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McEvoy JW, McCarthy CP, Bruno RM, Brouwers S, Canavan MD, Ceconi C, Christodorescu RM, Daskalopoulou SS, Ferro CJ, Gerdts E, Hanssen H, Harris J, Lauder L, McManus RJ, Molloy GJ, Rahimi K, Regitz-Zagrosek V, Rossi GP, Sandset EC, Scheenaerts B, Staessen JA, Uchmanowicz I, Volterrani M, Touyz RM. 2024 ESC Guidelines for the management of elevated blood pressure and hypertension. Eur Heart J 2024; 45:3912-4018. [PMID: 39210715 DOI: 10.1093/eurheartj/ehae178] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/04/2024] Open
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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; 47:2745-2759. [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] [MESH Headings] [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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Katsurada K, Kario K. Indications for renal denervation in the treatment of hypertension. Hypertens Res 2024; 47:2693-2699. [PMID: 39112539 DOI: 10.1038/s41440-024-01823-3] [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: 05/31/2024] [Revised: 07/07/2024] [Accepted: 07/09/2024] [Indexed: 10/08/2024]
Abstract
Renal denervation (RDN) is a neuromodulation therapy performed using an intraarterial catheter in patients with hypertension. Recent randomized sham-operated controlled trials have shown that RDN has significant antihypertensive effects in patients with resistant, uncontrolled, and/or drug-naïve hypertension. Based on available evidence, the European Society of Hypertension 2023 guidelines include a Class II recommendation for the use of RDN in individuals with resistant and uncontrolled hypertension. The US Food and Drug Administration approved two devices, the ultrasound-based ReCor ParadiseTM RDN system and the radiofrequency-based Medtronic Symplicity SpyralTM RDN system, as adjunctive therapy for patients with resistant and uncontrolled hypertension. The indications for RDN and incorporation of RDN into clinical practice will grow as clinical evidence accumulates. This mini review summarizes latest findings focusing on the safety and effectiveness of RDN for treating hypertension in the absence and presence of antihypertensive drugs, and discusses the indications for RDN. This mini review focuses on the safety and effectiveness of RDN for treating hypertension in the absence and presence of antihypertensive drugs. The indications for RDN and incorporation of RDN into clinical practice will grow as clinical evidence accumulates and should be reviewed and updated.
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Affiliation(s)
- Kenichi Katsurada
- Division of Cardiovascular Medicine, Department of Internal Medicine, Jichi Medical University School of Medicine, Shimotsuke, Tochigi, Japan.
- Division of Clinical Pharmacology, Department of Pharmacology, Jichi Medical University School of Medicine, Shimotsuke, Tochigi, Japan.
| | - Kazuomi Kario
- Division of Cardiovascular Medicine, Department of Internal Medicine, Jichi Medical University School of Medicine, Shimotsuke, Tochigi, Japan
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Cluett JL, Blazek O, Brown AL, East C, Ferdinand KC, Fisher NDL, Ford CD, Griffin KA, Mena-Hurtado CI, Sarathy H, Vongpatanasin W, Townsend RR. Renal Denervation for the Treatment of Hypertension: A Scientific Statement From the American Heart Association. Hypertension 2024; 81:e135-e148. [PMID: 39101202 DOI: 10.1161/hyp.0000000000000240] [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: 08/06/2024]
Abstract
Hypertension is a leading risk factor for cardiovascular morbidity and mortality. Despite the widespread availability of both pharmacological and lifestyle therapeutic options, blood pressure control rates across the globe are worsening. In fact, only 23% of individuals with high blood pressure in the United States achieve treatment goals. In 2023, the US Food and Drug Administration approved renal denervation, a catheter-based procedure that ablates the renal sympathetic nerves, as an adjunctive treatment for patients in whom lifestyle modifications and antihypertensive medications do not adequately control blood pressure. This approval followed the publication of multiple randomized clinical studies using rigorous trial designs, all incorporating renal angiogram as the sham control. Most but not all of the new generation of trials reached their primary end point, demonstrating modest efficacy of renal denervation in lowering blood pressure across a spectrum of hypertension, from mild to truly resistant. Individual patient responses vary, and further research is needed to identify those who may benefit most. The initial safety profile appears favorable, and multiple ongoing studies are assessing longer-term efficacy and safety. Multidisciplinary teams that include hypertension specialists and adequately trained proceduralists are crucial to ensure that referrals are made appropriately with full consideration of the potential risks and benefits. Incorporating patient preferences and engaging in shared decision-making conversations will help patients make the best decisions given their individual circumstances. Although further research is clearly needed, renal denervation presents a novel treatment strategy for patients with uncontrolled blood pressure.
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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; 113:1384-1392. [PMID: 38451261 PMCID: PMC11420252 DOI: 10.1007/s00392-024-02417-2] [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: 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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Götzinger F, Mahfoud F. Editorial: Ozone-mediated lumbar renal artery denervation - Another arrow in the quiver? CARDIOVASCULAR REVASCULARIZATION MEDICINE 2024; 67:58-59. [PMID: 38845283 DOI: 10.1016/j.carrev.2024.05.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2024] [Accepted: 05/28/2024] [Indexed: 09/21/2024]
Affiliation(s)
- Felix Götzinger
- Department of Cardiology, University Heart Center Basel, University Hospital Basel, Switzerland.
| | - Felix Mahfoud
- Department of Cardiology, University Heart Center Basel, University Hospital Basel, Switzerland
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Pathak A, Boulestreau R, Sapoval M, Lantelme P, Duly-Bouhanick B, Benamer H, Bejan-Angoulvant T, Cremer A, Amar L, Delarche N, Ormezzano O, Sabouret P, Silhol F, Sosner P, Lopez-Sublet M, Cohen A, Courand PY, Azizi M. Catheter-based renal denervation in the treatment of arterial hypertension: An expert consensus statement on behalf of the French Society of Hypertension (SFHTA), French Society of Radiology (SFR), French Society of Interventional Cardiology (GACI), French Society of Cardiology (SFC), French Association of Private Cardiologists (CNCF), French Association of Hospital Cardiologists (CNCH), French Society of Thoracic and Cardiovascular Surgery (SFCTCV) and French Society of Vascular and Endovascular Surgery (SCVE). Arch Cardiovasc Dis 2024:S1875-2136(24)00308-5. [PMID: 39332916 DOI: 10.1016/j.acvd.2024.05.122] [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: 04/19/2024] [Revised: 05/21/2024] [Accepted: 05/22/2024] [Indexed: 09/29/2024]
Abstract
Several high-quality, randomized, sham-controlled trials have provided evidence supporting the efficacy and safety of radiofrequency, ultrasound and alcohol catheter-based renal denervation (RDN) for reducing blood pressure (BP). A French clinical consensus document has therefore been developed to propose guidance for the appropriate use of RDN in the management of hypertension along with a dedicated care pathway and management strategy. The French experts group concluded that RDN can serve as an adjunct therapy for patients with confirmed uncontrolled, resistant essential hypertension despite treatment with≥3 antihypertensive drugs, including a long-acting calcium channel blocker, a renin-angiotensin system blocker and a thiazide/thiazide-like diuretic at maximally tolerated doses. Patients should have (1) an estimated glomerular filtration rate of≥40mL/min/1.73m2; (2) an eligible renal artery anatomy on pre-RDN scans and (3) exclusion of secondary forms of hypertension. Additional indications might be considered for patients with difficult-to-control hypertension. Any indication of RDN should be validated by multidisciplinary hypertension teams consisting of both hypertension specialists and endovascular interventionalists in European Society of Hypertension (ESH) Excellence Centres or ESH-BP clinics. Patients should be informed about the benefit/risk ratio of RDN. Expertise in renal artery interventions and training in RDN techniques are needed for endovascular interventionalists conducting RDN procedures while centres offering RDN should have the necessary resources to manage potential complications effectively. Lastly, all patients undergoing RDN should have their data collected in a nationwide French registry to facilitate monitoring and evaluation of RDN outcomes, contributing to ongoing research and quality improvement efforts.
