office BP <120/70 mmHg in all patients with CKD; recommendations for use of spironolactone or chlorthalidone for patients with resistant hypertension with estimated glomerular filtration rate (eGFR) higher or lower than 30 mL/min/1.73 m2, respectively; use of a sodium-glucose cotransporter 2 inhibitor for patients with CKD and estimated eGFR ≥20 mL/min/1.73 m2; use of finerenone for patients with CKD, type 2 diabetes mellitus, albuminuria, eGFR ≥25 mL/min/1.73 m2 and serum potassium <5.0 mmol/L; and revascularization in patients with atherosclerotic renovascular disease and secondary hypertension or high-risk phenotypes if stenosis ≥70% is present. The present report is a synopsis of sections of the ESH Guidelines that are relevant to the daily clinical practice of nephrologists, prepared by experts from ESH and ERA. The sections summarized are those referring to the role of CKD in hypertension staging and cardiovascular risk stratification, the evaluation of hypertension-mediated kidney damage and the overall management of hypertension in patients with CKD.
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Affiliation(s)
- Pantelis Sarafidis
- 1st Department of Nephrology, Aristotle University of Thessaloniki, Hippokration Hospital, Thessaloniki, Greece
| | - Roland Schmieder
- Department of Nephrology and Hypertension, University Hospital Erlangen, Germany
| | - Michel Burnier
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - Alexandre Persu
- Division of Cardiology, Cliniques Universitaires Saint-Luc and Pole of Cardiovascular Research, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
| | - Andrzej Januszewicz
- Department of Hypertension, National Institute of Cardiology, Warsaw, Poland
| | - Jean-Michel Halimi
- Service de Néphrologie-Hypertension, Dialyses, Transplantation rénale, CHRU Tours, Tours, France and INSERM SPHERE U1246, Université Tours, Université de Nantes, Tours, France
| | - Mustafa Arici
- Department of Nephrology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Alberto Ortiz
- Department of Nephrology and Hypertension, IIS-Fundacion Jimenez Diaz UAM, Madrid, Spain
| | | | | | - Reinhold Kreutz
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institut für Klinische Pharmakologie und Toxikologie, Berlin, Germany
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11
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Parodi R, Brandani L, Romero C, Klein M. Resistant hypertension: Diagnosis, evaluation, and treatment practical approach. Eur J Intern Med 2024; 123:23-28. [PMID: 38228447 DOI: 10.1016/j.ejim.2023.12.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 12/24/2023] [Accepted: 12/29/2023] [Indexed: 01/18/2024]
Abstract
The term RH describes a subgroup of hypertensive patients whose BP is uncontrolled despite the use of at least three antihypertensive drugs in an appropriate combination at optimal or best tolerated doses. True RH is considered when appropriate lifestyle measures and treatment with optimal or best tolerated doses of three or more drugs (a thiazide/thiazide-like diuretic, plus renin-angiotensin system -RAS- blocker and a calcium channel blocker -CCB-) fail to lower office BP to <140/90 mmHg; besides the inadequate BP control should be confirmed by home blood pressure monitoring (HBPM) or 24-hour ambulatory; and evidence of adherence to therapy and exclusion of secondary causes of hypertension are required. RH patients are at a high risk of cardiovascular events and death. RH is associated with a higher prevalence of end-organ damage. When stricter criteria are applied, a reasonable estimate of the prevalence of true RH is 5 % of the total hypertensive population. The predominant hemodynamic pattern appears to be increased systemic vascular resistance and plasma volume with normal or even low cardiac output. We must rule out pseudo-resistance before diagnosing true drug resistance. RH is a therapeutic challenge, and its management includes lifestyle interventions, avoiding nonadherence to treatment, avoiding inertia, appropriate use of antihypertensive drugs based on current evidence, especially long-acting diuretics, and the addition of mineralocorticoid receptor antagonists. RCTs to identify the most protective medical therapy in RH are needed. A series of drugs in different stages of investigation could significantly impact RH treatment in the future.
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Affiliation(s)
- Roberto Parodi
- Rosario National University, Hospital Provincial del Centenario, Rosario, Argentina.
| | - Laura Brandani
- Favaloro Foundation University Hospital, Buenos Aires, Buenos Aires, Argentina
| | - César Romero
- Renal Division, Emory University School of Medicine, Atlanta, GA, USA
| | - Manuel Klein
- Argentina Society of Medicine, Buenos Aires, Argentina
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12
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Lauder L, Kandzari DE, Lüscher TF, Mahfoud F. Renal denervation in the management of hypertension. EUROINTERVENTION 2024; 20:e467-e478. [PMID: 38629418 PMCID: PMC11017226 DOI: 10.4244/eij-d-23-00836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 01/09/2024] [Indexed: 04/19/2024]
Abstract
Arterial hypertension is a global leading cause of cardiovascular, cerebrovascular, and renal disease, as well as mortality. Although pharmacotherapy is safe and effective in lowering blood pressure (BP) and cardiovascular disease risk, BP control remains poor, and the mortality rates associated with high BP have been steadily increasing. Device-based therapies have been investigated to overcome barriers to pharmacotherapy, including non-adherence and low rates of persistence to daily medications. Among these device-based therapies, catheter-based renal denervation (RDN) has been most extensively examined over the past 15 years. In this state-of-the-art article, we summarise the rationale for RDN, review the available evidence, provide recommendations for a safe procedure, and discuss the role of RDN in current guidelines and clinical practice.
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Affiliation(s)
- Lucas Lauder
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes and Saarland University, Homburg, Germany
| | | | - Thomas F Lüscher
- Center for Molecular Cardiology, University of Zurich, Schlieren, Switzerland
- Royal Brompton & Harefield Hospitals, London, United Kingdom
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
- School of Cardiovascular Medicine and Sciences, King's College London, London, United Kingdom
| | - Felix Mahfoud
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes and Saarland University, Homburg, Germany
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA
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13
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Cai H, Fang Z, Wu X, Zhou W, Lin J, Peng F, Su J. Efficacy and safety of 3D reconstruction and basket multi-electrode renal denervation (RDN) for refractory hypertensive patients with chronic kidney disease. J Clin Hypertens (Greenwich) 2024; 26:338-348. [PMID: 38430475 PMCID: PMC11007785 DOI: 10.1111/jch.14781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 01/16/2024] [Accepted: 01/17/2024] [Indexed: 03/03/2024]
Abstract
Renal Artery Sympathetic Denervation (RDN) can lower blood pressure. Different ablation catheters (single electrode, multi-electrode) have different scopes of ablation (renal artery main stem and branches). Few studies have compared the advantages and disadvantages of different ablation catheters and different procedures in terms of antihypertensive efficacy. To compare the efficacy and safety of 3D reconstruction radiofrequency ablation (3DRA) and basket multi-electrode radiofrequency ablation (BMRA) in Renal Artery Sympathetic Denervation. Fifty-three patients with Refractory hypertension (RHT) were divided into BMRA, (n = 28) and 3DRA(n = 25). BMRA group used a stereobasket multi-electrode ablation catheter with a controlled ablation temperature of 60°C and an ablation time of 120 s per site. 3DRA group used a NavStar pressure-monitored perfusion monopolar ablation catheter with a controlled ablation temperature of 40°C, an ablation time of 40 s per site, and an ablation energy of 12 W. Baseline and RDN parameters and complications were compared in both groups. Home and 24 h ambulatory blood pressure, type of anti-hypertensive medication taken, and serum creatinine were followed up at 1, 3, 6, 12, and 24 months after the RDN. There were no differences in baseline characteristics between the two groups. (23.14 ± 2.00)months of follow-up in the BMRA group resulted in a total of (25.86 ± 8.61) loci ablation. (19.28 ± 7.40)months of follow-up in the 3DRA group resulted in a total of (21.04 ± 6.47)loci ablation. Home SBP was significantly lower in both groups at 1 month after RDN treatment compared to baseline(H-SBP/mmHg: BMRA 149.9 ± 10.59 vs. baseline 168.36 ± 12.76; 3DRA 152.6 ± 14.91 vs. 164.89 ± 12.96, both p < .05). The proportion of people with 24 h ambulatory SBP attainment was significantly higher in both groups and was maintained for 24 months. At each follow-up time point, there were no differences in home and 24-h flow SBP, DBP, or Scr between the two groups. There were two cases of severe renal artery complications from implanted vascular stents and one case of femoral artery pseudoaneurysm in the 3DRA group. At follow-up, 1 (1.9%) patient in the 3DRA group died of unexplained death and 1 (1.9%) patient developed heart failure, and 1 (1.9%) patient in the BMRA group died of unexplained death. Basket multi-electrode radiofrequency ablation and 3D reconstruction radiofrequency ablation of the renal artery applied to RDN have comparable efficacy in reducing systolic blood pressure.
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Affiliation(s)
- Han Cai
- Department of Cardiology, National Regional Medical Center, Binhai Campus of the First Affiliated HospitalFujian Medical UniversityFuzhouChina
- Fujian Hypertension Research InstituteThe First Affiliated Hospital of Fujian Medical UniversityFuzhouChina
| | - Zhoufei Fang
- Fujian Hypertension Research InstituteThe First Affiliated Hospital of Fujian Medical UniversityFuzhouChina
- Department of Geriatrics, National Regional Medical Center, Binhai Campus of the First Affiliated HospitalFujian Medical UniversityFuzhouChina
- Clinical Research Center for Geriatric Hypertension Disease of Fujian provinceThe First Affiliated Hospital of Fujian Medical UniversityFuzhouChina
- Branch of National Clinical Research Center for Aging and MedicineThe First Affiliated Hospital of Fujian Medical University, Fujian ProvinceFuzhouChina
| | - Xiangshu Wu
- The First Clinical Medical College of Fujian Medical UniversityFuzhouChina
| | - Wei Zhou
- Fujian Hypertension Research InstituteThe First Affiliated Hospital of Fujian Medical UniversityFuzhouChina
| | - Jinxiu Lin
- Department of Cardiology, National Regional Medical Center, Binhai Campus of the First Affiliated HospitalFujian Medical UniversityFuzhouChina
- Fujian Hypertension Research InstituteThe First Affiliated Hospital of Fujian Medical UniversityFuzhouChina
| | - Feng Peng
- Department of Cardiology, National Regional Medical Center, Binhai Campus of the First Affiliated HospitalFujian Medical UniversityFuzhouChina
- Fujian Hypertension Research InstituteThe First Affiliated Hospital of Fujian Medical UniversityFuzhouChina
| | - Jinzi Su
- Department of Cardiology, National Regional Medical Center, Binhai Campus of the First Affiliated HospitalFujian Medical UniversityFuzhouChina
- Fujian Hypertension Research InstituteThe First Affiliated Hospital of Fujian Medical UniversityFuzhouChina
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14
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Akrawinthawong K, Yamada T. Emerging Role of Renal Sympathetic Denervation as an Adjunct Therapy to Atrial Fibrillation Ablation. Rev Cardiovasc Med 2024; 25:122. [PMID: 39076548 PMCID: PMC11264041 DOI: 10.31083/j.rcm2504122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Revised: 11/27/2023] [Accepted: 12/01/2023] [Indexed: 07/31/2024] Open
Abstract
The central anatomical locus in the context of atrial fibrillation (AF) ablation has been the pulmonary veins. Despite the attainment of a modest long-term success rate through pulmonary vein isolation (PVI), the pursuit of achieving a therapeutic efficacy nearing a definitive cure has spurred an investigation into alternative strategies and anatomical loci beyond the pulmonary veins. Despite extensive exploration, none of these alternative targets have succeeded in establishing themselves as routine ablation sites comparable to the pulmonary veins. Consequently, there exists an imperative for further inquiry and refinement of ablation strategies to propel advancements within the domain of AF ablation, thereby augmenting patient outcomes. Simultaneously, the examination of the autonomic system's role in AF pathophysiology introduces an additional ablation target aimed at rectifying sympathovagal imbalance. This discourse presents a contemporary review of renal denervation (RDN) as an emergent and auspicious technique poised to complement PVI, thereby contributing substantively to the augmentation of long-term success within the ambit of AF rhythm-control strategies.
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Affiliation(s)
- Krittapoom Akrawinthawong
- Section of Cardiac Electrophysiology, University of Oklahoma Health Science Center, Oklahoma City, OK 73104, USA
| | - Takumi Yamada
- Section of Cardiac Electrophysiology, Cardiovascular Division, University of Minnesota, Minneapolis, MN 55455, USA
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15
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Al Ghorani H, Kulenthiran S, Lauder L, Recktenwald MJM, Dederer J, Kunz M, Götzinger F, Ewen S, Ukena C, Böhm M, Mahfoud F. Ultra-long-term efficacy and safety of catheter-based renal denervation in resistant hypertension: 10-year follow-up outcomes. Clin Res Cardiol 2024:10.1007/s00392-024-02417-2. [PMID: 38451261 DOI: 10.1007/s00392-024-02417-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 02/16/2024] [Indexed: 03/08/2024]
Abstract
BACKGROUND Randomized sham-controlled trials have confirmed the efficacy and safety of catheter-based renal denervation in hypertension. Data on the very long-term effects of renal denervation are scarce. AIMS This study evaluates the 10-year safety and efficacy of renal denervation in resistant hypertension. METHODS This prospective single-center study included patients with resistant hypertension undergoing radio-frequency renal denervation between 2010 and 2012. Office blood pressure, 24-h ambulatory blood pressure, antihypertensive medication, color duplex sonography, and renal function were assessed after 1-, 2- and 10-years. RESULTS Thirty-nine patients completed the 10-year follow-up (mean follow-up duration 9.4 ± 0.7 years). Baseline office and 24-h ambulatory systolic blood pressure were 164 ± 23 mmHg and 153 ± 16 mmHg, respectively. After 10 years, 24-h ambulatory and office systolic blood pressure were reduced by 16 ± 17 mmHg (P < 0.001) and 14 ± 23 mmHg (P = 0.001), respectively. The number of antihypertensive drugs remained unchanged from 4.9 ± 1.4 to 4.5 ± 1.2 drugs (P = 0.087). The estimated glomerular filtration rate declined within the expected range from 69 (95% CI 63 to 74) to 60 mL/min/1.73m2 (95% CI 53 to 68; P < 0.001) through 10-year follow-up. Three renal artery interventions were documented for progression of pre-existing renal artery stenosis in two patients and one patient with new-onset renal artery stenosis. No other adverse events were observed during the follow-up. CONCLUSION Renal denervation was safe and sustainedly reduced ambulatory and office blood pressure out to 10 years in patients with resistant hypertension.
