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Kandzari DE, Weber MA, Pathak A, Zidar JP, Saxena M, David SW, Schmieder RE, Janas AJ, Langer C, Persu A, Mendelsohn FO, Ameloot K, Foster M, Fischell TA, Parise H, Mahfoud F. Effect of Alcohol-Mediated Renal Denervation on Blood Pressure in the Presence of Antihypertensive Medications: Primary Results From the TARGET BP I Randomized Clinical Trial. Circulation 2024; 149:1875-1884. [PMID: 38587557 DOI: 10.1161/circulationaha.124.069291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2024] [Accepted: 03/18/2024] [Indexed: 04/09/2024]
Abstract
BACKGROUND Renal denervation (RDN) has demonstrated clinically relevant reductions in blood pressure (BP) among individuals with uncontrolled hypertension despite lifestyle intervention and medications. The safety and effectiveness of alcohol-mediated RDN have not been formally studied in this indication. METHODS TARGET BP I is a prospective, international, sham-controlled, randomized, patient- and assessor-blinded trial investigating the safety and efficacy of alcohol-mediated RDN. Patients with office systolic BP (SBP) ≥150 and ≤180 mm Hg, office diastolic BP ≥90 mm Hg, and mean 24-hour ambulatory SBP ≥135 and ≤170 mm Hg despite prescription of 2 to 5 antihypertensive medications were enrolled. The primary end point was the baseline-adjusted change in mean 24-hour ambulatory SBP 3 months after the procedure. Secondary end points included mean between-group differences in office and ambulatory BP at additional time points. RESULTS Among 301 patients randomized 1:1 to RDN or sham control, RDN was associated with a significant reduction in 24-hour ambulatory SBP at 3 months (mean±SD, -10.0±14.2 mm Hg versus -6.8±12.1 mm Hg; treatment difference, -3.2 mm Hg [95% CI, -6.3 to 0.0]; P=0.0487). Subgroup analysis of the primary end point revealed no significant interaction across predefined subgroups. At 3 months, the mean change in office SBP was -12.7±18.3 and -9.7±17.3 mm Hg (difference, -3.0 [95% CI, -7.0 to 1.0]; P=0.173) for RDN and sham, respectively. No significant differences in ambulatory or office diastolic BP were observed. Adverse safety events through 6 months were uncommon, with one instance of accessory renal artery dissection in the RDN group (0.7%). No significant between-group differences in medication changes or patient adherence were identified. CONCLUSIONS Alcohol-mediated RDN was associated with a modest but statistically significant reduction in 24-hour ambulatory SBP compared with sham control. No significant differences between groups in office BP or 6-month major adverse events were observed. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT02910414.
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Affiliation(s)
| | - Michael A Weber
- Division of Cardiovascular Medicine, State University of New York (SUNY), New York (M.A.W.)
| | - Atul Pathak
- Department of Cardiovascular Medicine, Princess Grace Hospital and ESH Hypertension Excellence Center, Monaco (A.P.)
| | - James P Zidar
- University of North Carolina (UNC), Rex Healthcare, Raleigh, NC (J.P.Z.)
| | - Manish Saxena
- Barts Health NHS Trust, Queen Mary University of London, United Kingdom (M.S.)
| | | | - Roland E Schmieder
- Department of Nephrology and Hypertension, University Hospital Erlangen, Friedrich Alexander University Erlangen/Nürnberg, Germany (R.E.S.)
| | - Adam J Janas
- Collegium Medicum of Andrzej Frycz Modrzewski Krakow University, Kraków, Poland (A.J.J.)
- Center of Cardiovascular Research and Development, American Heart of Poland, Katowice (A.J.J.)
| | | | - Alexandre Persu
- Division of Cardiology, Cliniques Universitaires Saint-Luc and Pole of Cardiovascular Research, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium (A.P.)
| | | | - Koen Ameloot
- Department of Cardiology, Ziekenhuis Oost Limburg, Genk, Belgium (K.A.)
| | - Malcolm Foster
- Tennova Turkey Creek Medical Center, Knoxville, TN (M.F.)
| | - Tim A Fischell
- Ablative Solutions Inc, Wakefield, MA (T.A.F.)