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Affiliation(s)
- Atul Pathak
- Department of Cardiovascular Medicine, Princess Grace Hospital, INI-CRCT network, 98000 Monaco, Monaco.
| | - Romain Boulestreau
- Université de Bordeaux, UMR Inserm 1034, Biologie des maladies cardiovasculaires, 33000 Bordeaux, France
| | - Marc Sapoval
- Department of Vascular and Oncological Interventional Radiology, Hôpital Européen Georges-Pompidou, 75015 Paris, France
| | - Pierre Lantelme
- Department of Cardiology, Hôpital de la Croix-Rousse, Hôpital Lyon Sud, Hospices Civils de Lyon, 69004 Lyon, France
| | | | - Hakim Benamer
- Department of Cardiology, ICPS Jacques-Cartier, 91300 Massy, France
| | | | - Antoine Cremer
- Department of Hypertension and Cardiology, Saint-André Hospital, CHU de Bordeaux, 33000 Bordeaux, France
| | - Laurence Amar
- Department of Cardiovascular Medicine, Princess Grace Hospital, INI-CRCT network, 98000 Monaco, Monaco
| | - Nicolas Delarche
- Department of Cardiology, Centre Hospitalier de Pau, 65000 Pau, France
| | - Olivier Ormezzano
- Department of Cardiology, University Hospital, 38000 Grenoble, France
| | - Pierre Sabouret
- Heart Institute and Action Group, Pitié-Salpétrière Hospital, 75013 Paris, France
| | - François Silhol
- Department of Vascular Medicine and Arterial Hypertension, CHU Timone, 13385 Marseille, France
| | - Philippe Sosner
- Diagnosis and Therapeutic Centre, AP-HP, Hôtel-Dieu Hospital, 75004 Paris, France; Laboratory MOVE (UR 20296), University of Poitiers, 86000 Poitiers, France
| | - Marilucy Lopez-Sublet
- Department of Internal Medicine, CHU Avicenne, AP-HP, 93000 Bobigny, France; INI-CRCT network, Inserm UMR 942, 75010 Paris, France
| | - Ariel Cohen
- Department of Cardiology, Saint-Antoine Hospital, 75012 Paris, France
| | - Pierre Yves Courand
- Department of Cardiology, Hôpital de la Croix-Rousse, Hôpital Lyon Sud, Hospices Civils de Lyon, 69004 Lyon, France
| | - Michel Azizi
- Department of Hypertension, Université Paris Cité, AP-HP, HEGP, 75015 Paris, France
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Chinitz L, Böhm M, Evonich R, Saba S, Sangriogoli R, Augostini R, O'Neill PG, Fellows C, Kim MY, Hettrick DA, Viktorova E, Ukena C. Long-Term Changes in Atrial Arrhythmia Burden After Renal Denervation Combined With Pulmonary Vein Isolation: SYMPLICITY-AF. JACC Clin Electrophysiol 2024; 10:2062-2073. [PMID: 38934973 DOI: 10.1016/j.jacep.2024.04.035] [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: 11/29/2023] [Revised: 04/22/2024] [Accepted: 04/27/2024] [Indexed: 06/28/2024]
Abstract
BACKGROUND The autonomic nervous system plays an important role in atrial fibrillation (AF) and hypertension. Renal denervation (RDN) lowers blood pressure (BP), but its role in AF is poorly understood. OBJECTIVES The purpose of this study was to investigate whether RDN reduces AF recurrence after pulmonary vein isolation (PVI). METHODS This study randomized patients from 8 centers (United States, Germany) with drug-refractory AF for treatment with PVI+RDN vs PVI alone. A multielectrode radiofrequency Spyral catheter system was used for RDN. Insertable cardiac monitors were used for continuous rhythm monitoring. The primary efficacy endpoint was ≥2 minutes of AF recurrence or repeat ablation during all follow-up. The secondary endpoints included atrial arrhythmia (AA) burden, discontinuation of class I/III antiarrhythmic drugs, and BP changes from baseline. RESULTS A total of 70 patients with AF (52 paroxysmal, 18 persistent) and uncontrolled hypertension were randomized (RDN+PVI, n = 34; PVI, n = 36). At 3.5 years, 26.2% and 21.4% of patients in RDN+PVI and PVI groups, respectively, were free from the primary efficacy endpoint (log rank P = 0.73). Patients with mean ≥1 h/d AA had less daily AA burden after RDN+PVI vs PVI (4.1 hours vs 9.2 hours; P = 0.016). More patients discontinued class I/III antiarrhythmic drugs after RDN+PVI vs PVI (45% vs 14%; P = 0.040). At 1 year, systolic BP changed by -17.8 ± 12.8 mm Hg and -13.7 ± 18.8 mm Hg after RDN+PVI and PVI, respectively (P = 0.43). The composite safety endpoint was not significantly different between groups. CONCLUSIONS In patients with AF and uncontrolled BP, RDN+PVI did not prevent AF recurrence more than PVI alone. However, RDN+PVI may reduce AF burden and antiarrhythmic drug usage, but this needs further prospective validation.
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Affiliation(s)
- Larry Chinitz
- New York University Langone Medical Center, New York, New York, USA.
| | - Michael Böhm
- Universitätsklinikum des Saarlandes, Saarland University, Homburg, Germany
| | | | - Samir Saba
- University of Pittsburgh Heart and Vascular Institute, Pittsburgh, Pennsylvania, USA
| | | | - Ralph Augostini
- The Ohio State University Wexner, Medical Center, Columbus, Ohio, USA
| | | | | | | | | | | | - Christian Ukena
- Universitätsklinikum des Saarlandes, Saarland University, Homburg, Germany; Marien Hospital Herne, Ruhr University Bochum, Herne, Germany
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Zweiker D, Koppelstätter C, Hohenstein K, Lang I, Perl S, Bugger H, Brandt MC, Horn S, Binder RK, Watschinger B, Frick M, Niessner A, Weber T. Renal sympathetic denervation 2024 in Austria: recommendations from the Austrian Society of Hypertension : Endorsed by the Austrian Society of Nephrology and the Working Group of Interventional Cardiology of the Austrian Society of Cardiology. Wien Klin Wochenschr 2024; 136:559-569. [PMID: 39311980 PMCID: PMC11420322 DOI: 10.1007/s00508-024-02440-3] [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] [Accepted: 08/21/2024] [Indexed: 09/26/2024]
Abstract
Renal sympathetic denervation (RDN) is an interventional supplement to medical treatment in patients with arterial hypertension. While the first sham-controlled trial, SYMPLICITY HTN‑3 was neutral, with improved procedural details, patient selection and follow-up, recent randomized sham-controlled trials of second-generation devices show a consistent blood pressure lowering effect of RDN, as compared to sham controls. These new data and the recent U.S. Food and Drug Administration (FDA) premarket approval of two RDN devices are the basis for the present recommendations update.This joint position paper from the Austrian Society of Hypertension, together with the Austrian Society of Nephrology and the Working Group of Interventional Cardiology from the Austrian Society of Cardiology includes an overview about the available evidence on RDN and gives specific recommendations for the work-up, patient selection, pretreatment, procedural management and follow-up in patients undergoing RDN in Austria. Specifically, RDN may be used in clinical routine care, together with lifestyle measures and antihypertensive drugs, in patients with resistant hypertension (i.e. uncontrolled blood pressure on 3 antihypertensive drugs) and in those with uncontrolled hypertension, after adequate work-up, if institutional, patient-related and procedural conditions are fulfilled.