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Affiliation(s)
- Hussam Al Ghorani
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University, Kirrberger Str. 100, Gebäude 41, 66421, Homburg/Saar, Germany.
| | - Saarraaken Kulenthiran
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University, Kirrberger Str. 100, Gebäude 41, 66421, Homburg/Saar, Germany
| | - Lucas Lauder
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University, Kirrberger Str. 100, Gebäude 41, 66421, Homburg/Saar, Germany
| | - Michael Johannes Maria Recktenwald
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University, Kirrberger Str. 100, Gebäude 41, 66421, Homburg/Saar, Germany
| | - Juliane Dederer
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University, Kirrberger Str. 100, Gebäude 41, 66421, Homburg/Saar, Germany
| | - Michael Kunz
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University, Kirrberger Str. 100, Gebäude 41, 66421, Homburg/Saar, Germany
| | - Felix Götzinger
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University, Kirrberger Str. 100, Gebäude 41, 66421, Homburg/Saar, Germany
| | - Sebastian Ewen
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University, Kirrberger Str. 100, Gebäude 41, 66421, Homburg/Saar, Germany
| | - Christian Ukena
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University, Kirrberger Str. 100, Gebäude 41, 66421, Homburg/Saar, Germany
- Medizinische Klinik II - Kardiologie/Angiologie, Marien Hospital Herne - Universitätsklinikum der Ruhr Universität Bochum, Hölkeskampring 40, 44625, Herne, Germany
| | - Michael Böhm
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University, Kirrberger Str. 100, Gebäude 41, 66421, Homburg/Saar, Germany
| | - Felix Mahfoud
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University, Kirrberger Str. 100, Gebäude 41, 66421, Homburg/Saar, Germany
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16
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Azizi M, Sharp ASP, Fisher NDL, Weber MA, Lobo MD, Daemen J, Lurz P, Mahfoud F, Schmieder RE, Basile J, Bloch MJ, Saxena M, Wang Y, Sanghvi K, Jenkins JS, Devireddy C, Rader F, Gosse P, Claude L, Augustin DA, McClure CK, Kirtane AJ. Patient-Level Pooled Analysis of Endovascular Ultrasound Renal Denervation or a Sham Procedure 6 Months After Medication Escalation: The RADIANCE Clinical Trial Program. Circulation 2024; 149:747-759. [PMID: 37883784 DOI: 10.1161/circulationaha.123.066941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 10/24/2023] [Indexed: 10/28/2023]
Abstract
BACKGROUND The randomized, sham-controlled RADIANCE-HTN (A Study of the Recor Medical Paradise System in Clinical Hypertension) SOLO, RADIANCE-HTN TRIO, and RADIANCE II (A Study of the Recor Medical Paradise System in Stage II Hypertension) trials independently met their primary end point of a greater reduction in daytime ambulatory systolic blood pressure (SBP) 2 months after ultrasound renal denervation (uRDN) in patients with hypertension. To characterize the longer-term effectiveness and safety of uRDN versus sham at 6 months, after the blinded addition of antihypertensive treatments (AHTs), we pooled individual patient data across these 3 similarly designed trials. METHODS Patients with mild to moderate hypertension who were not on AHT or with hypertension resistant to a standardized combination triple AHT were randomized to uRDN (n=293) versus sham (n=213); they were to remain off of added AHT throughout 2 months of follow-up unless specified blood pressure (BP) criteria were exceeded. In each trial, if monthly home BP was ≥135/85 mm Hg from 2 to 5 months, standardized AHT was sequentially added to target home BP <135/85 mm Hg under blinding to initial treatment assignment. Six-month outcomes included baseline- and AHT-adjusted change in daytime ambulatory, home, and office SBP; change in AHT; and safety. Linear mixed regression models using all BP measurements and change in AHT from baseline through 6 months were used. RESULTS Patients (70% men) were 54.1±9.3 years of age with a baseline daytime ambulatory/home/office SBP of 150.5±9.8/151.0±12.4/155.5±14.4 mm Hg, respectively. From 2 to 6 months, BP decreased in both groups with AHT titration, but fewer uRDN patients were prescribed AHT (P=0.004), and fewer additional AHT were prescribed to uRDN patients versus sham patients (P=0.001). Whereas the unadjusted between-group difference in daytime ambulatory SBP was similar at 6 months, the baseline and medication-adjusted between-group difference at 6 months was -3.0 mm Hg (95% CI, -5.7, -0.2; P=0.033), in favor of uRDN+AHT. For home and office SBP, the adjusted between-group differences in favor of uRDN+AHT over 6 months were -5.4 mm Hg (-6.8, -4.0; P<0.001) and -5.2 mm Hg (-7.1, -3.3; P<0.001), respectively. There was no heterogeneity between trials. Safety outcomes were few and did not differ between groups. CONCLUSIONS This individual patient-data analysis of 506 patients included in the RADIANCE trials demonstrates the maintenance of BP-lowering efficacy of uRDN versus sham at 6 months, with fewer added AHTs. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifiers: NCT02649426 and NCT03614260.
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Affiliation(s)
- Michel Azizi
- Université Paris Cité, France (M.A.)
- AP-HP, Hôpital Européen Georges-Pompidou, Hypertension Department and DMU CARTE, Paris, France (M.A.)
- INSERM, Paris, France (M.A.)
| | - Andrew S P Sharp
- University Hospital of Wales and Cardiff University, Cardiff, UK (A.S.P.S.)
| | | | - Michael A Weber
- Division of Cardiovascular Medicine, State University of New York, Downstate Medical Center, New York (M.A.W., M.S.)
| | - Melvin D Lobo
- Barts NIHR Biomedical Research Centre, William Harvey Research Institute, Queen Mary University of London, UK (M.D.L.)
| | - Joost Daemen
- Department of Cardiology, Erasmus University Medical Center Rotterdam, the Netherlands (J.D.)
| | - Philipp Lurz
- Zentrum für Kardiologie, Universitätsmedizin Mainz, Germany (P.L.)
| | - Felix Mahfoud
- Klinik für Innere Medizin III, Saarland University Hospital, Homburg/Saar, Germany (F.M.)
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge (F.M.)
| | - Roland E Schmieder
- Nephrology and Hypertension, University Hospital Erlangen, Friedrich Alexander University, Erlangen, Germany (R.E.S.)
| | - Jan Basile
- Division of Cardiovascular Medicine, Medical University of South Carolina, Ralph H. Johnson VA Medical Center, Charleston (J.B.)
| | - Michael J Bloch
- Department of Medicine, University of Nevada School of Medicine, Vascular Care, Renown Institute of Heart and Vascular Health, Reno (M.J.B.)
| | - Manish Saxena
- Division of Cardiovascular Medicine, State University of New York, Downstate Medical Center, New York (M.A.W., M.S.)
| | - Yale Wang
- Minneapolis Heart Institute, Abbott Northwestern Hospital, MN (Y.W.)
| | | | | | - Chandan Devireddy
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA (C.D.)
| | - Florian Rader
- Cedars-Sinai Heart Institute, Los Angeles, CA (F.R.)
| | | | - Lisa Claude
- Recor Medical, Inc., Palo Alto, CA (L.C., D.A.A.)
| | | | | | - Ajay J Kirtane
- Columbia University Irving Medical Center/New York-Presbyterian Hospital and the Cardiovascular Research Foundation, New York, NY (A.J.K.)
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17
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Gómez-Rosero JA, Duque-González L, Senior-Sánchez JM. [The current state of renal sympathetic denervation in hypertension]. ARCHIVOS DE CARDIOLOGIA DE MEXICO 2024; 94:366-372. [PMID: 38359455 PMCID: PMC11259422 DOI: 10.24875/acm.23000191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Accepted: 11/03/2023] [Indexed: 02/17/2024] Open
Abstract
This review provides an overview of the efficacy and safety of renal sympathetic denervation as a therapeutic approach for resistant hypertension. While the initial enthusiasm was sparked by the results of early clinical trials, it was dampened by the findings of the Symplicity HTN-3 study. However, recent advances in catheter technology and more refined patient selection criteria have yielded more promising results. Subsequent studies, such as SPYRAL HTN-OFF MED and RADIANCE II, demonstrated significant reductions in blood pressure, even in patients with mild to moderate hypertension. Despite the lack of robust data on major clinical outcomes, investigations into the time in therapeutic range for patients undergoing renal sympathetic denervation suggested potential cardiovascular benefits. Nevertheless, further research is needed to thoroughly understand the long-term impact, assess cost-effectiveness, and accurately identify which patient subgroups may derive the greatest benefits from this therapy.
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Affiliation(s)
- Jaime A Gómez-Rosero
- Departamento de Cardiología, Facultad de Medicina, Universidad CES, Medellín, Colombia
| | - Laura Duque-González
- Departamento de Cardiología, Facultad de Medicina, Universidad CES, Medellín, Colombia
- Departamento de Cardiología, Hospital San Vicente Fundación Rionegro, Rionegro, Colombia
| | - Juan M Senior-Sánchez
- Departamento de Cardiología, Servicio de Hemodinamia y Cardiología Intervencionista, Hospital San Vicente Fundación Rionegro, Colombia
- Departamento de Cardiología, Universidad de Antioquia, Medellín, Colombia
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18
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Miklovič M, Gawryś O, Honetschlägerová Z, Kala P, Husková Z, Kikerlová S, Vaňourková Z, Jíchová Š, Kvasilová A, Kitamoto M, Maxová H, Puertas-Frias G, Mráček T, Sedmera D, Melenovský V. Renal denervation improves cardiac function independently of afterload and restores myocardial norepinephrine levels in a rodent heart failure model. Hypertens Res 2024:10.1038/s41440-024-01580-3. [PMID: 38302774 DOI: 10.1038/s41440-024-01580-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 12/04/2023] [Accepted: 12/24/2023] [Indexed: 02/03/2024]
Abstract
Renal nerves play a critical role in cardiorenal interactions. Renal denervation (RDN) improved survival in some experimental heart failure (HF) models. It is not known whether these favorable effects are indirect, explainable by a decrease in vascular afterload, or diminished neurohumoral response in the kidneys, or whether RDN procedure per se has direct myocardial effects in the failing heart. To elucidate mechanisms how RDN affects failing heart, we studied load-independent indexes of ventricular function, gene markers of myocardial remodeling, and cardiac sympathetic signaling in HF, induced by chronic volume overload (aorto-caval fistula, ACF) of Ren2 transgenic rats. Volume overload by ACF led to left ventricular (LV) hypertrophy and dysfunction, myocardial remodeling (upregulated Nppa, MYH 7/6 genes), increased renal and circulating norepinephrine (NE), reduced myocardial NE content, increased monoaminoxidase A (MAO-A), ROS production and decreased tyrosine hydroxylase (+) nerve staining. RDN in HF animals decreased congestion in the lungs and the liver, improved load-independent cardiac function (Ees, PRSW, Ees/Ea ratio), without affecting arterial elastance or LV pressure, reduced adverse myocardial remodeling (Myh 7/6, collagen I/III ratio), decreased myocardial MAO-A and inhibited renal neprilysin activity. RDN increased myocardial expression of acetylcholinesterase (Ache) and muscarinic receptors (Chrm2), decreased circulating and renal NE, but increased myocardial NE content, restoring so autonomic control of the heart. These changes likely explain improvements in survival after RDN in this model. The results suggest that RDN has remote, load-independent and favorable intrinsic myocardial effects in the failing heart. RDN therefore could be a useful therapeutic strategy in HF.
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Affiliation(s)
- Matúš Miklovič
- Center for Experimental Medicine, Institute for Clinical and Experimental Medicine-IKEM, Prague, Czech Republic
- Department of Pathophysiology, 2nd Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Olga Gawryś
- Center for Experimental Medicine, Institute for Clinical and Experimental Medicine-IKEM, Prague, Czech Republic
| | - Zuzana Honetschlägerová
- Center for Experimental Medicine, Institute for Clinical and Experimental Medicine-IKEM, Prague, Czech Republic
| | - Petr Kala
- Center for Experimental Medicine, Institute for Clinical and Experimental Medicine-IKEM, Prague, Czech Republic
- Department of Cardiology, University Hospital Motol and 2nd Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Zuzana Husková
- Center for Experimental Medicine, Institute for Clinical and Experimental Medicine-IKEM, Prague, Czech Republic
| | - Soňa Kikerlová
- Center for Experimental Medicine, Institute for Clinical and Experimental Medicine-IKEM, Prague, Czech Republic
| | - Zdeňka Vaňourková
- Center for Experimental Medicine, Institute for Clinical and Experimental Medicine-IKEM, Prague, Czech Republic
| | - Šárka Jíchová
- Center for Experimental Medicine, Institute for Clinical and Experimental Medicine-IKEM, Prague, Czech Republic
| | - Alena Kvasilová
- Institute of Anatomy, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Misuzu Kitamoto
- Institute of Anatomy, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Hana Maxová
- Center for Experimental Medicine, Institute for Clinical and Experimental Medicine-IKEM, Prague, Czech Republic
- Department of Pathophysiology, 2nd Faculty of Medicine, Charles University, Prague, Czech Republic
| | | | - Tomáš Mráček
- Institute of Physiology, Czech Academy of Sciences, Prague, Czech Republic
| | - David Sedmera
- Institute of Anatomy, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Vojtěch Melenovský
- Center for Experimental Medicine, Institute for Clinical and Experimental Medicine-IKEM, Prague, Czech Republic.