- Yale University School of Medicine, New Haven, CT (T.A.F., H.P.)
| | - Helen Parise
- Yale University School of Medicine, New Haven, CT (T.A.F., H.P.)
| | - Felix Mahfoud
- Department of Internal Medicine III, Cardiology, Angiology, Intensive Care Medicine, Saarland University Medical Center, Homburg, Germany (F.M.)
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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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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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Pathak A, Rudolph UM, Saxena M, Zeller T, Müller-Ehmsen J, Lipsic E, Schmieder RE, Sievert H, Halbach M, Sharif F, Parise H, Fischell TA, Weber MA, Kandzari DE, Mahfoud F. Alcohol-mediated renal denervation in patients with hypertension in the absence of antihypertensive medications. EUROINTERVENTION 2023; 19:602-611. [PMID: 37427416 PMCID: PMC10493775 DOI: 10.4244/eij-d-23-00088] [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: 02/02/2023] [Accepted: 05/30/2023] [Indexed: 07/11/2023]
Abstract
BACKGROUND Ultrasound and radiofrequency renal denervation (RDN) have been shown to safely lower blood pressure (BP) in hypertension. AIMS The TARGET BP OFF-MED trial investigated the efficacy and safety of alcohol-mediated renal denervation (RDN) in the absence of antihypertensive medications. METHODS This randomised, blinded, sham-controlled trial was conducted in 25 centres in Europe and the USA. Patients with a 24-hour systolic BP of 135-170 mmHg, an office systolic BP 140-180 mmHg and diastolic BP ≥90 mmHg on 0-2 antihypertensive medications were enrolled. The primary efficacy endpoint was the change in mean 24-hour systolic BP at 8 weeks. Safety endpoints included major adverse events up to 30 days. RESULTS A total of 106 patients were randomised; the baseline mean office BP following medication washout was 159.4/100.4±10.9/7.0 mmHg (RDN) and 160.1/98.3±11.0/6.1 mmHg (sham), respectively. At 8 weeks post-procedure, the mean (±standard deviation) 24-hour systolic BP change was â2.9±7.4 mmHg (p=0.009) versus â1.4±8.6 mmHg (p=0.25) in the RDN and sham groups, respectively (mean between-group difference: 1.5 mmHg; p=0.27). There were no differences in safety events between groups. After 12 months of blinded follow-up, with medication escalation, patients achieved similar office systolic BP (RDN: 147.9±18.5 mmHg; sham: 147.8±15.1 mmHg; p=0.68) with a significantly lower medication burden in the RDN group (mean daily defined dose: 1.5±1.5 vs 2.3±1.7; p=0.017). CONCLUSIONS In this trial, alcohol-mediated RDN was delivered safely but was not associated with significant BP differences between groups. Medication burden was lower in the RDN group up to 12 months.
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Affiliation(s)
- Atul Pathak
- Department of Cardiovascular Medicine, Princess Grace Hospital, Principality of Monaco
| | - Ulrike M Rudolph
- Klinik und Poliklinik für Kardiologie, Universitätsklinikum Leipzig, Universität Leipzig, Leipzig, Germany
| | - Manish Saxena
- Barts NIHR Biomedical Research Centre, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Thomas Zeller
- Universitäts-Herzzentrum Bad Krozingen, Bad Krozingen, Germany
| | | | - Erik Lipsic
- Department of Cardiology, University Medical Center Groningen, Groningen, the Netherlands
| | - Roland E Schmieder
- Universitätsklinikum Erlangen, Erlangen, Germany and Friedrich Alexander University Erlangen/Nürnberg, Erlangen, Germany
| | - Horst Sievert
- CardioVasculäres Centrum (CVC) Frankfurt, Frankfurt, Germany
| | - Marcel Halbach
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Clinic III for Internal Medicine, Cologne, Germany and Herzzentrum der Uniklinik Koln, Koln, Germany
| | - Faisal Sharif
- Saolta University Healthcare Group, University Hospital Galway, Galway, Ireland
| | - Helen Parise
- Yale University School of Medicine, New Haven, CT, USA
| | | | - Michael A Weber
- Division of Cardiovascular Medicine, State University of New York (SUNY), New York, NY, USA
| | - David E Kandzari
- Department of Interventional Cardiology, Piedmont Heart Institute, Atlanta, GA, USA
| | - Felix Mahfoud
- Department of Internal Medicine III - cardiology, angiology and internal intensive care medicine, Saarland University Medical Center, Homburg, Germany
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA
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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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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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Kandzari DE. Catheter-Based Renal Denervation Therapy: Evolution of Evidence and Future Directions. Circ Cardiovasc Interv 2021; 14:e011130. [PMID: 34903035 DOI: 10.1161/circinterventions.121.011130] [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] [Indexed: 11/16/2022]