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Affiliation(s)
- David Zweiker
- Third Medical Department for Cardiology and Intensive Care, Vienna Healthcare Group, Clinic Ottakring, Montleartstraße 36, Pavillon 29, 1160, Vienna, Austria.
- Division of Cardiology, Medical University of Graz, Graz, Austria.
| | | | - Katharina Hohenstein
- Division of Internal Medicine, Nephrology, Medical University of Vienna, Vienna, Austria
| | - Irene Lang
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Sabine Perl
- Division of Cardiology, Medical University of Graz, Graz, Austria
| | - Heiko Bugger
- Division of Cardiology, Medical University of Graz, Graz, Austria
| | | | - Sabine Horn
- Department of Internal Medicine, Villach State Hospital, Villach, Austria
| | - Ronald K Binder
- Department of Internal Medicine II, Cardiology and Intensive Care Medicine, Klinikum Wels-Grieskirchen, Wels, Austria
| | - Bruno Watschinger
- Division of Internal Medicine, Nephrology, Medical University of Vienna, Vienna, Austria
| | - Matthias Frick
- Department of Internal Medicine I, Academic Teaching Hospital Feldkirch, Feldkirch, Austria
| | - Alexander Niessner
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
- Second Department of Cardiology and Intensive Care Medicine, Vienna Healthcare Group, Clinic Landstraße, Vienna, Austria
| | - Thomas Weber
- Department of Internal Medicine II, Cardiology and Intensive Care Medicine, Klinikum Wels-Grieskirchen, Wels, Austria
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10
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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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11
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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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12
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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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13
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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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14
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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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15
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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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16
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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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17
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Lauder L, Mahfoud F, Böhm M. Management of Resistant Hypertension. Annu Rev Med 2024; 75:443-457. [PMID: 37738507 DOI: 10.1146/annurev-med-050922-052605] [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: 09/24/2023]
Abstract
Resistant hypertension (RH) is a severe form of hypertension associated with increased cardiovascular risk. Although true RH affects less than 10% of the patients receiving antihypertensive therapy, the absolute number is high and continues to increase. The workup of these patients requires screening for secondary hypertension and pseudoresistance, including poor adherence to prescribed medicines and the white-coat phenomenon. The treatment of RH consists of lifestyle modifications and pharmacological therapies. Lifestyle modifications include dietary adjustments, weight loss, physical activity, and limiting alcohol consumption; pharmacological therapies include diuretics, mineralocorticoid receptor antagonists, beta blockers, angiotensin receptor-neprilysin inhibitors, and others. Over the last 15 years, interventional approaches have emerged as adjunct treatment options; we highlight catheter-based renal denervation. This review summarizes the rationales and latest clinical evidence and, based thereon, proposes an updated algorithm for the management of RH.
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Affiliation(s)
- Lucas Lauder
- Department of Internal Medicine III, Cardiology, Angiology, and Intensive Care Medicine, Universitätsklinikum des Saarlandes and Saarland University, Homburg, Germany; , ,
| | - Felix Mahfoud
- Department of Internal Medicine III, Cardiology, Angiology, and Intensive Care Medicine, Universitätsklinikum des Saarlandes and Saarland University, Homburg, Germany; , ,
| | - Michael Böhm
- Department of Internal Medicine III, Cardiology, Angiology, and Intensive Care Medicine, Universitätsklinikum des Saarlandes and Saarland University, Homburg, Germany; , ,
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18
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Kandzari DE, Townsend RR, Kario K, Mahfoud F, Weber MA, Schmieder RE, Pocock S, Tsioufis K, Konstantinidis D, Choi J, East C, Lauder L, Cohen DL, Kobayashi T, Schmid A, Lee DP, Ma A, Weil J, Agdirlioglu T, Schlaich MP, Shetty S, Devireddy CM, Lea J, Aoki J, Sharp ASP, Anderson R, Fahy M, DeBruin V, Brar S, Böhm M. Safety and Efficacy of Renal Denervation in Patients Taking Antihypertensive Medications. J Am Coll Cardiol 2023; 82:1809-1823. [PMID: 37914510 DOI: 10.1016/j.jacc.2023.08.045] [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: 04/13/2023] [Revised: 08/22/2023] [Accepted: 08/28/2023] [Indexed: 11/03/2023]
Abstract
BACKGROUND Renal denervation (RDN) reduces blood pressure (BP) in patients with uncontrolled hypertension in the absence of antihypertensive medications. OBJECTIVES This trial assessed the safety and efficacy of RDN in the presence of antihypertensive medications. METHODS SPYRAL HTN-ON MED is a prospective, randomized, sham-controlled, patient- and assessor-blinded trial enrolling patients from 56 clinical centers worldwide. Patients were prescribed 1 to 3 antihypertensive medications. Patients were randomized to radiofrequency RDN or sham control procedure. The primary efficacy endpoint was the baseline-adjusted change in mean 24-hour ambulatory systolic BP at 6 months between groups using a Bayesian trial design and analysis. RESULTS The treatment difference in the mean 24-hour ambulatory systolic BP from baseline to 6 months between the RDN group (n = 206; -6.5 ± 10.7 mm Hg) and sham control group (n = 131; -4.5 ± 10.3 mm Hg) was -1.9 mm Hg (95% CI: -4.4 to 0.5 mm Hg; P = 0.12). There was no significant difference between groups in the primary efficacy analysis with a posterior probability of superiority of 0.51 (Bayesian treatment difference: -0.03 mm Hg [95% CI: -2.82 to 2.77 mm Hg]). However, there were changes and increases in medication intensity among sham control patients. RDN was associated with a reduction in office systolic BP compared with sham control at 6 months (adjusted treatment difference: -4.9 mm Hg; P = 0.0015). Night-time BP reductions and win ratio analysis also favored RDN. There was 1 adverse safety event among 253 assessed patients. CONCLUSIONS There was no significant difference between groups in the primary analysis. However, multiple secondary endpoint analyses favored RDN over sham control. (SPYRAL HTN-ON MED Study [Global Clinical Study of Renal Denervation With the Symplicity Spyral Multi-electrode Renal Denervation System in Patients With Uncontrolled Hypertension in the Absence of Antihypertensive Medications]; NCT02439775).