- Department of Cardiology, Institute for Clinical and Experimental Medicine-IKEM, Prague, Czech Republic.
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19
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Azzam O, Nejad SH, Carnagarin R, Nolde JM, Galindo-Kiuchi M, Schlaich MP. Taming resistant hypertension: The promise of novel pharmacologic approaches and renal denervation. Br J Pharmacol 2024; 181:319-339. [PMID: 37715452 DOI: 10.1111/bph.16247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Revised: 08/11/2023] [Accepted: 09/02/2023] [Indexed: 09/17/2023] Open
Abstract
Resistant hypertension is associated with an exceedingly high cardiovascular risk and there remains an unmet therapeutic need driven by pathophysiologic pathways unaddressed by guideline-recommended therapy. While spironolactone is widely considered as the preferable fourth-line drug, its broad application is limited by its side effect profile, especially off-target steroid receptor-mediated effects and hyperkalaemia in at-risk subpopulations. Recent landmark trials have reported promising safety and efficacy results for a number of novel compounds targeting relevant pathophysiologic pathways that remain unopposed by contemporary drugs. These include the dual endothelin receptor antagonist, aprocitentan, the aldosterone synthase inhibitor, baxdrostat and the nonsteroidal mineralocorticoid receptor antagonist finerenone. Furthermore, the evidence base for consideration of catheter-based renal denervation as a safe and effective adjunct therapeutic approach across the clinical spectrum of hypertension has been further substantiated. This review will summarise the recently published evidence on novel antihypertensive drugs and renal denervation in the context of resistant hypertension.
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Affiliation(s)
- Omar Azzam
- Dobney Hypertension Centre, Medical School-Royal Perth Hospital Unit, Royal Perth Hospital Medical Research Foundation, The University of Western Australia, Perth, Western Australia, Australia
- Department of Nephrology, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Sayeh Heidari Nejad
- Dobney Hypertension Centre, Medical School-Royal Perth Hospital Unit, Royal Perth Hospital Medical Research Foundation, The University of Western Australia, Perth, Western Australia, Australia
| | - Revathy Carnagarin
- Dobney Hypertension Centre, Medical School-Royal Perth Hospital Unit, Royal Perth Hospital Medical Research Foundation, The University of Western Australia, Perth, Western Australia, Australia
| | - Janis M Nolde
- Dobney Hypertension Centre, Medical School-Royal Perth Hospital Unit, Royal Perth Hospital Medical Research Foundation, The University of Western Australia, Perth, Western Australia, Australia
| | - Marcio Galindo-Kiuchi
- Dobney Hypertension Centre, Medical School-Royal Perth Hospital Unit, Royal Perth Hospital Medical Research Foundation, The University of Western Australia, Perth, Western Australia, Australia
| | - Markus P Schlaich
- Dobney Hypertension Centre, Medical School-Royal Perth Hospital Unit, Royal Perth Hospital Medical Research Foundation, The University of Western Australia, Perth, Western Australia, Australia
- Department of Nephrology, Royal Perth Hospital, Perth, Western Australia, Australia
- Department of Cardiology, Royal Perth Hospital, Perth, Western Australia, Australia
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20
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Goyal A, Jain H, Verma A, Jain J, Shamim U, Kanagala SG, Motwani J, Dey RC, Chunawala Z, Sohail AH, Belur AD. The role of renal denervation in cardiology and beyond: An updated comprehensive review and future directives. Curr Probl Cardiol 2024; 49:102196. [PMID: 37952794 DOI: 10.1016/j.cpcardiol.2023.102196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Accepted: 11/09/2023] [Indexed: 11/14/2023]
Abstract
Renal denervation (RDN) is a minimally invasive intervention performed by denervation of the nervous fibers in the renal plexus, which decreases sympathetic activity. These sympathetic nerves influence various physiological functions that regulate blood pressure (BP), including intravascular volume, electrolyte composition, and vascular tone. Although proven effective in some trials, controversial trials, such as the Controlled Trial of Renal Denervation for Resistant Hypertension (SYMPLICITY-HTN3), have demonstrated contradictory results for the effectiveness of RDN in resistant hypertension (HTN). In the treatment of HTN, individuals with primary HTN are expected to experience greater benefits compared to those with secondary HTN due to the diverse underlying causes of secondary HTN. Beyond its application for HTN, RDN has also found utility in addressing cardiac arrhythmias, such as atrial fibrillation, and managing cases of heart failure. Non-cardiogenic applications of RDN include reducing the intensity of obstructive sleep apnea (OSA), overcoming insulin resistance, and in chronic kidney disease (CKD) patients. This article aims to provide a comprehensive review of RDN and its uses in cardiology and beyond, along with providing future directions and perspectives.
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Affiliation(s)
- Aman Goyal
- Department of Internal Medicine, Seth GS Medical College and KEM Hospital, Mumbai, India
| | - Hritvik Jain
- Department of Internal Medicine, All India Institute of Medical Sciences (AIIMS), Jodhpur, Rajasthan, India
| | - Amogh Verma
- Department of Medicine and Surgery, Rama Medical College Hospital and Research Centre, Hapur, India
| | - Jyoti Jain
- Department of Internal Medicine, All India Institute of Medical Sciences (AIIMS), Jodhpur, Rajasthan, India
| | - Urooj Shamim
- Department of Internal Medicine, Aga Khan University Hospital, Karachi, Pakistan
| | - Sai Gautham Kanagala
- Department of Internal Medicine, Metropolitan Hospital Center, NY, New York, United States
| | - Jatin Motwani
- Department of Internal Medicine, Liaquat National Hospital and Medical College, Karachi, Pakistan
| | - Rohit Chandra Dey
- Department of Internal Medicine, Altai State Medical University, Barnaul, Altai Krai, Russia
| | - Zainali Chunawala
- Department of Internal Medicine, University of Texas Southwestern, Dallas, Texas, United States
| | - Amir H Sohail
- Department of Surgery, University of New Mexico Health Sciences, Albuquerque, NM, United States
| | - Agastya D Belur
- Department of Cardiovascular Medicine, University of Louisville, Louisville, KY, United States.
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21
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Hu Y, Bao J, Gao Z, Ye L, Wang L. Sodium-Glucose Cotransporter Protein 2 Inhibitors: Novel Application for the Treatment of Obesity-Associated Hypertension. Diabetes Metab Syndr Obes 2024; 17:407-415. [PMID: 38292009 PMCID: PMC10826576 DOI: 10.2147/dmso.s446904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 01/13/2024] [Indexed: 02/01/2024] Open
Abstract
Obesity is becoming increasingly prevalent in China and worldwide and is closely related to the development of hypertension. The pathophysiology of obesity-associated hypertension is complex, including an overactive sympathetic nervous system (SNS), activation of the renin-angiotensin-aldosterone system (RAAS), insulin resistance, hyperleptinemia, renal dysfunction, inflammatory responses, and endothelial function, which complicates treatment. Sodium-glucose cotransporter protein 2 (SGLT-2) inhibitors, novel hypoglycemic agents, have been shown to reduce body weight and blood pressure and may serve as potential novel agents for the treatment of obesity-associated hypertension. This review discusses the beneficial mechanisms of SGLT-2 inhibitors for the treatment of obesity-associated hypertension. SGLT-2 inhibitors can inhibit SNS activity, reduce RAAS activation, ameliorate insulin resistance, reduce leptin secretion, improve renal function, and inhibit inflammatory responses. SGLT-2 inhibitors can, therefore, simultaneously target multiple mechanisms of obesity-associated hypertension and may serve as an effective treatment for obesity-associated hypertension.
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Affiliation(s)
- Yilan Hu
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, People’s Republic of China
- Heart Center, Department of Cardiovascular Medicine, Zhejiang Provincial People’s Hospital, Affiliated People’s Hospital, Hangzhou Medical College, Hangzhou, People’s Republic of China
| | - Jiaqi Bao
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, People’s Republic of China
- Heart Center, Department of Cardiovascular Medicine, Zhejiang Provincial People’s Hospital, Affiliated People’s Hospital, Hangzhou Medical College, Hangzhou, People’s Republic of China
| | - Zhicheng Gao
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, People’s Republic of China
- Heart Center, Department of Cardiovascular Medicine, Zhejiang Provincial People’s Hospital, Affiliated People’s Hospital, Hangzhou Medical College, Hangzhou, People’s Republic of China
| | - Lifang Ye
- Heart Center, Department of Cardiovascular Medicine, Zhejiang Provincial People’s Hospital, Affiliated People’s Hospital, Hangzhou Medical College, Hangzhou, People’s Republic of China
| | - Lihong Wang
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, People’s Republic of China
- Heart Center, Department of Cardiovascular Medicine, Zhejiang Provincial People’s Hospital, Affiliated People’s Hospital, Hangzhou Medical College, Hangzhou, People’s Republic of China
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22
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Jelaković B, Perkov D, Barišić K, Bukal N, Gellineo L, Jelaković A, Josipović J, Prkačin I, Željković Vrkić T, Živko M. Renal Denervation in the Treatment of Resistant Hypertension and Difficult-to-Control Hypertension - Consensus Document of the Croatian Hypertension League - Croatian Society of Hypertension, Croatian Cardiac Society, Croatian Endovascular Initiative, Croatian Society for Diabetes and Metabolic Diseases, Croatian Renal Association, and Croatian Society of Family Physicians of the Croatian Medical Association. Vasc Health Risk Manag 2023; 19:805-826. [PMID: 38108022 PMCID: PMC10724019 DOI: 10.2147/vhrm.s422773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 11/21/2023] [Indexed: 12/19/2023] Open
Abstract
Renal denervation (RDN) as a method of treating arterial hypertension (AH) was introduced in Croatia in 2012. A multidisciplinary team and a network of hospitals that diagnose and treat patients with severe forms of AH were established, and a very strict diagnostic-treatment algorithm was prepared. At monthly meetings patients with truly resistant hypertension who were candidates for RDN were discussed. According to the 2021 ESH position statement and 2023 ESH guidelines, RDN is considered an alternative and additional, not a competitive method of treating patients with various forms of AH which must be performed by following a structured procedure and the patient's preference should be considered. In view of the changes in the global scientific community, the Croatian Hypertension League brings this consensus document on RDN conducted with radiofrequency-based catheter, the only currently available method in Croatia. In this document, exclusion and inclusion criteria are shown, as well as three groups of patients in whom RDN could be considered. The new diagnostic-treatment algorithm is prepared and follow-up procedure is explained. In Croatia, RDN is reimbursed by the national insurance company, thus pharmacoeconomic analyses is also shown. Criteria required by an individual centre to be approved of RDN are listed, and plans for prospective research on RDN in Croatia, including the Croatian registry for RDN, are discussed.
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Affiliation(s)
- Bojan Jelaković
- School of Medicine University of Zagreb, Zagreb, Croatia
- Department of Nephrology, Hypertension, Dialysis and Transplantation, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Dražen Perkov
- Department of Diagnostic and Interventional Radiology, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Klara Barišić
- Department of Nephrology, Hypertension, Dialysis and Transplantation, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Nikolina Bukal
- Department of Internal Medicine, Nephrology and Pulmonology, General Hospital “Dr. J. Benčević”, Slavonski Brod, Croatia
| | - Lana Gellineo
- Department of Nephrology, Hypertension, Dialysis and Transplantation, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Ana Jelaković
- Department of Nephrology, Hypertension, Dialysis and Transplantation, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Josipa Josipović
- Croatian Catholic University, Zagreb, Croatia
- Department of Nephrology and Dialysis, University Hospital Centre Sestre Milosrdnice, Zagreb, Croatia
| | - Ingrid Prkačin
- Department for Emergency Medicine, Clinical Hospital Merkur, Zagreb, Croatia
| | | | - Marijana Živko
- Department of Nephrology, Hypertension, Dialysis and Transplantation, University Hospital Centre Zagreb, Zagreb, Croatia
| | - On the behalf of Task force for the Resistant Hypertension and Renal Denervation of the Croatian Hypertension League
- School of Medicine University of Zagreb, Zagreb, Croatia
- Department of Nephrology, Hypertension, Dialysis and Transplantation, University Hospital Centre Zagreb, Zagreb, Croatia
- Department of Diagnostic and Interventional Radiology, University Hospital Centre Zagreb, Zagreb, Croatia
- Department of Internal Medicine, Nephrology and Pulmonology, General Hospital “Dr. J. Benčević”, Slavonski Brod, Croatia
- Croatian Catholic University, Zagreb, Croatia
- Department of Nephrology and Dialysis, University Hospital Centre Sestre Milosrdnice, Zagreb, Croatia
- Department for Emergency Medicine, Clinical Hospital Merkur, Zagreb, Croatia
- Institute for Cardiovascular Prevention and Rehabilitation, Zagreb, Croatia
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23
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Dimitriadis K, Schmieder RE, Iliakis P, Nickel L, Tsioufis K, Weil J. Long-term efficacy and safety of renal denervation: an update from registries and randomised trials. Blood Press 2023; 32:2266664. [PMID: 37804153 DOI: 10.1080/08037051.2023.2266664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 09/30/2023] [Indexed: 10/09/2023]
Affiliation(s)
- Kyriakos Dimitriadis
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Athens, Greece
| | - Roland E Schmieder
- Department of Nephrology and Hypertension, University Hospital Erlangen, Friedrich Alexander University Erlangen Nürnberg, Erlangen, Germany (R.E.S)
| | - Panagiotis Iliakis
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Athens, Greece
| | - Laura Nickel
- Medizinische Klinik II, Sana Kliniken Lübeck GmbH, Lübeck, Germany
| | - Konstantinos Tsioufis
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Athens, Greece
| | - Joachim Weil
- Medizinische Klinik II, Sana Kliniken Lübeck GmbH, Lübeck, Germany
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24
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Persu A, Stoenoiu MS, Maes F, Kreutz R, Mancia G, Kjeldsen SE. Late outcomes of renal denervation are more favourable than early ones: facts or fancies? Clin Kidney J 2023; 16:2357-2364. [PMID: 38046011 PMCID: PMC10689164 DOI: 10.1093/ckj/sfad231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Indexed: 12/05/2023] Open
Abstract
Following second-generation randomized trials, there is evidence that renal denervation (RDN) decreases blood pressure (BP), although to a lesser extent than suggested in the initial controlled and observational studies. The recent publication of the 36-month follow-up of the Symplicity HTN-3 trial has raised expectations, suggesting increasing, late benefits of the procedure, despite initially negative results. These findings come after those obtained at 36 months in the sham-controlled trial SPYRAL HTN-ON MED and in the Global Symplicity Registry. However, they are susceptible to biases inherent in observational studies (after unblinding for sham-control) and non-random, substantial attrition of treatment groups at 36 months, and used interpolation of missing BPs. More importantly, in SPYRAL HTN-ON MED and Symplicity HTN-3, long-term BP changes in patients from the initial RDN group were compared with those in a heterogeneous control group, including both control patients who did not benefit from RDN and patients who eventually crossed over to RDN. In crossover patients, the last BP before RDN was imputed to subsequent follow-up. In Symplicity HTN-3, this particular approach led to the claim of increasing long-term benefits of RDN. However, comparison of BP changes in patients from the RDN group and control patients who did not undergo RDN, without imputation of BPs from crossover patients, does not support this view. The good news is that despite the suggestion of sympathetic nerve regrowth after RDN in some animal models, there is no strong signal in favour of a decreasing effect of RDN over time, up to 24 or even 36 months. Still, current data do not support a long-term increase in the effect of RDN and the durability of RDN-related BP reduction remains to be formally demonstrated.