Abstract
Motivated by the persistence of uncontrolled blood pressure and its public health impact, the development and evaluation of device-based therapies for hypertension has advanced at an accelerated pace to complement pharmaceutical and lifestyle intervention strategies. Countering widespread interest from early studies, the lack of demonstrable efficacy for renal denervation (RDN) in a large, sham-controlled randomized trial motivated revision of trial design and conduct to account for confounding variables of procedural technique, medication variability, and selection of both patients and end points. Now amidst varied trial design and methods, several sham-controlled, randomized trials have demonstrated clinically meaningful reductions in blood pressure with RDN. With this momentum, additional studies are underway to position RDN as a potential part of standard therapy for the world's leading cause of death and disability. In parallel, further studies will address unresolved issues including durability of blood pressure lowering and reduction in antihypertensive medications, late-term safety, and impact on clinical outcomes. Identifying predictors of treatment effect and surveys of patient-reported outcomes and treatment preferences are also evolving areas of investigation. Aside from confirmatory studies of safety and effectiveness, these additional studies will further inform patient selection, expand experience with RDN in broader populations with hypertension, and provide guidance to how RDN may be incorporated into treatment pathways.
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Weber MA. Hypertension research from Japan: advancing the field of renal denervation. Hypertens Res 2021; 45:188-192. [PMID: 34893698 DOI: 10.1038/s41440-021-00814-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 11/24/2021] [Indexed: 10/19/2022]
Affiliation(s)
- Michael A Weber
- Professor of Medicine, Division of Cardiovascular Medicine, State University of New York, Downstate Medical College, Brooklyn, NY, USA.
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Li L, Hu Z, Xiong Y, Yao Y. Device-Based Sympathetic Nerve Regulation for Cardiovascular Diseases. Front Cardiovasc Med 2021; 8:803984. [PMID: 34957267 PMCID: PMC8695731 DOI: 10.3389/fcvm.2021.803984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 11/22/2021] [Indexed: 12/05/2022] Open
Abstract
Sympathetic overactivation plays an important role in promoting a variety of pathophysiological processes in cardiovascular diseases (CVDs), including ventricular remodeling, vascular endothelial injury and atherosclerotic plaque progression. Device-based sympathetic nerve (SN) regulation offers a new therapeutic option for some CVDs. Renal denervation (RDN) is the most well-documented method of device-based SN regulation in clinical studies, and several large-scale randomized controlled trials have confirmed its value in patients with resistant hypertension, and some studies have also found RDN to be effective in the control of heart failure and arrhythmias. Pulmonary artery denervation (PADN) has been clinically shown to be effective in controlling pulmonary hypertension. Hepatic artery denervation (HADN) and splenic artery denervation (SADN) are relatively novel approaches that hold promise for a role in cardiovascular metabolic and inflammatory-immune related diseases, and their first-in-man studies are ongoing. In addition, baroreflex activation, spinal cord stimulation and other device-based therapies also show favorable outcomes. This review summarizes the pathophysiological rationale and the latest clinical evidence for device-based therapies for some CVDs.
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Affiliation(s)
| | | | | | - Yan Yao
- National Center for Cardiovascular Diseases, Peking Union Medical College, Chinese Academy of Medical Sciences, Fu Wai Hospital, Beijing, China
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Flood SP, Aronow HD. Catheter-Based Alcohol-Mediated Renal Denervation for Treating Resistant Hypertension: Is the Peregrine Predator or Prey? Circ Cardiovasc Interv 2021; 14:e011293. [PMID: 34470499 DOI: 10.1161/circinterventions.121.011293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Shane P Flood
- Mater Private Network, City Gate, Mahon, Cork, Ireland (S.P.F.)
| | - Herbert D Aronow
- Warren Alpert Medical School of Brown University, Lifespan Cardiovascular Institute, Providence, RI (H.D.A.)
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