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Affiliation(s)
| | - Raymond R Townsend
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kazuomi Kario
- Departmnet of Cardiovascular Medicine, Jichi Medical University School of Medicine, Tochigi, Japan
| | - Felix Mahfoud
- Universitätsklinikum des Saarlandes, Saarland University, Homburg, Germany
| | | | | | - Stuart Pocock
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | | | - James Choi
- Baylor Research Institute, Jack and Jane Hamilton Heart and Vascular Hospital, Dallas, Texas, USA
| | - Cara East
- Baylor Research Institute, Jack and Jane Hamilton Heart and Vascular Hospital, Dallas, Texas, USA
| | - Lucas Lauder
- Universitätsklinikum des Saarlandes, Saarland University, Homburg, Germany
| | - Debbie L Cohen
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Taisei Kobayashi
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Axel Schmid
- University Hospital Erlangen, Erlangen, Germany
| | - David P Lee
- Stanford Hospital and Clinics, Stanford, California, USA
| | - Adrian Ma
- Stanford Hospital and Clinics, Stanford, California, USA
| | | | | | - Markus P Schlaich
- Department of Cardiology, Fiona Stanley and Royal Perth Hospitals, and Dobney Hypertension Centre, University of Western Australia, Perth, Western Australia, Australia
| | - Sharad Shetty
- Department of Cardiology, Fiona Stanley and Royal Perth Hospitals, and Dobney Hypertension Centre, University of Western Australia, Perth, Western Australia, Australia
| | | | - Janice Lea
- Emory University School of Medicine, Atlanta, Georgia, USA
| | - Jiro Aoki
- Mitsui Memorial Hospital, Tokyo, Japan
| | | | | | | | | | | | - Michael Böhm
- Universitätsklinikum des Saarlandes, Saarland University, Homburg, Germany
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19
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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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20
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Mahfoud F, Wijns W. Renal Denervation for Treatment of Hypertension: From High-Level Quality Evidence to Implementation in Clinical Practice. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2023; 2:101130. [PMID: 39129893 PMCID: PMC11308034 DOI: 10.1016/j.jscai.2023.101130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 08/08/2023] [Indexed: 08/13/2024]
Affiliation(s)
- Felix Mahfoud
- Klinik für Innere Medizin III, Universitätsklinikum des Saarlandes and Saarland University, Homburg, Germany
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, Massachusetts
| | - William Wijns
- The Lambe Institute for Translational Medicine, and University of Galway, Galway, Ireland
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21
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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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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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23
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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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24
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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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25
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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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26
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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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27
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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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28
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Kandzari DE, Weber MA, Poulos C, Coulter J, Cohen SA, DeBruin V, Jones D, Pathak A. Patient Preferences for Pharmaceutical and Device-Based Treatments for Uncontrolled Hypertension: Discrete Choice Experiment. Circ Cardiovasc Qual Outcomes 2023; 16:e008997. [PMID: 36484251 PMCID: PMC9848220 DOI: 10.1161/circoutcomes.122.008997] [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] [Indexed: 12/13/2022]
Abstract
BACKGROUND Discrete choice experiment is a survey method used to understand how individuals make decisions and to quantify the relative importance of features. Using discrete choice experiment methods, we quantified patient benefit-risk preferences for hypertension treatments, including pharmaceutical and interventional treatments, like renal denervation. METHODS Respondents from the United States with physician-confirmed uncontrolled hypertension selected between treatments involving a procedure or pills, using a structured survey. Treatment features included interventional, noninterventional, or no hypertension treatment; number of daily blood pressure (BP) pills; expected reduction in office systolic BP; duration of effect; and risks of drug side effects, access site pain, or vascular injury. The results of a random-parameters logit model were used to estimate the importance of each treatment attribute. RESULTS Among 400 patients completing the survey between 2020 and 2021, demographics included: 52% women, mean age 59.2±13.0 years, systolic BP 155.1±12.3 mm Hg, and 1.8±0.9 prescribed antihypertensive medications. Reduction in office systolic BP was the most important treatment attribute. The remaining attributes, in decreasing order, were duration of effect, whether treatment was interventional, number of daily pills, risk of vascular injury, and risk of drug side effects. Risk of access site pain did not influence choice. In general, respondents preferred noninterventional over interventional treatments, yet only a 2.3 mm Hg reduction in office systolic BP was required to offset this preference. Small reductions in office systolic BP would offset risks of vascular injury or drug side effects. At least a 20% risk of vascular injury or drug side effects would be tolerated in exchange for improved BP. CONCLUSIONS Reduction in systolic BP was identified as the most important driver of patient treatment preference, while treatment-related risks had less influence. The results indicate that respondents would accept interventional treatments in exchange for modest reductions in systolic BP compared with those observed in renal denervation trials.
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Affiliation(s)
| | | | | | - Joshua Coulter
- RTI Health Solutions, Research Triangle Park, NC, (J.C.)
| | | | | | - Denise Jones
- Medtronic, Santa Rosa, CA (S.A.C., V.D.B., D.J.)
| | - Atul Pathak
- Department of Cardiovascular Medicine, Centre Hospitalier Princese Grace, Monaco (A.P.).,UMR UT CNRS 88 Hypertension and Heart Failure: molecular and clinical investigations. Toulouse, France, INI-CRCT F-CRIN, GREAT Networks (A.P.)
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29
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Zeijen VJM, Kroon AA, van den Born BH, Blankestijn PJ, Meijvis SCA, Nap A, Lipsic E, Elvan A, Versmissen J, van Geuns RJ, Voskuil M, Tonino PAL, Spiering W, Deinum J, Daemen J. 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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Affiliation(s)
- V J M Zeijen
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - A A Kroon
- Department of Internal Medicine, Maastricht University Medical Center & Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
| | - B H van den Born
- Department of Vascular Medicine, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - P J Blankestijn
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, The Netherlands
| | - S C A Meijvis
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, The Netherlands
| | - A Nap
- Department of Cardiology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - E Lipsic
- Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands
| | - A Elvan
- Department of Cardiology, Isala Heart Center, Zwolle, The Netherlands
| | - J Versmissen
- Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - R J van Geuns
- Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - M Voskuil
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - P A L Tonino
- Department of Cardiology, Catharina Hospital, Eindhoven, The Netherlands
| | - W Spiering
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - J Deinum
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - J Daemen
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands.
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30
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Lauder L, Mahfoud F, Azizi M, Bhatt DL, Ewen S, Kario K, Parati G, Rossignol P, Schlaich MP, Teo KK, Townsend RR, Tsioufis C, Weber MA, Weber T, Böhm M. Hypertension management in patients with cardiovascular comorbidities. Eur Heart J 2022:6808663. [DOI: 10.1093/eurheartj/ehac395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 06/23/2022] [Accepted: 07/08/2022] [Indexed: 11/09/2022] Open
Abstract
Abstract
Arterial hypertension is a leading cause of death globally. Due to ageing, the rising incidence of obesity, and socioeconomic and environmental changes, its incidence increases worldwide. Hypertension commonly coexists with Type 2 diabetes, obesity, dyslipidaemia, sedentary lifestyle, and smoking leading to risk amplification. Blood pressure lowering by lifestyle modifications and antihypertensive drugs reduce cardiovascular (CV) morbidity and mortality. Guidelines recommend dual- and triple-combination therapies using renin–angiotensin system blockers, calcium channel blockers, and/or a diuretic. Comorbidities often complicate management. New drugs such as angiotensin receptor-neprilysin inhibitors, sodium–glucose cotransporter 2 inhibitors, glucagon-like peptide-1 receptor agonists, and non-steroidal mineralocorticoid receptor antagonists improve CV and renal outcomes. Catheter-based renal denervation could offer an alternative treatment option in comorbid hypertension associated with increased sympathetic nerve activity. This review summarises the latest clinical evidence for managing hypertension with CV comorbidities.