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Affiliation(s)
- Alexandre Persu
- Division of Cardiology, Cliniques Universitaires Saint-Luc Université Catholique de Louvain, Brussels, Belgium
- Pole of Cardiovascular Research, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
| | - Maria S Stoenoiu
- Department of Internal Medicine, Rheumatology, Cliniques Universitaires Saint-Luc, Institut de Recherche Expérimentale et Clinique, Université catholique de Louvain, Brussels, Belgium
| | - Frédéric Maes
- Division of Cardiology, Cliniques Universitaires Saint-Luc Université Catholique de Louvain, Brussels, Belgium
- Pole of Cardiovascular Research, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
| | - Reinhold Kreutz
- Charité – Universitätsmedizin Berlin, Institute of Clinical Pharmacology and Toxicology, Berlin, Germany
| | | | - Sverre E Kjeldsen
- Institute of Clinical Medicine, University of Oslo, Departments of Cardiology and Nephrology, Ullevaal Hospital, Oslo, Norway
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25
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Creegan D, McEvoy JW. Selected highlights in the updated treatment of hypertension. Trends Cardiovasc Med 2023:S1050-1738(23)00097-X. [PMID: 37981201 DOI: 10.1016/j.tcm.2023.11.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 10/30/2023] [Accepted: 11/11/2023] [Indexed: 11/21/2023]
Abstract
Hypertension remains the leading international risk factor for cardiovascular disease and premature death but, despite effective treatments, hypertension remains significantly underdiagnosed and undertreated. In the present review paper, we provide a selected update on recent developments of interest in the management of hypertension. We focus on summarizing four topics that we believe are worth highlighting to a clinical audience: (1) the evidence and strong motivation for new lower systolic BP treatment targets; (2) new studies reporting on the efficacy of renal denervation in the management of hypertension; (3) interesting new data to inform the great salt debate; and (4), perhaps most importantly, pioneering new work highlighting the huge potential of multi-disciplinary care in the management of hypertension.
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Affiliation(s)
- Daniel Creegan
- University Hospital Galway and SAOLTA University Health Care Group, Galway, Ireland; School of Medicine, University of Galway, Ireland
| | - John W McEvoy
- University Hospital Galway and SAOLTA University Health Care Group, Galway, Ireland; School of Medicine, University of Galway, Ireland; National Institute for Prevention and Cardiovascular Health, Moyola Lane, Galway, H91 FF68, Ireland; Johns Hopkins University School of Medicine and Bloomberg School of Public Health, Baltimore, MD, USA.
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26
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Mahfoud F, Azizi M, Daemen J, Sharp ASP, Patak A, Iglesias JF, Kirtane A, Fisher NDL, Scicli A, Lobo MD. Real-world experience with ultrasound renal denervation utilizing home blood pressure monitoring: the Global Paradise System registry study design. Clin Res Cardiol 2023:10.1007/s00392-023-02325-x. [PMID: 37943324 DOI: 10.1007/s00392-023-02325-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 10/13/2023] [Indexed: 11/10/2023]
Abstract
BACKGROUND Hypertension is a major public health issue due to its association with cardiovascular disease risk. Despite the availability of effective antihypertensive drugs, rates of blood pressure (BP) control remain suboptimal. Renal denervation (RDN) has emerged as an effective non-pharmacological, device-based treatment option for patients with hypertension. The multicenter, single-arm, observational Global Paradise™ System (GPS) registry has been designed to examine the long-term safety and effectiveness of ultrasound RDN (uRDN) with the Paradise System in a large population of patients with hypertension. METHODS The study aims to enroll up to 3000 patients undergoing uRDN in routine clinical practice. Patients will be recruited over a 4-year period and followed for 5 years (at 3, 6, and 12 months after the uRDN procedure and annually thereafter). Standardized home BP measurements will be taken every 3 months with automatic upload to the cloud. Office and ambulatory BP and adverse events will be collected as per routine clinical practice. Quality-of-Life questionnaires will be used to capture patient-reported outcomes. CONCLUSIONS This observational registry will provide real-world information on the safety and effectiveness of uRDN in a large population of patients treated during routine clinical practice, and also allow for a better understanding of responses in prespecified subgroups. The focus on home BP in this registry is expected to improve completeness of long-term follow-up and provide unique insights into BP over time. Global Paradise System registry study design. ABP, ambulatory blood pressure; BP, blood pressure; FU, follow-up; M, month; OBP, office blood pressure.
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Affiliation(s)
- Felix Mahfoud
- Klinik für Innere Medizin III, Saarland University Hospital, Homburg/Saar, Germany.
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA.
| | - Michel Azizi
- Université Paris Cité, 75006, Paris, France
- AP-HP, Hôpital Européen Georges-Pompidou, Hypertension Department and DMU CARTE, 75015, Paris, France
- INSERM, CIC1418, 75015, Paris, France
| | - Joost Daemen
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Andrew S P Sharp
- University Hospital of Wales, Cardiff and Cardiff University, Cardiff, UK
| | - Atul Patak
- Department of Cardiovascular Medicine, Princess Grace Hospital, Monaco and University of Toulouse, Toulouse, France
| | - Juan F Iglesias
- Department of Cardiology, Geneva University Hospitals, Geneva, Switzerland
| | - Ajay Kirtane
- Columbia University Medical Center/New York-Presbyterian Hospital and the Cardiovascular Research Foundation, New York, NY, USA
| | - Naomi D L Fisher
- Division of Endocrinology, Diabetes and Hypertension, The Brigham and Women's Hospital, Boston, MA, USA
| | | | - Melvin D Lobo
- Barts NIHR Biomedical Research Centre, William Harvey Research Institute, Queen Mary University of London, London, UK
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Mazza A, Dell'Avvocata F, Torin G, Bulighin F, Battaglia Y, Fiorini F. Does Renal Denervation a Reasonable Treatment Option in Hemodialysis-Dependent Patient with Resistant Hypertension? A Narrative Review. Curr Hypertens Rep 2023; 25:353-363. [PMID: 37672130 PMCID: PMC10598141 DOI: 10.1007/s11906-023-01264-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/22/2023] [Indexed: 09/07/2023]
Abstract
PURPOSE OF REVIEW This narrative review aims to assess the pathophysiology, diagnosis, and treatment of resistant hypertension (RH) in end-stage kidney disease (ESKD) patients on dialysis, with a specific focus on the effect of renal denervation (RDN) on short-term and long-term blood pressure (BP) control. Additionally, we share our experience with the use of RDN in an amyloidotic patient undergoing hemodialysis with RH. RECENT FINDINGS High BP, an important modifiable cardiovascular risk factor, is often observed in patients in ESKD, despite the administration of multiple antihypertensive medications. However, in clinical practice, it remains challenging to identify RH patients on dialysis treatment because of the absence of specific definition for RH in this context. Moreover, the use of invasive approaches, such as RDN, to treat RH is limited by the exclusion of patients with reduced renal function (eGFR < 45 mL/min/1.73 m3) in the clinical trials. Nevertheless, recent studies have reported encouraging results regarding the effectiveness of RDN in stage 3 and 4 chronic kidney disease (CKD) and ESKD patients on dialysis, with reductions in BP of nearly up to 10 mmhg. Although multiple underlying pathophysiological mechanisms contribute to RH, the overactivation of the sympathetic nervous system in ESKD patients on dialysis plays a crucial role. The diagnosis of RH requires both confirmation of adherence to antihypertensive therapy and the presence of uncontrolled BP values by ambulatory BP monitoring or home BP monitoring. Treatment involves a combination of nonpharmacological approaches (such as dry weight reduction, sodium restriction, dialysate sodium concentration reduction, and exercise) and pharmacological treatments. A promising approach for managing of RH is based on catheter-based RDN, through radiofrequency, ultrasound, or alcohol infusion, directly targeting on sympathetic overactivity.
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Affiliation(s)
- Alberto Mazza
- ESH Excellence Hpertension Centre and Dept. of Internal Medicine, Santa Maria della Misericordia General Hospital, AULSS 5 Polesana, Rovigo, Italy
| | - Fabio Dell'Avvocata
- Cardiovascular Diagnosis and Endoluminal Interventions Unit, Santa Maria della Misericordia General Hospital, AULSS 5 Polesana, Rovigo, Italy
| | - Gioia Torin
- ESH Excellence Hpertension Centre and Dept. of Internal Medicine, Santa Maria della Misericordia General Hospital, AULSS 5 Polesana, Rovigo, Italy
| | - Francesca Bulighin
- Department of Medicine, University of Verona, 37129, Verona, Italy
- Nephrology and Dialysis Unit, Pederzoli Hospital, Via Monte Baldo, 24, 37019, Peschiera del Garda, Italy
| | - Yuri Battaglia
- Department of Medicine, University of Verona, 37129, Verona, Italy.
- Nephrology and Dialysis Unit, Pederzoli Hospital, Via Monte Baldo, 24, 37019, Peschiera del Garda, Italy.
| | - Fulvio Fiorini
- Nephrology, Dialysis and Dietology Unit, Santa Maria della Misericordia General Hospital, AULSS 5 Polesana, Rovigo, Italy
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Verdecchia P, Cavallini C, Sclafani R, Santucci A, Notaristefano F, Zingarini G, Colombo GA, Angeli F. Catheter-based renal artery denervation: facts and expectations. Eur J Intern Med 2023; 117:66-77. [PMID: 37544846 DOI: 10.1016/j.ejim.2023.07.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 07/27/2023] [Accepted: 07/31/2023] [Indexed: 08/08/2023]
Abstract
Catheter-based renal artery denervation (RAD) is entering a new era. After the disappointing results of SYMPLICITY-HTN 3 trial in year 2014, several technical and methodological advancements led to execution of important SHAM-controlled randomized trials with promising results. Now, the 2023 ESH Guidelines give RAD a class of recommendation II with a Level of Evidence B. Currently, catheter-based RAD has two main areas of application: (a) Hypertensive patients who are still untreated, in whom RAD is a sort of a first-line treatment; (b) Difficult-to-control or true resistant hypertensive patients. Notably, randomized SHAM-controlled trials met their primary end-point in both these conditions. So far, we do not dispose of established predictors of the antihypertensive response to RAD. Some data suggest that younger patients with systo-diastolic hypertension, absence of diffuse atherosclerosis and evidence of sympathetic nervous system overactivity experience a better BP response to the procedure. We reviewed the available data on catheter-based RAD and included an updated meta-analysis of the results of the available SHAM-controlled trials. Overall, the reduction in 24-h systolic blood pressure (BP) after RAD exceeded that after SHAM by 4.58 mmHg (95% CI 3.07-6.10) in untreated patients, and by 3.82 mmHg (95% CI 2.46-5.18) in treated patients, without significant heterogeneity across trials, patient phenotype (untreated versus treated patients) and technique (radiofrequency versus ultrasound). There were no important safety signals related to the procedure. Notably, some data suggest that RAD could be an effective additional approach in patients with atrial fibrillation and other conditions characterized by sympathetic nervous system overactivity.
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Affiliation(s)
- Paolo Verdecchia
- Division of Cardiology, Hospital S. Maria della Misericordia, Perugia, Italy.
| | - Claudio Cavallini
- Division of Cardiology, Hospital S. Maria della Misericordia, Perugia, Italy
| | - Rocco Sclafani
- Division of Cardiology, Hospital S. Maria della Misericordia, Perugia, Italy
| | - Andrea Santucci
- Division of Cardiology, Hospital S. Maria della Misericordia, Perugia, Italy
| | | | - Gianluca Zingarini
- Division of Cardiology, Hospital S. Maria della Misericordia, Perugia, Italy
| | - Giovanni Andrea Colombo
- Department of Medicine and Technological Innovation (DiMIT), University of Insubria, Varese and Department of Medicine and Cardiopulmonary Rehabilitation, Maugeri Care and Research Institute, IRCCS, Tradate, Italy
| | - Fabio Angeli
- Department of Medicine and Technological Innovation (DiMIT), University of Insubria, Varese and Department of Medicine and Cardiopulmonary Rehabilitation, Maugeri Care and Research Institute, IRCCS, Tradate, Italy
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29
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Kharazmi F, Hosseini-Dastgerdi H, Pourshanazari AA, Nematbakhsh M. The denervation or activation of renal sympathetic nerve and renal blood flow. JOURNAL OF RESEARCH IN MEDICAL SCIENCES : THE OFFICIAL JOURNAL OF ISFAHAN UNIVERSITY OF MEDICAL SCIENCES 2023; 28:76. [PMID: 38152073 PMCID: PMC10751519 DOI: 10.4103/jrms.jrms_216_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 07/09/2023] [Accepted: 07/17/2023] [Indexed: 12/29/2023]
Abstract
The denervation or activation of the sympathetic nerve in the kidney can affect renal hemodynamics. The sympathetic nervous system regulates the physiological functions of the kidneys. Stimulation of sympathetic efferent nerves affects various parameters related to renal hemodynamics, including sodium excretion, renin secretion, and renal blood flow (RBF). Hence, renal sympathetic fibers may also play an essential role in regulating systemic vascular resistance and controlling blood pressure. In the absence of renal nerves, the hemodynamics response to stimuli is negligible or absent. The effect of renal sympathetic denervation on RBF is dependent on several factors such as interspecies differences, the basic level of nerve activity in the vessels or local density of adrenergic receptor in the vascular bed. The role of renal denervation has been investigated therapeutically in hypertension and related disorders. Hence, the dynamic impact of renal nerves on RBF enables using RBF dynamic criteria as a marker for renal denervation therapy.
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Affiliation(s)
- Fatemeh Kharazmi
- Water and Electrolytes Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
- Department of Physiology, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Hajaralsadat Hosseini-Dastgerdi
- Water and Electrolytes Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
- Department of Physiology, Isfahan University of Medical Sciences, Isfahan, Iran
| | | | - Mehdi Nematbakhsh
- Water and Electrolytes Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
- Department of Physiology, Isfahan University of Medical Sciences, Isfahan, Iran
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30
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Martínez-Hernández SL, Muñoz-Ortega MH, Ávila-Blanco ME, Medina-Pizaño MY, Ventura-Juárez J. Novel Approaches in Chronic Renal Failure without Renal Replacement Therapy: A Review. Biomedicines 2023; 11:2828. [PMID: 37893201 PMCID: PMC10604533 DOI: 10.3390/biomedicines11102828] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 09/28/2023] [Accepted: 10/12/2023] [Indexed: 10/29/2023] Open
Abstract
Chronic kidney disease (CKD) is characterized by renal parenchymal damage leading to a reduction in the glomerular filtration rate. The inflammatory response plays a pivotal role in the tissue damage contributing to renal failure. Current therapeutic options encompass dietary control, mineral salt regulation, and management of blood pressure, blood glucose, and fatty acid levels. However, they do not effectively halt the progression of renal damage. This review critically examines novel therapeutic avenues aimed at ameliorating inflammation, mitigating extracellular matrix accumulation, and fostering renal tissue regeneration in the context of CKD. Understanding the mechanisms sustaining a proinflammatory and profibrotic state may offer the potential for targeted pharmacological interventions. This, in turn, could pave the way for combination therapies capable of reversing renal damage in CKD. The non-replacement phase of CKD currently faces a dearth of efficacious therapeutic options. Future directions encompass exploring vaptans as diuretics to inhibit water absorption, investigating antifibrotic agents, antioxidants, and exploring regenerative treatment modalities, such as stem cell therapy and novel probiotics. Moreover, this review identifies pharmaceutical agents capable of mitigating renal parenchymal damage attributed to CKD, targeting molecular-level signaling pathways (TGF-β, Smad, and Nrf2) that predominate in the inflammatory processes of renal fibrogenic cells.
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Affiliation(s)
- Sandra Luz Martínez-Hernández
- Departamento de Microbiología, Centro de Ciencias Básicas, Universidad Autónoma de Aguascalientes, Aguascalientes 20100, Ags, Mexico
| | - Martín Humberto Muñoz-Ortega
- Departamento de Química, Centro de Ciencias Básicas, Universidad Autónoma de Aguascalientes, Aguascalientes 20100, Ags, Mexico
| | - Manuel Enrique Ávila-Blanco
- Departamento de Morfología, Centro de Ciencias Básicas, Universidad Autónoma de Aguascalientes, Aguascalientes 20100, Ags, Mexico
| | - Mariana Yazmin Medina-Pizaño
- Departamento de Morfología, Centro de Ciencias Básicas, Universidad Autónoma de Aguascalientes, Aguascalientes 20100, Ags, Mexico
| | - Javier Ventura-Juárez
- Departamento de Morfología, Centro de Ciencias Básicas, Universidad Autónoma de Aguascalientes, Aguascalientes 20100, Ags, Mexico
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31
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Gosse P, Sentilhes L, Boulestreau R, Doublet J, Gaudissard J, Azizi M, Cremer A. Endovascular ultrasound renal denervation to lower blood pressure in young hypertensive women planning pregnancy: study protocol for a multicentre randomised, blinded and sham controlled proof of concept study. BMJ Open 2023; 13:e071164. [PMID: 37775290 PMCID: PMC10546167 DOI: 10.1136/bmjopen-2022-071164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 09/08/2023] [Indexed: 10/01/2023] Open
Abstract
INTRODUCTION A major issue confronting clinicians treating hypertension in pregnancy is the limited number of pharmacological options. Endovascular catheter-based renal denervation (RDN) is a new method to lower blood pressure (BP) in patients with hypertension by reducing the activity of the renal sympathetic nervous system. Drugs that affect this system are safe in pregnant women. So there is reasonable evidence that RDN performed before pregnancy should not have deleterious effects for the fetus. Because the efficacy of RDN may be greater in younger patients and in women, we may expect a larger proportion of BP normalisation in young hypertensive women, but this remains to be proven. Our primary objective is to quantify the proportion of BP normalisation with RDN in this population. METHODS AND ANALYSIS WHY-RDN is a multicentre randomised sham-controlled trial conducted in six French hypertension centres that will include 80 women with essential hypertension treated or untreated, who are planning a pregnancy in the next 2 years and will be randomly assigned to RDN or classic renal arteriography and sham RDN in a ratio of 1:1. The primary outcome is the normalisation of 24-hour BP (<130/80 mm Hg) at 2-month post procedure off treatment. Sample size is calculated with the following assumptions: 5% one-sided significance level (α), 80% power (1-β), expected responder rates of 24% and 3% in the treatment and control group, respectively. Secondary outcomes include the absence of adverse outcomes for a future pregnancy, the variations of BP in ambulatory and home BP measurements and the evaluation of treatment prescribed. ETHICS AND DISSEMINATION WHY-RDN has been approved by the French Ethics Committee (Tours, Region Centre, Ouest 1- number 2021T1-28 HPS). This project is being carried out in accordance with national and international guidelines. The findings of this study will be disseminated by publication. TRIAL REGISTRATION NUMBER ClinicalTrials.gov, NCT05563337.
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Affiliation(s)
- Philippe Gosse
- Department of Cardiology/Hypertension, University Hospital Centre Bordeaux, Bordeaux, France
| | - Loïc Sentilhes
- University Hospital Centre Bordeaux, Bordeaux, France
- University of Bordeaux, Bordeaux, France
| | - Romain Boulestreau
- Cardiologie/Hypertension arterielle, University Hospital Centre Bordeaux, Bordeaux, France
| | - Julien Doublet
- Cardiologie/Hypertension arterielle, University Hospital Centre Bordeaux, Bordeaux, France
| | - Julie Gaudissard
- Cardiologie/Hypertension arterielle, University Hospital Centre Bordeaux, Bordeaux, France
| | - Michel Azizi
- Department of Hypertension, Hopital Europeen Georges Pompidou, Paris, France
| | - Antoine Cremer
- Cardiologie/Hypertension arterielle, University Hospital Centre Bordeaux, Bordeaux, France
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Schmieder RE, Mahfoud F, Mancia G, Narkiewicz K, Ruilope L, Hutton DW, Cao KN, Hettrick DA, Fahy M, Schlaich MP, Böhm M, Pietzsch JB. Clinical event reductions in high-risk patients after renal denervation projected from the global SYMPLICITY registry. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2023; 9:575-582. [PMID: 36057838 PMCID: PMC10495746 DOI: 10.1093/ehjqcco/qcac056] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 08/15/2022] [Accepted: 08/31/2022] [Indexed: 06/15/2023]
Abstract
AIMS Renal denervation has been shown to lower blood pressure in sham-controlled trials and represents a device-based treatment option for hypertension. We sought to project clinical event reductions after radiofrequency renal denervation using a novel modelling approach. METHODS AND RESULTS The Global SYMPLICITY Registry is a global, prospective all-comer registry to evaluate safety and efficacy after renal denervation. For this analysis, change in office systolic blood pressure from baseline was calculated from reported follow-up in the Global SYMPLICITY Registry. Relative risks for death and other cardiovascular events as well as numbers needed to treat for event avoidance were obtained for the respective blood pressure reductions based on previously reported meta-regression analyses for the full cohort and high-risk subgroups including type 2 diabetes, chronic kidney disease, resistant hypertension, and high basal cardiovascular risk. Average baseline office systolic blood pressure and reduction estimates for the full cohort (N = 2651) were 166±25 and -14.8 ± 0.4 mmHg, respectively. Mean reductions in blood pressure ranged from -11.0--21.8 mmHg for the studied high-risk subgroups. Projected relative risks ranged from 0.57 for stroke in the resistant hypertension cohort to 0.92 for death in the diabetes cohort. Significant absolute reductions in major adverse cardiovascular events over 3 years compared with the projected control (8.6 ± 0.7% observed vs. 11.7 ± 0.9% for projected control; P < 0.01) were primarily due to reduced stroke incidence. The robustness of findings was confirmed in sensitivity and scenario analyses. CONCLUSION Model-based projections suggest radiofrequency renal denervation for patients with uncontrolled hypertension adds considerable clinical benefit across a spectrum of different cohort characteristics.
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Affiliation(s)
- Roland E Schmieder
- Department of Nephrology and Hypertension, University Hospital Erlangen, Erlangen, Bavaria 91054, Germany
| | - Felix Mahfoud
- Internal Medicine and Cardiology, Saarland University Hospital, Homburg/Saar, Saarland 66421, Germany
| | - Giuseppe Mancia
- Department of Medicine, University of Milano-Bicocca, Monza, Lombardia 20126, Italy
| | - Krzysztof Narkiewicz
- Hypertension and Diabetology, Medical University of Gdansk, Gdansk 80-210, Poland
| | - Luis Ruilope
- Cardiorenal Investigation, Institute of Research, Hospital Universitario 12 de Octubre and CIBERCV and School of Doctoral Studies and Research, Universidad Europea de Madrid, Madrid 28041, Spain
| | - David W Hutton
- School of Public Health, University of Michigan, Ann Arbor, MI 48109, USA
| | - Khoa N Cao
- Wing Tech Inc., Menlo Park, CA 94025, USA
| | | | - Martin Fahy
- Coronary and Renal Denervation, Medtronic, Santa Rosa, CA 95403, USA
| | - Markus P Schlaich
- Dobney Hypertension Centre, School of Medicine—Royal Perth Hospital Unit, The University of Western Australia, Perth, WA 6009, Australia
| | - Michael Böhm
- Internal Medicine and Cardiology, Saarland University Hospital, Homburg/Saar, Saarland 66421, Germany
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Reyes KRL, Rader F. Long-Term Safety and Antihypertensive Effects of Renal Denervation: Current Insights. Integr Blood Press Control 2023; 16:59-70. [PMID: 37701066 PMCID: PMC10494925 DOI: 10.2147/ibpc.s392410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 09/01/2023] [Indexed: 09/14/2023] Open
Abstract
Hypertension is the most potent modifiable risk factor for the development of cardiovascular morbidity and mortality worldwide. Nevertheless, blood pressure (BP) control on a broad scale appears to be insurmountable and has even worsened in the US. Barriers to sustained hypertension control are multifactorial and although lack of patient awareness and socioeconomic barriers to healthcare access may play a role, medication non-compliance and therapeutic inertia are major causes. Renal denervation (RDN) is a minimally invasive procedure that has been the subject of interest in clinical trials for more than a decade and although the first sham-controlled trial could not detect group difference between treated and untreated hypertensives, subsequent, better designed sham-controlled trials clearly demonstrated the BP lowering effect of RDN, as well as its safety. While to-date, RDN is not available for routine clinical practice, one major requirement for broad implementation is that the BP lowering effect is durable. Therefore, this review will summarize the available long-term data of the different RDN modalities with respect to both effectiveness and safety.