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Affiliation(s)
- Lucas Lauder
- Klinik für Innere Medizin III, Universitätsklinikum des Saarlandes, Saarland University , Kirrberger Str. 1, 66421 Homburg , Germany
| | - Felix Mahfoud
- Klinik für Innere Medizin III, Universitätsklinikum des Saarlandes, Saarland University , Kirrberger Str. 1, 66421 Homburg , Germany
| | - Michel Azizi
- Université Paris Cité, INSERM CIC1418 , F-75015 Paris , France
- AP-HP, Hôpital Européen Georges-Pompidou, Hypertension Department, DMU CARTE , F-75015 Paris , France
- FCRIN INI-CRCT , Nancy , France
| | - Deepak L Bhatt
- Brigham and Women’s Hospital Heart and Vascular Center, Harvard Medical School , Boston, MA , USA
| | - Sebastian Ewen
- Klinik für Innere Medizin III, Universitätsklinikum des Saarlandes, Saarland University , Kirrberger Str. 1, 66421 Homburg , Germany
| | - Kazuomi Kario
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine , Tochigi , Japan
| | - Gianfranco Parati
- Department of Medicine and Surgery, Cardiology Unit, University of Milano-Bicocca and Istituto Auxologico Italiano, IRCCS , Milan , Italy
| | - Patrick Rossignol
- FCRIN INI-CRCT , Nancy , France
- Université de Lorraine, INSERM, Centre d'Investigations Cliniques - Plurithématique 14-33 and INSERM U1116 , Nancy , France
- CHRU de Nancy , Nancy , France
| | - Markus P Schlaich
- Dobney Hypertension Centre, Medical School—Royal Perth Hospital Unit, Medical Research Foundation, The University of Western Australia , Perth, WA , Australia
- Departments of Cardiology and Nephrology, Royal Perth Hospital , Perth, WA , Australia
| | - Koon K Teo
- Population Health Research Institute, McMaster University , Hamilton, ON , Canada
| | - Raymond R Townsend
- Perelman School of Medicine, University of Pennsylvania , Philadelphia, PA , USA
| | - Costas Tsioufis
- National and Kapodistrian University of Athens, 1st Cardiology Clinic, Hippocratio Hospital , Athens , Greece
| | | | - Thomas Weber
- Department of Cardiology, Klinikum Wels-Grieskirchen , Wels , Austria
| | - Michael Böhm
- Klinik für Innere Medizin III, Universitätsklinikum des Saarlandes, Saarland University , Kirrberger Str. 1, 66421 Homburg , Germany
- Cape Heart Institute (CHI), Faculty of Health Sciences, University of Cape Town , Cape Town , South Africa
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31
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Rey-García J, Townsend RR. Renal Denervation: A Review. Am J Kidney Dis 2022; 80:527-535. [PMID: 35598810 DOI: 10.1053/j.ajkd.2022.03.015] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 03/14/2022] [Indexed: 02/02/2023]
Abstract
Uncontrolled hypertension persists as an important health issue despite the availability of many medications and nondrug therapies that lower blood pressure. Increasingly, nonadherence to medication is found in approximately 2 of every 5 patients with uncontrolled hypertension. In the search for interventions that lower blood pressure that do not rely on adherence to a regimen requiring daily ingestion of medication or repeated physical activity, device-based methods that denervate the renal arteries have emerged as a potential complement to standard antihypertensive treatments. At least 3 different approaches to renal artery denervation are under active investigation, including the use of radiofrequency energy, ultrasound, or the injection of neurolytic agents into the renal perivascular tissue. In this review, we cover what is currently known about the mechanisms of antihypertensive effects of renal denervation, summarize the efficacy and safety of renal denervation using recent controlled trial publications in a number of hypertensive populations, and conclude with some thoughts about challenges in the field, including the optimization of patient selection for the procedure and what the reader can expect in the near future in this rapidly developing field.
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Affiliation(s)
- Jimena Rey-García
- Department of Preventive Medicine and Public Health, Universidad Autónoma de Madrid, Madrid, Spain; Internal Medicine Department, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria, Madrid, Spain
| | - Raymond R Townsend
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
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32
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Messerli FH, Bavishi C, Brguljan J, Burnier M, Dobner S, Elijovich F, Ferdinand KC, Kjeldsen S, Laffer CL, S Ram CV, Rexhaj E, Ruilope LM, Shalaeva EV, Siontis GC, Staessen JA, Textor SC, Vongpatanasin W, Vogt L, Volpe M, Wang J, Williams B. Renal denervation in the antihypertensive arsenal - knowns and known unknowns. J Hypertens 2022; 40:1859-1875. [PMID: 36052518 PMCID: PMC10010701 DOI: 10.1097/hjh.0000000000003171] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Revised: 03/26/2022] [Accepted: 03/26/2022] [Indexed: 01/21/2023]
Abstract
Even though it has been more than a decade since renal denervation (RDN) was first used to treat hypertension and an intense effort on researching this therapy has been made, it is still not clear how RDN fits into the antihypertensive arsenal. There is no question that RDN lowers blood pressure (BP), it does so to an extent at best corresponding to one antihypertensive drug. The procedure has an excellent safety record. However, it remains clinically impossible to predict whose BP responds to RDN and whose does not. Long-term efficacy data on BP reduction are still unconvincing despite the recent results in the SPYRAL HTN-ON MED trial; experimental studies indicate that reinnervation is occurring after RDN. Although BP is an acceptable surrogate endpoint, there is complete lack of outcome data with RDN. Clear indications for RDN are lacking although patients with resistant hypertension, those with documented increase in activity of the sympathetic system and perhaps those who desire to take fewest medication may be considered.
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Affiliation(s)
- Franz H. Messerli
- Department of BioMedical Research, University of Bern, Bern, Switzerland
- Jagiellonian University Krakow, Krakow, Poland
| | - Chirag Bavishi
- Department of Cardiology, University of Missouri, Columbia, Missouri, USA
| | - Jana Brguljan
- University Medical Centre Ljubljana, Department of Hypertension, Medical University Ljubljana, Slovenia
| | - Michel Burnier
- University of Lausanne. Faculty of Biology and Medicine, Lausanne, Switzerland
| | - Stephan Dobner
- Department of Cardiology, Bern University Hospital University of Bern, Bern, Switzerland
| | - Fernando Elijovich
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University, USA
| | | | - Sverre Kjeldsen
- Department of Cardiology, University of Oslo Hospital, Oslo, Norway
| | - Cheryl L. Laffer
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - C. Venkata S Ram
- Apollo Hospitals and Medical College, Hyderabad, Telangana, India
| | - Emrush Rexhaj
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland
- Department of BioMedical Research, University of Bern, Bern, Switzerland
| | - Luis M. Ruilope
- Cardiorenal Translational Laboratory and Hypertension Unit, Institute of Research i+12, CIBER-CV, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Evgeniya V. Shalaeva
- Division of Public Health Science, Westminster International University in Tashkent, Tashkent, Uzbekistan
- Department of Cardiology, Tashkent Medical Academy, Tashkent, Uzbekistan
| | - George C.M. Siontis
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jan A. Staessen
- NPO Research Institute Alliance for the Promotion of Preventive Medicine, Mechelen, Belgium
- Biomedical Science Group, Faculty of Medicine, Leuven, Belgium
| | - Stephen C. Textor
- Division of Hypertension and Nephrology, Mayo Clinic, Rochester, Minnesota, USA
| | - Wanpen Vongpatanasin
- Hypertension Section, Cardiology Division, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Liffert Vogt
- Department of Internal Medicine, section Nephrology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Massimo Volpe
- Department of Clinical and Molecular Medicine, University of Rome Sapienza, Rome, Italy
| | - Jiguang Wang
- The Shanghai Institute of Hypertension, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Bryan Williams
- Institute of Cardiovascular Science, University College London, London, United Kingdom
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Renal Denervation for Resistant Hypertension: A Concise Update on Treatment Options and the Latest Clinical Evidence. Cardiol Ther 2022; 11:385-392. [PMID: 35943714 PMCID: PMC9381663 DOI: 10.1007/s40119-022-00275-5] [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: 06/23/2022] [Accepted: 07/22/2022] [Indexed: 11/21/2022] Open
Abstract
Evidence from recent sham-controlled trials supports the use of endovascular renal denervation (RDN) to lower blood pressure in general as well as in treatment-resistant hypertension. According to recent studies, the effects of RDN are long lasting. Newer technologies using multipolar radiofrequency catheters and an additional ablation of the renal side branches as well as ultrasound with improved circumferential tissue penetration have made these advances possible. This has initiated a change of the perspective on RDN in clinical guidelines and has thereby set a cornerstone for a broader clinical application of RDN in the future.
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Rao A, Krishnan N. Update on Renal Sympathetic Denervation for the Treatment of Hypertension. Curr Cardiol Rep 2022; 24:1261-1271. [PMID: 35895182 DOI: 10.1007/s11886-022-01753-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/19/2022] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Hypertension is a leading risk factor for all-cause mortality in adults; however, medication non-adherence and intolerance present an enormous treatment challenge. Given the critical role of renal sympathetic nerves in neurogenic control of blood pressure and pathophysiology of hypertension, renal sympathetic denervation (RDN) has been explored as a therapeutic strategy in hypertension treatment over the last 15 years. In this review, we will discuss the role of renal sympathetic nerves in the pathophysiology of hypertension, provide an update on the available evidence regarding the short- and long-term safety and effectiveness of RDN in the treatment of hypertension, and consider its future perspectives. RECENT FINDINGS RDN is a percutaneous endovascular catheter-based neuromodulation approach that enables ablation of renal sympathetic nerve fibers within the adventitial layer of the renal arteries using radiofrequency (most extensively studied), ultrasound energy, or neurolytics (e.g., alcohol). In the last decade, advancements in procedural techniques and well-designed sham-controlled trials utilizing 24-h ambulatory blood pressure measurements have demonstrated that RDN has an excellent safety profile and results in a modest reduction of blood pressure, in a wide range of hypertensive phenotypes (mild to resistant), irrespective of antihypertensive drug use and this effect is sustained over a 3-year period. Superiority of a particular RDN modality has not been yet established. Despite strong evidence demonstrating efficacy and safety of RDN, current data does not support its use as a primary approach in the treatment of hypertension due to its modest treatment effect and concerns around long-term sustainability. Perhaps the best utility of RDN is in hypertensives intolerant to antihypertensive medications or as an adjunct to aldosterone antagonists in the management of resistant hypertension. Patient selection will be critical to demonstrate a meaningful benefit of RDN. Future well-designed studies are necessary to determine predictors and measures of response to RDN, long-term efficacy given question of renal nerve regeneration, comparison of available technologies, safety in patients with advanced kidney disease, and improvement in patient quality of life measures.
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Affiliation(s)
- Arundati Rao
- Yale School of Medicine, Section of Nephrology, New Haven, CT, USA
| | - Namrata Krishnan
- Yale School of Medicine, Section of Nephrology, New Haven, CT, USA. .,Veterans Affairs Medical Center, Section of Nephrology, Dialysis unit, bldg 2, ground floor. 950 Campbell ave, West Haven, CT, 06516, USA.
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Schmieder RE. Renal denervation in patients with chronic kidney disease: current evidence and future perspectives. Nephrol Dial Transplant 2022; 38:1089-1096. [PMID: 35617138 PMCID: PMC10157753 DOI: 10.1093/ndt/gfac189] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Indexed: 11/14/2022] Open
Abstract
Supported by several high-quality randomised clinical trials and registry analyses, catheter-based renal denervation is becoming an important adjunctive treatment modality for the safe and efficacious treatment of hypertension besides lifestyle modifications and antihypertensive medication. Renal denervation is of particular interest to nephrologists as the intervention may provide additional benefits to hypertensive people with chronic kidney disease (CKD), a condition typically characterised by sympathetic hyperactivity. A growing body of clinical evidence supports the safety and efficacy of renal denervation in this difficult-to-control population. In addition, preclinical and clinical research indicate potential nephroprotective effects in CKD patients. The current review examines recent research on renal denervation with focus on renal disease and assesses the latest findings and their implications from a nephrologist's perspective.
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Affiliation(s)
- Roland E Schmieder
- Department of Nephrology and Hypertension, University Hospital Erlangen, Friedrich-Alexander-University, Erlangen-Nuremberg, Germany
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36
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Mahfoud F, Kandzari DE, Kario K, Townsend RR, Weber MA, Schmieder RE, Tsioufis K, Pocock S, Dimitriadis K, Choi JW, East C, D'Souza R, Sharp ASP, Ewen S, Walton A, Hopper I, Brar S, McKenna P, Fahy M, Böhm M. Long-term efficacy and safety of renal denervation in the presence of antihypertensive drugs (SPYRAL HTN-ON MED): a randomised, sham-controlled trial. Lancet 2022; 399:1401-1410. [PMID: 35390320 DOI: 10.1016/s0140-6736(22)00455-x] [Citation(s) in RCA: 128] [Impact Index Per Article: 64.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 02/28/2022] [Accepted: 03/03/2022] [Indexed: 02/06/2023]
Abstract
BACKGROUND Renal denervation has been shown to lower blood pressure in the presence of antihypertensive medications; however, long-term safety and efficacy data from randomised trials of renal denervation are lacking. In this pre-specified analysis of the SPYRAL HTN-ON MED study, we compared changes in blood pressure, antihypertensive drug use, and safety up to 36 months in renal denervation versus a sham control group. METHODS This randomised, single-blind, sham-controlled trial enrolled patients from 25 clinical centres in the USA, Germany, Japan, the UK, Australia, Austria, and Greece, with uncontrolled hypertension and office systolic blood pressure between 150 mm Hg and 180 mm Hg and diastolic blood pressure of 90 mm Hg or higher. Eligible patients had to have 24-h ambulatory systolic blood pressure between 140 mm Hg and less than 170 mm Hg, while taking one to three antihypertensive drugs with stable doses for at least 6 weeks. Patients underwent renal angiography and were randomly assigned (1:1) to radiofrequency renal denervation or a sham control procedure. Patients and physicians were unmasked after 12-month follow-up and sham control patients could cross over after 12-month follow-up completion. The primary endpoint was the treatment difference in mean 24-h systolic blood pressure at 6 months between the renal denervation group and the sham control group. Statistical analyses were done on the intention-to-treat population. Long-term efficacy was assessed using ambulatory and office blood pressure measurements up to 36 months. Drug surveillance was used to assess medication use. Safety events were assessed up to 36 months. This trial is registered with ClinicalTrials.gov, NCT02439775; prospectively, an additional 260 patients are currently being randomly assigned as part of the SPYRAL HTN-ON MED Expansion trial. FINDINGS Between July 22, 2015, and June 14, 2017, among 467 enrolled patients, 80 patients fulfilled the qualifying criteria and were randomly assigned to undergo renal denervation (n=38) or a sham control procedure (n=42). Mean ambulatory systolic and diastolic blood pressure were significantly reduced from baseline in the renal denervation group, and were significantly lower than the sham control group at 24 and 36 months, despite a similar treatment intensity of antihypertensive drugs. The medication burden at 36 months was 2·13 medications (SD 1·15) in the renal denervation group and 2·55 medications (2·19) in the sham control group (p=0·26). 24 (77%) of 31 patients in the renal denervation group and 25 (93%) of 27 patients in the sham control group adhered to medication at 36 months. At 36 months, the ambulatory systolic blood pressure reduction was -18·7 mm Hg (SD 12·4) for the renal denervation group (n=30) and -8·6 mm Hg (14·6) for the sham control group (n=32; adjusted treatment difference -10·0 mm Hg, 95% CI -16·6 to -3·3; p=0·0039). Treatment differences between the renal denervation group and sham control group at 36 months were -5·9 mm Hg (95% CI -10·1 to -1·8; p=0·0055) for mean ambulatory diastolic blood pressure, -11·0 mm Hg (-19·8 to -2·1; p=0·016) for morning systolic blood pressure, and -11·8 mm Hg (-19·0 to -4·7; p=0·0017) for night-time systolic blood pressure. There were no short-term or long-term safety issues associated with renal denervation. INTERPRETATION Radiofrequency renal denervation compared with sham control produced a clinically meaningful and lasting blood pressure reduction up to 36 months of follow-up, independent of concomitant antihypertensive medications and without major safety events. Renal denervation could provide an adjunctive treatment modality in the management of patients with hypertension. FUNDING Medtronic.