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Affiliation(s)
| | - Florian Rader
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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Filippone EJ, Naccarelli GV, Foy AJ. Controversies in Hypertension IV: Renal Denervation. Am J Med 2023; 136:857-868. [PMID: 37230403 DOI: 10.1016/j.amjmed.2023.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 05/03/2023] [Indexed: 05/27/2023]
Abstract
Renal denervation is not a cure for hypertension. Although more recent sham-controlled trials were positive, a significant minority of patients in each trial were unresponsive. The optimal patient or patients need to be defined. Combined systolic/diastolic hypertension appears more responsive than isolated systolic hypertension. It remains uncertain whether patients with comorbidities associated with higher adrenergic tone should be targeted, including obesity, diabetes, sleep apnea, and chronic kidney disease. No biomarker can adequately predict response. A key to a successful response is the adequacy of denervation, which currently cannot be assessed in real time. It is uncertain what is the optimal denervation methodology: radiofrequency, ultrasound, or ethanol injection. Radiofrequency requires targeting the distal main renal artery plus major branches and accessory arteries. Although denervation appears to be safe, conclusive data on quality of life, improved target organ damage, and reduced cardiovascular events/mortality are required before denervation can be generally recommended.
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Affiliation(s)
- Edward J Filippone
- Division of Nephrology, Department of Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pa.
| | - Gerald V Naccarelli
- Department of Medicine, Penn State University Heart and Vascular Institute; Penn State M.S Hershey Medical Center and College of Medicine, Hershey, Pa
| | - Andrew J Foy
- Department of Medicine, Penn State University Heart and Vascular Institute; Penn State M.S Hershey Medical Center and College of Medicine, Hershey, Pa
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Wagener M, Dolan E, Arnous S, Galvin J, Murphy AW, Casserly I, Eustace J, O’Connor S, McCreery C, Shand J, Wall C, Matiullah S, Sharif F. Renal Denervation as a Complementary Treatment Option for Uncontrolled Arterial Hypertension: A Situation Assessment. J Clin Med 2023; 12:5634. [PMID: 37685701 PMCID: PMC10488551 DOI: 10.3390/jcm12175634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Revised: 08/20/2023] [Accepted: 08/25/2023] [Indexed: 09/10/2023] Open
Abstract
Uncontrolled arterial hypertension is a major global health issue. Catheter-based renal denervation has shown to lower blood pressure in sham-controlled trials and represents a device-based, complementary treatment option for hypertension. In this situation assessment, the authors, who are practicing experts in hypertension, nephrology, general practice and cardiology in the Republic of Ireland, discuss the current evidence base for the BP-lowering efficacy and safety of catheter-based renal denervation with different modalities. Although important questions remain regarding the identification of responders, and long-term efficacy and safety of the intervention, renal denervation has the potential to provide much-needed help to address hypertension and its adverse consequences. The therapeutic approach needs to be multidisciplinary and personalised to take into account the perspective of patients and healthcare professionals in a shared decision-making process.
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Affiliation(s)
- Max Wagener
- University Hospital Galway, University of Galway, H91 TK33 Galway, Ireland
| | - Eamon Dolan
- Stroke and Hypertension Unit, Connolly Hospital, D15 X40D Dublin, Ireland
| | - Samer Arnous
- University Hospital Limerick, V94 F858 Limerick, Ireland
| | - Joseph Galvin
- The Mater Misericordiae University Hospital, D07 R2WY Dublin, Ireland
| | - Andrew W. Murphy
- Turloughmore Medical Centre, University of Galway, H91 TK33 Galway, Ireland
| | - Ivan Casserly
- The Mater Misericordiae University Hospital, D07 R2WY Dublin, Ireland
| | | | | | | | - James Shand
- St. Vincent’s University Hospital, D04 T6F4 Dublin, Ireland
| | | | | | - Faisal Sharif
- University Hospital Galway, University of Galway, H91 TK33 Galway, Ireland
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Rosch S, Rommel K, Blazek S, Kresoja K, Schöber A, von Roeder M, Desch S, Thiele H, Lurz P, Fengler K. Twenty-Four-Month Blood Pressure Results After Renal Denervation Using Endovascular Ultrasound. J Am Heart Assoc 2023; 12:e030767. [PMID: 37581398 PMCID: PMC10492948 DOI: 10.1161/jaha.123.030767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 07/13/2023] [Indexed: 08/16/2023]
Abstract
BACKGROUND Renal denervation has proven its efficacy to lower blood pressure in comparison to sham treatment in recent randomized clinical trials. Although there is a large body of evidence for the durability and safety of radiofrequency-based renal denervation, there are a paucity of data for endovascular ultrasound-based renal denervation (uRDN). We aimed to assess the long-term efficacy and safety of uRDN in a single-center cohort of patients. METHODS AND RESULTS Data from 2 previous studies on uRDN were pooled. Ambulatory 24-hour blood pressure measurements were taken before as well as 3, 6, 12, and 24 months after treatment with uRDN. A total of 130 patients (mean age 63±9 years, 24% women) underwent uRDN. After 3, 6, 12, and 24 months, systolic mean 24-hour ambulatory blood pressure values were reduced by 10±12, 10±14, 8±15, and 10±15 mm Hg, respectively, when compared with baseline (P<0.001). Corresponding diastolic values were reduced by 6±8, 6±8, 5±9, and 6±9 mm Hg, respectively (P<0.001). Periprocedural adverse events occurred in 16 patients, and all recovered without sequelae. CONCLUSIONS In this single-center study, uRDN effectively lowered blood pressure up to 24 months after treatment.
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Affiliation(s)
- Sebastian Rosch
- Department of CardiologyHeart Center Leipzig at University of LeipzigLeipzigGermany
| | - Karl‐Philipp Rommel
- Department of CardiologyHeart Center Leipzig at University of LeipzigLeipzigGermany
| | - Stephan Blazek
- Department of CardiologyHeart Center Leipzig at University of LeipzigLeipzigGermany
| | - Karl‐Patrik Kresoja
- Department of CardiologyHeart Center Leipzig at University of LeipzigLeipzigGermany
| | - Anne Schöber
- Department of CardiologyHeart Center Leipzig at University of LeipzigLeipzigGermany
| | | | - Steffen Desch
- Department of CardiologyHeart Center Leipzig at University of LeipzigLeipzigGermany
| | - Holger Thiele
- Department of CardiologyHeart Center Leipzig at University of LeipzigLeipzigGermany
| | - Philipp Lurz
- Department of CardiologyHeart Center Leipzig at University of LeipzigLeipzigGermany
| | - Karl Fengler
- Department of CardiologyHeart Center Leipzig at University of LeipzigLeipzigGermany
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Götzinger F, Kunz M, Lauder L, Mahfoud F, Böhm M. Radio frequency-based renal denervation: a story of simplicity? Future Cardiol 2023; 19:431-440. [PMID: 37791469 DOI: 10.2217/fca-2023-0059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/05/2023] Open
Abstract
Radio frequency-based renal denervation is a safe and effective way of lowering blood pressure, a common condition associated with high cardiovascular risk. Several catheters have been developed to administer energy to the renal arteries and their side branches, thereby modulating sympathetic renal activity. The Symplicity Flex™ and Symplicity Spyral™ are first- and second-generation devices, respectively, for radio frequency-based renal denervation. There is a continuous need to further improve and adjust interventional antihypertensive therapies. Several randomized controlled trials have been conducted to investigate the safety and efficacy of these catheters and most were able to show radio frequency-based renal denervation to be feasible, safe and effective in lowering blood pressure in hypertensive patients with and without concomitant antihypertensive medication. Herein, the authors discuss the pathophysiologic concepts of renal denervation and its procedural approaches, report catheter designs, summarize clinical trials outcomes and, finally, discuss real-world evidence.
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Affiliation(s)
- Felix Götzinger
- Department of Internal Medicine III, Cardiology, Angiology & Intensive Care Medicine, University Hospital Saarland, Saarland University, Homburg, 66421, Germany
| | - Michael Kunz
- Department of Internal Medicine III, Cardiology, Angiology & Intensive Care Medicine, University Hospital Saarland, Saarland University, Homburg, 66421, Germany
| | - Lucas Lauder
- Department of Internal Medicine III, Cardiology, Angiology & Intensive Care Medicine, University Hospital Saarland, Saarland University, Homburg, 66421, Germany
| | - Felix Mahfoud
- Department of Internal Medicine III, Cardiology, Angiology & Intensive Care Medicine, University Hospital Saarland, Saarland University, Homburg, 66421, Germany
| | - Michael Böhm
- Department of Internal Medicine III, Cardiology, Angiology & Intensive Care Medicine, University Hospital Saarland, Saarland University, Homburg, 66421, Germany
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Kiuchi MG, Carnagarin R, Matthews VB, Schlaich MP. Multi-organ denervation: a novel approach to combat cardiometabolic disease. Hypertens Res 2023; 46:1747-1758. [PMID: 37088807 PMCID: PMC10319631 DOI: 10.1038/s41440-023-01287-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 02/17/2023] [Accepted: 04/02/2023] [Indexed: 04/25/2023]
Abstract
Cardiometabolic disorders are associated with a substantial loss in quality of life and pose a large burden on healthcare systems worldwide. Overactivation of the sympathetic nervous system has been shown to be a key player in several aspects relating to cardiometabolic disturbances. While diet- and exercise-induced approaches to help reduce weight remains the main strategy to combat metabolic disorders, this is often difficult to achieve. Current pharmacological approaches result in variable responses in different patient cohorts and long-term efficacy may be limited by medication side effects and non-adherence in the long term. There is a clear clinical need for complementary therapies to curb the burden of cardiometabolic disease. One such approach may include interventional sympathetic neuromodulation of organs relevant to cardiometabolic control. Data from sham-controlled clinical trials demonstrate the feasibility, safety and efficacy of catheter-based renal denervation. In analogy, denervation of the common hepatic artery is now feasible in humans and may prove to be similarly useful in modulating sympathetic overdrive directed towards the liver, pancreas and duodenum. Such a targeted multi-organ neuromodulation strategy may beneficially influence multiple aspects of the cardiometabolic disease continuum including blood pressure, glucose and lipid control.
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Affiliation(s)
- Márcio Galindo Kiuchi
- Dobney Hypertension Centre, Medical School-Royal Perth Hospital Unit and RPH Research Foundation, The University of Western Australia, Perth, WA, Australia
| | - Revathy Carnagarin
- Dobney Hypertension Centre, Medical School-Royal Perth Hospital Unit and RPH Research Foundation, The University of Western Australia, Perth, WA, Australia
| | - Vance B Matthews
- Dobney Hypertension Centre, Medical School-Royal Perth Hospital Unit and RPH Research Foundation, The University of Western Australia, Perth, WA, Australia
| | - Markus P Schlaich
- Dobney Hypertension Centre, Medical School-Royal Perth Hospital Unit and RPH Research Foundation, The University of Western Australia, Perth, WA, Australia.
- Departments of Cardiology and Nephrology, Royal Perth Hospital, Perth, WA, Australia.
- Neurovascular Hypertension & Kidney Disease Laboratory, Baker Heart and Diabetes Institute, Melbourne, VIC, Australia.
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Vogt A, Dutzmann J, Nußbaum M, Hoyer D, Tongers J, Schlitt A, Sedding D, Plehn A. Safety and efficacy of renal sympathetic denervation: a 9-year long-term follow-up of 24-hour ambulatory blood pressure measurements. Front Cardiovasc Med 2023; 10:1210801. [PMID: 37404730 PMCID: PMC10315532 DOI: 10.3389/fcvm.2023.1210801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Accepted: 05/26/2023] [Indexed: 07/06/2023] Open
Abstract
Background Renal sympathetic denervation (RDN) has been shown to lower arterial blood pressure both in the presence and in the absence of antihypertensive medication in an observation period of up to 3 years. However, long-term results beyond 3 years are scarcely reported. Methods We performed a long-term follow-up on patients who were previously enrolled in a local renal denervation registry and who underwent radiofrequency RDN with the Symplicity Flex® renal denervation system between 2011 and 2014. The patients were assessed to evaluate their renal function by performing 24-hour ambulatory blood pressure measurement (ABPM), recording their medical history, and conducting laboratory tests. Results Ambulatory blood pressure readings for 24 h were available for 72 patients at long-term follow-up (FU) [9.3 years (IQR: 8.5-10.1)]. We found a significant reduction of ABP from 150.1/86.1 ± 16.9/12.0 mmHg at baseline to 138.3/77.1 ± 16.5/11.1 mmHg at long-term FU (P < 0.001 for both systolic and diastolic ABP). The number of antihypertensive medications used by the patients significantly decreased from 5.4 ± 1.5 at baseline to 4.8 ± 1.6 at long-term FU (P < 0.01). Renal function showed a significant but expected age-associated decrease in the eGFR from 87.8 (IQR: 81.0-100.0) to 72.5 (IQR: 55.8-86.8) ml/min/1.73 m2 (P < 0.01) in patients with an initial eGFR > 60 ml/min/1.73 m2, while a non-significant decrease was observed in patients with an initial eGFR < 60 ml/min/1.73 m2 at long-term FU [56.0 (IQR: 40.9-58.4) vs. 39.0 (IQR: 13.5-56.3) ml/min/1.73 m2]. Conclusions RDN was accompanied by a long-lasting reduction in blood pressure with a concomitant reduction in antihypertensive medication. No negative effects could be detected, especially with regard to renal function.