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Affiliation(s)
- Felix Mahfoud
- Universitätsklinikum des Saarlandes, Saarland University, Homburg, Germany.
| | | | - Kazuomi Kario
- Department of Cardiovascular Medicine, Jichi Medical University School of Medicine, Tochigi, Japan
| | - Raymond R Townsend
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Michael A Weber
- Department of Medicine, SUNY Downstate College of Medicine, New York, NY, USA
| | | | - Konstantinos Tsioufis
- National and Kapodistrian University of Athens, Hippocratio Hospital, Athens, Greece
| | - Stuart Pocock
- London School of Hygiene & Tropical Medicine, London, UK
| | - Kyriakos Dimitriadis
- National and Kapodistrian University of Athens, Hippocratio Hospital, Athens, Greece
| | - James W Choi
- Baylor Research Institute, Jack and Jane Hamilton Heart and Vascular Hospital, Dallas, TX, USA
| | - Cara East
- Baylor Research Institute, Jack and Jane Hamilton Heart and Vascular Hospital, Dallas, TX, USA
| | | | | | - Sebastian Ewen
- Universitätsklinikum des Saarlandes, Saarland University, Homburg, Germany
| | | | | | | | | | | | - Michael Böhm
- Universitätsklinikum des Saarlandes, Saarland University, Homburg, Germany
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Kandzari DE, Mahfoud F, Weber MA, Townsend R, Parati G, Fisher NDL, Lobo MD, Bloch M, Böhm M, Sharp ASP, Schmieder RE, Azizi M, Schlaich MP, Papademetriou V, Kirtane AJ, Daemen J, Pathak A, Ukena C, Lurz P, Grassi G, Myers M, Finn AV, Morice MC, Mehran R, Jüni P, Stone GW, Krucoff MW, Whelton PK, Tsioufis K, Cutlip DE, Spitzer E. Clinical Trial Design Principles and Outcomes Definitions for Device-Based Therapies for Hypertension: A Consensus Document From the Hypertension Academic Research Consortium. Circulation 2022; 145:847-863. [PMID: 35286164 PMCID: PMC8912966 DOI: 10.1161/circulationaha.121.057687] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The clinical implications of hypertension in addition to a high prevalence of both uncontrolled blood pressure and medication nonadherence promote interest in developing device-based approaches to hypertension treatment. The expansion of device-based therapies and ongoing clinical trials underscores the need for consistency in trial design, conduct, and definitions of clinical study elements to permit trial comparability and data poolability. Standardizing methods of blood pressure assessment, effectiveness measures beyond blood pressure alone, and safety outcomes are paramount. The Hypertension Academic Research Consortium (HARC) document represents an integration of evolving evidence and consensus opinion among leading experts in cardiovascular medicine and hypertension research with regulatory perspectives on clinical trial design and methodology. The HARC document integrates the collective information among device-based therapies for hypertension to better address existing challenges and identify unmet needs for technologies proposed to treat the world’s leading cause of death and disability. Consistent with the Academic Research Consortium charter, this document proposes pragmatic consensus clinical design principles and outcomes definitions for studies aimed at evaluating device-based hypertension therapies.
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Affiliation(s)
| | - Felix Mahfoud
- Piedmont Heart Institute, Atlanta, GA (D.E.K.).,Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge (F.M.)
| | - Michael A Weber
- State University of New York, Downstate Medical College, New York (M.A.W.)
| | - Raymond Townsend
- University of Pennsylvania, Perelman School of Medicine, Philadelphia (R.T.)
| | - Gianfranco Parati
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy (G.P.).,Istituto Auxologico Italiano Istituto di Ricovero e Cura a Carattere scientifico (IRCCS), Ospedale San Luca, Milan, Italy (G.P.)
| | | | - Melvin D Lobo
- Barts National Institute for Health Research Biomedical Research Centre, William Harvey Research Institute, Queen Mary University of London, United Kingdom (M.D.L.)
| | - Michael Bloch
- University of Nevada/Reno School of Medicine (M. Bloch).,Renown Institute for Heart and Vascular Health, Reno, NV (M. Bloch)
| | - Michael Böhm
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University, Homburg, Germany (F.M., M. Böhm, C.U.)
| | - Andrew S P Sharp
- University Hospital of Wales, Cardiff and University of Exeter, United Kingdom (A.S.P.S.)
| | - Roland E Schmieder
- Department of Nephrology and Hypertension, University Hospital Erlangen, Friedrich Alexander University Erlangen/Nürnberg, Germany (R.E.S.)
| | - Michel Azizi
- University of Paris, Institut national de la santé et de la recherche médicale (INSERM), Centre d'investigation clinique 418, Assistance Publique-Hôpitaux de Paris Hypertension Department and Département médico-universitaire Cardiologie Rein Transplantation Neurovasculaire, Georges Pompidou European Hospital, France (M.A.)
| | - Markus P Schlaich
- Dobney Hypertension Centre, School of Medicine-Royal Perth Hospital Unit and Research Foundation, University of Western Australia (M.P.S.)
| | - Vasilios Papademetriou
- Department of Veterans Affairs and Georgetown University Medical Centers, Washington, DC (V.P.)
| | - Ajay J Kirtane
- Columbia University Irving Medical Center/New York-Presbyterian Hospital, New York' NY (A.J.K.).,Cardiovascular Research Foundation, New York (A.J.K., R.M., G.W.S.)
| | - Joost Daemen
- Thoraxcenter, Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands (J.D., E.S.)
| | - Atul Pathak
- Department of Cardiovasculaire Medicine, European Society of Hypertension Excellence Center, Princess Grace Hospital, Monaco (A.P.).,Centre for Anthropobiology and Genomics of Toulouse, Toulouse, France (A.P.)
| | - Christian Ukena
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University, Homburg, Germany (F.M., M. Böhm, C.U.)
| | - Philipp Lurz
- Heart Center Leipzig at University of Leipzig, Germany (P.L.)
| | - Guido Grassi
- Clinica Medica University Milano-Bicocca, Milan, Italy (G.G.)
| | - Martin Myers
- Division of Cardiology, Sunnybrook Health Sciences Centre (M.M.), University of Toronto, Canada
| | | | | | - Roxana Mehran
- Cardiovascular Research Foundation, New York (A.J.K., R.M., G.W.S.).,Mount Sinai Hospital, New York (R.M., G.W.S.)
| | - Peter Jüni
- Applied Health Research Centre, Li Ka Shing Knowledge Institute of St Michael's Hospital, Department of Medicine and Institute of Health Policy, Management and Evaluation (P.J.), University of Toronto, Canada
| | - Gregg W Stone
- Cardiovascular Research Foundation, New York (A.J.K., R.M., G.W.S.)
| | | | - Paul K Whelton
- Departments of Epidemiology and Medicine, Tulane University Health Sciences Center, New Orleans, LA (P.K.W.)
| | - Konstantinos Tsioufis
- 1st Department of Cardiology, National and Kapodistrian University of Athens, Hippocratio Hospital, Greece (K.T.)
| | - Donald E Cutlip
- Baim Institute for Clinical Research, Boston, MA (D.E.C.).,Beth Israel Deaconess Medical Center, Boston, MA (D.E.C.)