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Affiliation(s)
- Alexander Vogt
- Department of Internal Medicine III, University Hospital Halle (Saale), Halle (Saale), Germany
| | - Jochen Dutzmann
- Department of Internal Medicine III, University Hospital Halle (Saale), Halle (Saale), Germany
| | - Michael Nußbaum
- Department of Internal Medicine III, University Hospital Halle (Saale), Halle (Saale), Germany
| | - Daniel Hoyer
- Department of Internal Medicine III, University Hospital Halle (Saale), Halle (Saale), Germany
| | - Jörn Tongers
- Department of Internal Medicine III, University Hospital Halle (Saale), Halle (Saale), Germany
| | - Axel Schlitt
- Department of Cardiology and Diabetes, Paracelsus-Harz-Clinic Bad Suderode, Quedlinburg, Germany
| | - Daniel Sedding
- Department of Internal Medicine III, University Hospital Halle (Saale), Halle (Saale), Germany
| | - Alexander Plehn
- Department of Internal Medicine III, University Hospital Halle (Saale), Halle (Saale), Germany
- Praxisklinik Salzatal, Salzatal, Germany
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Kirtane AJ, Sharp ASP, Mahfoud F, Fisher NDL, Schmieder RE, Daemen J, Lobo MD, Lurz P, Basile J, Bloch MJ, Weber MA, Saxena M, Wang Y, Sanghvi K, Jenkins JS, Devireddy C, Rader F, Gosse P, Sapoval M, Barman NC, Claude L, Augustin D, Thackeray L, Mullin CM, Azizi M. Patient-Level Pooled Analysis of Ultrasound Renal Denervation in the Sham-Controlled RADIANCE II, RADIANCE-HTN SOLO, and RADIANCE-HTN TRIO Trials. JAMA Cardiol 2023; 8:464-473. [PMID: 36853627 PMCID: PMC9975919 DOI: 10.1001/jamacardio.2023.0338] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 02/06/2023] [Indexed: 03/01/2023]
Abstract
Importance Ultrasound renal denervation (uRDN) was shown to lower blood pressure (BP) in patients with uncontrolled hypertension (HTN). Establishing the magnitude and consistency of the uRDN effect across the HTN spectrum is clinically important. Objective To characterize the effectiveness and safety of uRDN vs a sham procedure from individual patient-level pooled data across uRDN trials including either patients with mild to moderate HTN on a background of no medications or with HTN resistant to standardized triple-combination therapy. Data Sources A Study of the ReCor Medical Paradise System in Clinical Hypertension (RADIANCE-HTN SOLO and TRIO) and A Study of the ReCor Medical Paradise System in Stage II Hypertension (RADIANCE II) trials. Study Selection Trials with similar designs, standardized operational implementation (medication standardization and blinding of both patients and physicians to treatment assignment), and follow-up. Data Extraction and Synthesis Pooled analysis using individual patient-level data using linear regression models to compare uRDN with sham across the trials. Main Outcomes and Measures The primary outcome was baseline-adjusted change in 2-month daytime ambulatory systolic BP (dASBP) between groups. Results A total of 506 patients were randomized in the 3 studies (uRDN, 293; sham, 213; mean [SD] age, 54.1 [9.3]; 354 male [70.0%]). After a 1-month medication stabilization period, dASBP was similar between the groups (mean [SD], uRDN, 150.3 [9.2] mm Hg; sham, 150.8 [10.5] mm Hg). At 2 months, dASBP decreased by 8.5 mm Hg to mean (SD) 141.8 (13.8) mm Hg among patients treated with uRDN and by 2.9 mm Hg to 147.9 (14.6) mm Hg among patients treated with a sham procedure (mean difference, -5.9; 95% CI, -8.1 to -3.8 mm Hg; P < .001 in favor of uRDN). BP decreases from baseline with uRDN vs sham were consistent across trials and across BP parameters (office SBP: -10.4 mm Hg vs -3.4 mm Hg; mean difference, -6.4 mm Hg; 95% CI, -9.1 to -3.6 mm Hg; home SBP: -8.4 mm Hg vs -1.4 mm Hg; mean difference, -6.8 mm Hg; 95% CI, -8.7 to -4.9 mm Hg, respectively). The BP reductions with uRDN vs sham were consistent across prespecified subgroups. Independent predictors of a larger BP response to uRDN were higher baseline BP and heart rate and the presence of orthostatic hypertension. No differences in early safety end points were observed between groups. Conclusions and Relevance Results of this patient-level pooled analysis suggest that BP reductions with uRDN were consistent across HTN severity in sham-controlled trials designed with a 2-month primary end point to standardize medications across randomized groups. Trial Registration ClinicalTrials.gov Identifier: NCT02649426 and NCT03614260.
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Affiliation(s)
- Ajay J. Kirtane
- Columbia University Medical Center/NewYork-Presbyterian Hospital and the Cardiovascular Research Foundation, New York
- Associate Editor, JAMA Cardiology
| | - Andrew S. P. Sharp
- University Hospital of Wales and Cardiff University, Cardiff, United Kingdom
| | - Felix Mahfoud
- Klinik für Innere Medizin III, Saarland University Hospital, Homburg/Saar, Germany
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge
| | | | - Roland E. Schmieder
- Nephrology and Hypertension, University Hospital Erlangen, Friedrich Alexander University, Erlangen, Germany
| | - Joost Daemen
- Department of Cardiology, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Melvin D. Lobo
- Barts NIHR Biomedical Research Centre, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Philipp Lurz
- Heart Center Leipzig, University of Leipzig, Leipzig, Germany
| | - Jan Basile
- Division of Cardiovascular Medicine, Medical University of South Carolina, Ralph H. Johnson VA Medical Center, Charleston
| | - Michael J. Bloch
- Vascular Care, Renown Institute of Heart and Vascular Health, Department of Medicine, University of Nevada School of Medicine, Reno
| | - Michael A. Weber
- Division of Cardiovascular Medicine, State University of New York, Downstate Medical Center, New York
| | - Manish Saxena
- Barts NIHR Biomedical Research Centre, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Yale Wang
- Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | | | | | - Chandan Devireddy
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Florian Rader
- Cedars-Sinai Heart Institute, Los Angeles, California
| | | | - Marc Sapoval
- Université Paris Cité, Paris, France
- AP-HP, Hôpital Européen Georges-Pompidou, Hypertension Department and DMU CARTE, Paris, France
- INSERM, CIC1418, Paris, France
| | | | | | | | | | | | - Michel Azizi
- Université Paris Cité, Paris, France
- AP-HP, Hôpital Européen Georges-Pompidou, Hypertension Department and DMU CARTE, Paris, France
- INSERM, CIC1418, Paris, France
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41
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Xiong B, Chen S, Chen W, Yin Y, Ling Z. Advances in Renal Denervation in the Treatment of Hypertension. CARDIOVASCULAR INNOVATIONS AND APPLICATIONS 2023. [DOI: 10.15212/cvia.2023.0014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/03/2023] Open
Abstract
Hypertension significantly increases the risk of cardiovascular events and it is associated with high rates of disability and mortality. Hypertension is a common cause of cardiovascular and cerebrovascular accidents, which severely affect patients’ quality of life and lifespan. Current treatment strategies for hypertension are based primarily on medication and lifestyle interventions. The renal sympathetic nervous system plays an important role in the pathogenesis of hypertension, and catheter-based renal denervation (RDN) has provided a new concept for the treatment of hypertension. In recent years, studies on RDN have been performed worldwide. This article reviews the latest preclinical research and clinical evidence for RDN.
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Barbato E, Azizi M, Schmieder RE, Lauder L, Böhm M, Brouwers S, Bruno RM, Dudek D, Kahan T, Kandzari DE, Lüscher TF, Parati G, Pathak A, Ribichini FL, Schlaich MP, Sharp ASP, Sudano I, Volpe M, Tsioufis C, Wijns W, Mahfoud F. Renal denervation in the management of hypertension in adults. A clinical consensus statement of the ESC Council on Hypertension and the European Association of Percutaneous Cardiovascular Interventions (EAPCI). EUROINTERVENTION 2023; 18:1227-1243. [PMID: 36789560 PMCID: PMC10020821 DOI: 10.4244/eij-d-22-00723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 11/19/2022] [Indexed: 02/16/2023]
Abstract
Since the publication of the 2018 European Society of Cardiology/European Society of Hypertension (ESC/ESH) Guidelines for the Management of Arterial Hypertension, several high-quality studies, including randomised, sham-controlled trials on catheter-based renal denervation (RDN) were published, confirming both the blood pressure (BP)-lowering efficacy and safety of radiofrequency and ultrasound RDN in a broad range of patients with hypertension, including resistant hypertension. A clinical consensus document by the ESC Council on Hypertension and the European Association of Percutaneous Cardiovascular Interventions (EAPCI) on RDN in the management of hypertension was considered necessary to inform clinical practice. This expert group proposes that RDN is an adjunct treatment option in uncontrolled resistant hypertension, confirmed by ambulatory BP measurements, despite best efforts at lifestyle and pharmacological interventions. RDN may also be used in patients who are unable to tolerate antihypertensive medications in the long term. A shared decision-making process is a key feature and preferably includes a patient who is well informed on the benefits and limitations of the procedure. The decision-making process should take (i) the patient's global cardiovascular (CV) risk and/or (ii) the presence of hypertension-mediated organ damage or CV complications into account. Multidisciplinary hypertension teams involving hypertension experts and interventionalists evaluate the indication and facilitate the RDN procedure. Interventionalists require expertise in renal interventions and specific training in RDN procedures. Centres performing these procedures require the skills and resources to deal with potential complications. Future research is needed to address open questions and investigate the impact of BP-lowering with RDN on clinical outcomes and potential clinical indications beyond hypertension.
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Affiliation(s)
- Emanuele Barbato
- Department of Clinical and Molecular Medicine, Sapienza University of Rome, Rome, Italy
| | - Michel Azizi
- Paris Centre de Recherche Cardiovasculaire, INSERM, Université Paris Cité, Paris, France
- Hypertension Department, AP-HP, Hôpital Européen Georges-Pompidou, Paris, France and FCRIN INI-CRCT, Université de Lorraine, Nancy, France
| | - Roland E Schmieder
- Department of Nephrology and Hypertension, University Hospital Erlangen, Erlangen, Germany and Friedrich Alexander University Erlangen-Nürnberg, Erlangen, Germany
| | - Lucas Lauder
- Klinik für Innere Medizin III, Universitätsklinikum des Saarlandes and Saarland University, Homburg, Germany
| | - Michael Böhm
- Klinik für Innere Medizin III, Universitätsklinikum des Saarlandes and Saarland University, Homburg, Germany
| | - Sofie Brouwers
- Cardiovascular Center Aalst, OLV Hospital Aalst, Aalst, Belgium and Department of Experimental Pharmacology, Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium
| | - Rosa Maria Bruno
- Paris Centre de Recherche Cardiovasculaire, INSERM, Université Paris Cité, Paris, France
- Pharmacology Unit, AP-HP, Hôpital Européen Georges-Pompidou, Paris, France
| | - Dariusz Dudek
- Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland and GVM Care & Research, Maria Cecilia Hospital, Cotignola, Italy
| | - Thomas Kahan
- Department of Clinical Sciences, Karolinska Institute, Solna, Sweden and Division of Cardiovascular Medicine, Danderyd Hospital, Stockholm, Sweden and Department of Cardiology, Danderyd University Hospital Corporation, Stockholm, Sweden
| | | | - Thomas F Lüscher
- Department of Cardiology, Royal Brompton and Harefield Hospitals, London, UK, and National Heart and Lung Institute, Imperial College, London, UK, and School of Cardiovascular Medicine and Sciences, Kings College London, London, UK, and Center for Molecular Cardiology, University of Zurich, Schlieren, Switzerland
| | - Gianfranco Parati
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy and Cardiology Unit, Istituto Auxologico Italiano, IRCCS, Milan, Italy
- Department of Cardiovascular Medicine, Centre Hospitalier Princesse Grace, Monte Carlo, Monaco
| | - Atul Pathak
- Department of Cardiovascular Medicine, Centre Hospitalier Princesse Grace, Monte Carlo, Monaco
| | - Flavio L Ribichini
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Markus P Schlaich
- Dobney Hypertension Centre, Medical School, Perth, WA, Australia, and Royal Perth Hospital Unit, Medical Research Foundation, The University of Western Australia, Perth, WA, Australia and Departments of Cardiology and Nephrology, Royal Perth Hospital, Perth, WA, Australia
| | - Andrew S P Sharp
- Department of Cardiology, University Hospital of Wales, Cardiff, UK
| | - Isabella Sudano
- Department of Cardiology, University Heart Center, University Hospital Zurich, Zurich, Switzerland
| | - Massimo Volpe
- Department of Cardiology, Sapienza University of Rome, Sant'Andrea Hospital, Rome, Italy
| | - Costas Tsioufis
- 1st Department of Cardiology, National and Kapodistrian University of Athens, Athens, Greece and Hippocratio Hospital, Athens, Greece
| | - William Wijns
- The Lambe Institute for Translational Medicine, Galway, Ireland and University of Galway, Galway, Ireland
- The Smart Sensors Lab, London, UK and CURAM, London, UK
| | - Felix Mahfoud
- Klinik für Innere Medizin III, Universitätsklinikum des Saarlandes and Saarland University, Homburg, Germany
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Schmieder R, Burnier M, East C, Tsioufis K, Delaney S. Renal Denervation: A Practical Guide for Health Professionals Managing Hypertension. Interv Cardiol 2023; 18:e06. [PMID: 37601735 PMCID: PMC10433107 DOI: 10.15420/icr.2022.38] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 02/02/2023] [Indexed: 03/09/2023] Open
Abstract
Growing evidence demonstrates the suitability of renal denervation in a broad population of patients; however, questions remain over its suitability and practical implementation. Given the rapidity of emerging data, this has been a challenging field for potential adopters to navigate. The purpose of this article is twofold: to provide navigation through emerging clinical data and evolving guidance; and to provide physicians with practical, evidence-based advice for identifying eligible patients and providing appropriate management in the pre- and postintervention settings. Although many of these recommendations are based on existing published guidance documents, we reflect equally on our own experiences of using this technology.
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Affiliation(s)
- Roland Schmieder
- University Hospital Erlangen, Department of Nephrology and HypertensionErlangen, Germany
| | | | - Cara East
- Cardiology, Baylor Heart & Vascular HospitalDallas, TX, US
| | - Konstantinos Tsioufis
- National and Kapodistrian University of Athens, 1st Cardiology Clinic, Hippocratio HospitalAthens, Greece
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Alhabeeb W, Tash AA, Alshamiri M, Arafa M, Balghith MA, ALmasood A, Eltayeb A, Elghetany H, Hassan T, Alshemmari O. National Heart Center/Saudi Heart Association 2023 Guidelines on the Management of Hypertension. J Saudi Heart Assoc 2023; 35:16-39. [PMID: 37020975 PMCID: PMC10069676 DOI: 10.37616/2212-5043.1328] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Revised: 12/27/2022] [Accepted: 01/30/2023] [Indexed: 03/17/2023] Open
Abstract
Background Hypertension is a highly prevalent disease in Saudi Arabia with poor control rates. Updated guidelines are needed to guide the management of hypertension and improve treatment outcomes. Methodology A panel of experts representing the National Heart Center (NHC) and the Saudi Heart Association (SHA) reviewed existing evidence and formulated guidance relevant to the local population, clinical practice and the healthcare system. The recommendations were reviewed to ensure scientific and medical accuracy. Recommendations Hypertension was defined and a new classification was proposed as relevant to the Saudi population. Recommendations on diagnosis, clinical evaluation, cardiovascular assessment were detailed, along with guidance on measurement modalities and screening/follow-up. Non-pharmacological management is the first line of hypertension treatment. Pharmacological therapy should be used appropriately as needed. Treatment priority is to control blood pressure regardless of the drug class used. The choice of treatment should be tailored to the patient profile in order to achieve treatment targets and ensure patient compliance. Recommendations were provided on pharmacological options available in Saudi Arabia, as well as guidance on the treatment of special conditions. Conclusion Hypertension management should be based on appropriate screening, timely diagnosis and lifestyle changes supplemented with pharmacological therapy, as needed. Clinical management should be individualized, and careful consideration should be given to special conditions and patient groups.
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Affiliation(s)
- Waleed Alhabeeb
- Department of Cardiac Sciences, King Saud University, Riyadh,
Saudi Arabia
| | - Adel A. Tash
- Consultant Cardiac Surgeon, Adult Cardiac Surgery, Ministry of Health,
Saudi Arabia
| | - Mostafa Alshamiri
- Professor of Cardiac Sciences, King Saud University Medical College, Riyadh,
Saudi Arabia
| | - Mohamed Arafa
- Professor of Cardiac Sciences, King Saud University,
Saudi Arabia
| | - Mohammed A. Balghith
- Senior Cardiologist, King Abdulaziz, National Guard Hospital, Riyadh,
Saudi Arabia
| | - Ali ALmasood
- Consultant Cardiologist, Specialized Medical Center, Riyadh,
Saudi Arabia
| | - Abdulla Eltayeb
- Senior Cardiologist, Almana Group of Hospitals, Dammam,
Saudi Arabia
| | - Hossam Elghetany
- Consultant Cardiologist, Dr. Soliman Fakeeh Hospital, Jeddah,
Saudi Arabia
| | - Taher Hassan
- Consultant Cardiologist, Bugshan Center,
Saudi Arabia
| | - Owayed Alshemmari
- Consultant Cardiologist Dr. Sulaiman Alhabib Hospital, Ar-Rayyan Hospital, Riyadh,
Saudi Arabia
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45
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Zeijen VJ, Hirsch A, Betjes MG, Daemen J. Unilateral renal atrophy 4 years after renal sympathetic denervation: a case report. J Hypertens 2023; 41:516-519. [PMID: 36728602 PMCID: PMC9894127 DOI: 10.1097/hjh.0000000000003350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Renal sympathetic denervation (RDN) carries a low risk of renal artery stenosis, and most cases occur within the first year. However, limited data are available on long-term incidence. Here, we present a case of a 68-year-old woman who underwent radiofrequency RDN for resistant hypertension. Ambulatory blood pressure improved following RDN and uptitration of antihypertensive drugs. Between year 3 and 4 after RDN, eGFR reduced from 87 to 50 ml/min per 1.73 m 2 . Ultrasound imaging revealed left renal atrophy, while subsequent magnetic resonance angiography showed a haemodynamically significant stenosis of the left renal artery. The patient remained in good clinical condition with stable blood pressure, while eGFR mildly deteriorated during a 6-year follow-up period. This case of renal artery stenosis occurred in a patient with multiple risk factors. A causal relationship to the RDN procedure cannot be confirmed nor ruled out. Long-term surveillance for adverse events should be considered in all RDN patients.
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Affiliation(s)
| | - Alexander Hirsch
- Department of Cardiology
- Department of Radiology and Nuclear Medicine
| | - Michiel G.H. Betjes
- Department of Internal Medicine, Section Nephrology and Transplantation, Erasmus University Medical Center, Rotterdam, the Netherlands
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46
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Janas A, Wojakowski W. Peregrine system infusion catheter for neurolytic renal denervation in hypertension: an overview of its safety and efficacy. Expert Rev Med Devices 2023; 20:179-186. [PMID: 36846949 DOI: 10.1080/17434440.2023.2183838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
INTRODUCTION Resistant hypertension (HTN), despite the tremendous advances in pharmacotherapy, is a major global problem. Transcatheter renal denervation (RDN) could be a pertinent strategy for resistant HTN and patients with poor pharmacotherapy adherence. Nonetheless, the adoption of energy-based RDN in clinical practice is slow and alternative approaches are needed. AREAS COVERED The review focuses on the assessment of the Peregrine System Infusion Catheters. The system is designed for chemically mediated transcatheter RDN by the infusion publications on the Peregrine system. The theoretical assumptions for chemically mediated RDN, design of the system, data from preclinical and clinical studies, and further perspectives are discussed. EXPERT OPINION Peregrine System Infusion Catheters are the only catheter on the market designed for chemically mediated RDN by the infusion of the neurolytic agent. Chemical neurolysis more efficiently destroys nerves around the renal artery in comparison to energy-based catheters, due to deeper tissue penetration and circumferential distribution resulting in a wider range of effective nerve injury. Chemically mediated RDN by the infusion of the neurolytic agent (alcohol) has an excellent safety profile as confirmed in initial clinical trials which also suggested high efficacy. Currently, there is an ongoing phase III sham-control study. Other possible applications of this technology include clinical settings like heart failure or atrial fibrillation.
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Affiliation(s)
- Adam Janas
- Faculty of Medicine and Health Sciences, Andrzej Frycz Modrzewski Cracow University, Kraków, Poland.,American Heart of Poland, Center of Cardiovascular Research and Development, Poland
| | - Wojciech Wojakowski
- Division of Cardiology and Structural Heart Diseases, Medical University of Silesia, Katowice, Poland
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Fengler K, Rommel KP, Kriese W, Blazek S, Besler C, von Roeder M, Desch S, Thiele H, Lurz P. 6- and 12-Month Follow-Up From a Randomized Clinical Trial of Ultrasound vs Radiofrequency Renal Denervation (RADIOSOUND-HTN). JACC Cardiovasc Interv 2023; 16:367-369. [PMID: 36792266 DOI: 10.1016/j.jcin.2022.10.058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 10/20/2022] [Accepted: 10/31/2022] [Indexed: 02/16/2023]
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Roubsanthisuk W, Kunanon S, Chattranukulchai P, Panchavinnin P, Wongpraparut N, Chaipromprasit J, Pienvichitr P, Ayudhya RKN, Sukonthasarn A. 2022 Renal denervation therapy for the treatment of hypertension: a statement from the Thai Hypertension Society. Hypertens Res 2023; 46:898-912. [PMID: 36759658 PMCID: PMC10073020 DOI: 10.1038/s41440-022-01133-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Revised: 11/18/2022] [Accepted: 11/25/2022] [Indexed: 02/11/2023]
Abstract
Hypertension remains a significant risk factor for major cardiovascular events worldwide. Poor adherence to treatment is extremely common in clinical practice, leading to uncontrolled hypertension. However, some patients with resistant hypertension still have uncontrolled blood pressure despite good medical compliance. A specific group of patients also develop adverse reactions to many blood pressure-lowering medications. These scenarios indicate that innovative strategies to lower blood pressure in challenging cases of hypertension are needed. The blood pressure-lowering efficacy of catheter-based renal denervation therapy to decrease sympathetic tone has been confirmed in many publications in recent years. Apart from both the invasiveness and the expensiveness of this technology, appropriate case selection to undergo this procedure is still developing. The utilization of renal denervation therapy for hypertension treatment in Thailand has lasted for 10 years with a good response in most cases. Currently, only certain interventionists at a few medical schools in Thailand can perform this procedure. However, more physicians are now interested in applying this technology to their patients. The Thai Hypertension Society Committee has reviewed updated information to provide principles for the appropriate utilization of renal denervation therapy. The blood pressure-lowering mechanism, efficacy, suitable patient selection, pre- and postprocedural assessment and procedural safety of renal denervation are included in this statement.
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Affiliation(s)
- Weranuj Roubsanthisuk
- Division of Hypertension, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Sirisawat Kunanon
- Division of Hypertension, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Pairoj Chattranukulchai
- Division of Cardiovascular Medicine, Department of Medicine, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Pariya Panchavinnin
- Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Nattawut Wongpraparut
- Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Jarkarpun Chaipromprasit
- Division of Cardiovascular Medicine, Department of Medicine, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Pavit Pienvichitr
- Division of Cardiology, Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | | | - Apichard Sukonthasarn
- Cardiology Division, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand.
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Sato Y, Sharp ASP, Mahfoud F, Tunev S, Forster A, Ellis M, Gomez A, Dhingra R, Ullman J, Schlaich M, Lee D, Trudel J, Hettrick DA, Kandzari DE, Virmani R, Finn AV. Translational value of preclinical models for renal denervation: a histological comparison of human versus porcine renal nerve anatomy. EUROINTERVENTION 2023; 18:e1120-e1128. [PMID: 36214318 PMCID: PMC9909452 DOI: 10.4244/eij-d-22-00369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 08/11/2022] [Indexed: 02/09/2023]
Abstract
BACKGROUND Preclinical models have provided key insights into the response of local tissues to radiofrequency (RF) renal denervation (RDN) that is unobtainable from human studies. However, the anatomic translatability of these models to the procedure in humans is incompletely understood. Aims: We aimed to compare the renal arterial anatomy in normotensive pigs treated with RF-RDN to that of human cadavers to evaluate the suitability of normotensive pigs for determining the safety of RF-RDN. METHODS Histopathologic analyses were performed on RF-treated renal arteries in a porcine model and untreated control renal arteries. Similar analyses were performed on untreated renal arteries from human cadavers. Results: In both human and porcine renal arteries, the median number of nerves was lower in the more distal sections (the numbers in the proximal, middle, distal, 1st bifurcation, and 2nd bifurcation sections were 65, 58, 47, 22.5, and 14.7 in humans, respectively, and 39, 26, 29, 16.5, and 9.3 in the porcine models, respectively). Renal nerves were common in the regions between arteries and adjacent veins, but only 3% and 13% of the renal nerves in humans and pigs, respectively, were located behind the renal vein. The semiquantitative score of RF-induced renal arterial nerve necrosis was significantly greater at 7 days than 28 days (0.98 vs 0.75; p=0.01), and injury to surrounding organs was rarely observed. CONCLUSIONS The distribution of nerve tissue and the relative distribution of extravascular anatomic structures along the renal artery was similar between humans and pigs, which validates the translational value of the normotensive porcine model for RDN.
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Affiliation(s)
- Yu Sato
- CVPath Institute Inc., Gaithersburg, MD, USA
| | | | - Felix Mahfoud
- Department of Internal Medicine III, Cardiology, Angiology and Intensive Care Medicine, Saarland University Hospital, Hamburg, Germany
| | | | | | | | - Ana Gomez
- CVPath Institute Inc., Gaithersburg, MD, USA
| | | | | | | | - David Lee
- Stanford Hospital and Clinics, Palo Alto, CA, USA
| | | | | | - David E Kandzari
- Department of Cardiovascular Surgery, Marcus Valve Center, Piedmont Heart Institute, Atlanta, GA, USA
| | | | - Aloke V Finn
- CVPath Institute Inc., Gaithersburg, MD, USA
- University of Maryland, Baltimore, MD, USA
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50
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The position of renal denervation in treatment of hypertension: an expert consensus statement. Neth Heart J 2023; 31:3-11. [PMID: 36001280 PMCID: PMC9807711 DOI: 10.1007/s12471-022-01717-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/01/2022] [Indexed: 01/07/2023] Open
Abstract
Hypertension is an important risk factor for cardiovascular disease. In the Netherlands, there are approximately 2.8 million people with hypertension. Despite treatment recommendations including lifestyle changes and antihypertensive drugs, most patients do not meet guideline-recommended blood pressure (BP) targets. In order to improve BP control and lower the risk of subsequent cardiovascular events, renal sympathetic denervation (RDN) has been introduced and studied as a non-pharmacological approach. While early data on the efficacy of RDN showed conflicting results, improvements in treatment protocols and study design resulted in robust new evidence supporting the potential of the technology to improve patient care in hypertensive subjects. Recently, 5 randomised sham-controlled trials demonstrated the safety and efficacy of the technology. Modelling studies have further shown that RDN is cost-effective in the Dutch healthcare setting. Given the undisputable disease burden along with the shortcomings of current therapeutic options, we postulate a new, clearly framed indication for RDN as an adjunct in the treatment of hypertension. The present consensus statement summarises current guideline-recommended BP targets, proposed workup and treatment for hypertension, and position of RDN for those patients with primary hypertension who do not meet guideline-recommended BP targets (see central illustration).
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