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Renal denervation: basic and clinical evidence. Hypertens Res 2022; 45:198-209. [PMID: 34921299 DOI: 10.1038/s41440-021-00827-7] [Citation(s) in RCA: 43] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 11/29/2021] [Accepted: 11/30/2021] [Indexed: 01/20/2023]
Abstract
Renal nerves have critical roles in regulating blood pressure and fluid volume, and their dysfunction is closely related with cardiovascular diseases. Renal nerves are composed of sympathetic efferent and sensory afferent nerves. Activation of the efferent renal sympathetic nerves induces renin secretion, sodium absorption, and increased renal vascular resistance, which lead to increased blood pressure and fluid retention. Afferent renal sensory nerves, which are densely innervated in the renal pelvic wall, project to the hypothalamic paraventricular nucleus in the brain to modulate sympathetic outflow to the periphery, including the heart, kidneys, and arterioles. The effects of renal denervation on the cardiovascular system are mediated by both efferent denervation and afferent denervation. The first half of this review focuses on basic research using animal models of hypertension and heart failure, and addresses the therapeutic effects of renal denervation for hypertension and heart failure, including underlying mechanisms. The second half of this review focuses on clinical research related to catheter-based renal denervation in patients with hypertension. Randomized sham-controlled trials using second-generation devices, endovascular radiofrequency-based devices and ultrasound-based devices are reviewed and their results are assessed. This review summarizes the basic and clinical evidence of renal denervation to date, and discusses future prospects and potential developments in renal denervation therapy for cardiovascular diseases.
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Coates P, Tunev S, Trudel J, Hettrick DA. Time, temperature, power, and impedance considerations for radiofrequency catheter renal denervation. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2022; 42:171-177. [DOI: 10.1016/j.carrev.2022.02.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 02/18/2022] [Accepted: 02/18/2022] [Indexed: 11/28/2022]
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Striepe K, Schiffer M, Schmieder R. [Renal denervation : Really an alternative to reducing blood pressure?]. Internist (Berl) 2022; 63:330-340. [PMID: 35029703 DOI: 10.1007/s00108-021-01242-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/13/2021] [Indexed: 10/19/2022]
Abstract
Since the current guidelines were published in 2018, a total of 5 sham-controlled high-quality studies evaluating renal denervation have been conducted and the results were published. These five studies clearly confirmed the efficacy and safety of renal denervation, which correspond to the knowledge of the Clinical Consensus Conference. Thus, an update of the guidelines for the treatment of arterial hypertension regarding the clinical significance of renal denervation is urgently necessary. For this reason, the position paper of the working group of the European Society of Hypertension on the current state of renal denervation was reviewed. An approval of this procedure can soon be expected. In Germany there is a diagnosis-related group (DRG) for the reimbursement of renal denervation, which was suspended due to the erroneous Symplicity 3 study. This DRG should be revived in practice by a structured process of the implementation of renal denervation. It will then be a joint task of treating physicians and specialists in certified centers to identify eligible patients. In the future, antihypertensive treatment will consist of three pillars: lifestyle measures, pharmacotherapy and interventional treatment. These three treatment options should not be regarded as competitive (which is better) but alternative (patient preference) and additive (the aim is blood pressure control). It is the task of the treating physician to provide the patient with the ideal treatment concept. Clearly, renal denervation will not replace antihypertensive pharmacotherapy; however, it can lead to a reduction of the drug burden and increase of patient adherence to medication. It represents an option of modern antihypertensive treatment and will also become increasingly more important in special patient groups.
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Affiliation(s)
- Kristina Striepe
- Medizinische Klinik 4, Nephrologie und Hypertensiologie, Universitätsklinik Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Ulmenweg 18, 91054, Erlangen, Deutschland
| | - Mario Schiffer
- Medizinische Klinik 4, Nephrologie und Hypertensiologie, Universitätsklinik Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Ulmenweg 18, 91054, Erlangen, Deutschland
| | - Roland Schmieder
- Medizinische Klinik 4, Nephrologie und Hypertensiologie, Universitätsklinik Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Ulmenweg 18, 91054, Erlangen, Deutschland.
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Mahfoud F, Bloch M, Azizi M, Wang Y, Schmieder R, Lobo M, Sharp A, Daemen J, Basile J, Weber M, Scicli A, McClure C, Kirtane A. Changes in blood pressure after crossover to ultrasound renal denervation in patients initially treated with sham in the RADIANCE-HTN SOLO trial. EUROINTERVENTION 2021; 17:e1024-e1032. [PMID: 34236037 PMCID: PMC9724980 DOI: 10.4244/eij-d-21-00295] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND The multicentre, randomised, sham-controlled RADIANCE-HTN SOLO trial reported the blood pressure (BP)-lowering efficacy and safety of ultrasound renal denervation (RDN) in the absence (2 months) and presence (6 and 12 months) of antihypertensive medications in patients with mild-to-moderate hypertension. AIMS The aim of this report was to evaluate patients originally assigned to the sham group who crossed over to RDN. METHODS After the primary endpoint was met, patients in the sham arm who remained uncontrolled were allowed to cross over to receive RDN. All patients were unblinded and treated with standard of care medications at the time of crossover. Ambulatory BP was evaluated 2 and 6 months after crossover. RESULTS Among 72 subjects of the sham arm, 33 underwent ultrasound RDN after an average follow-up of 23±6 months. Prior to crossover, patients had a daytime ambulatory BP of 144.1±10.1/89.9±8.4 mmHg and received 1.2±0.8 antihypertensive medications. Mean change in daytime ambulatory BP from pre-crossover to 2 and 6 months post RDN was -11.2±13.7/-7.1±8.9 mmHg (n=33; p<0.001; p<0.001) and -10.8±17.3/-7.8±11.6 mmHg (n=27; p=0.002; p<0.001). The number of antihypertensive medications did not change from pre-crossover baseline to 2 and 6 months. Eighteen of 33 (54.5%) patients had their daytime ambulatory BP controlled (<135/85 mmHg) at 2 months and 44.4% (12/27) at 6 months post RDN. No major procedure-related adverse events occurred. CONCLUSIONS During unblinded long-term follow-up of the RADIANCE-HTN SOLO study, patients originally assigned to a sham procedure who remained uncontrolled had significant reductions in BP following crossover treatment with ultrasound RDN.
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Affiliation(s)
- Felix Mahfoud
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Kirrberger Str. 1, IMED, Geb. 41, 66421 Homburg/Saar, Germany
E-mail:
| | - Michael Bloch
- Department of Medicine, University of Nevada School of Medicine, Vascular Care, Renown Institute of Heart and Vascular Health, Reno, NV, USA
| | - Michel Azizi
- Université de Paris, Paris, and AP-HP, Hôpital Européen Georges-Pompidou, Hypertension Department, and DMU CARTE, Paris, France
| | - Yale Wang
- Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Roland Schmieder
- Nephrology and Hypertension, University Hospital Erlangen, Friedrich Alexander University, Erlangen, Germany
| | - Melvin Lobo
- Barts NIHR Biomedical Research Centre, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Andrew Sharp
- University Hospital of Wales, Cardiff, and University of Exeter, Exeter, United Kingdom
| | - Joost Daemen
- Erasmus University Medical Center, Department of Cardiology, Rotterdam, the Netherlands
| | - Jan Basile
- Seinsheimer Cardiovascular Health Program, Medical University of South Carolina, Ralph H. Johnson VA Medical Center, Charleston, SC, USA
| | - Michael Weber
- Division of Cardiovascular Medicine, State University of New York, Downstate Medical Center, New York, NY, USA
| | | | | | - Ajay Kirtane
- Columbia University Medical Center/NewYork-Presbyterian Hospital, and the Cardiovascular Research Foundation, New York, NY, USA
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Damianaki A, Polychronopoulou E, Wuerzner G, Burnier M. New Aspects in the Management of Hypertension in Patients with Chronic Kidney Disease not on Renal Replacement Therapy. High Blood Press Cardiovasc Prev 2021; 29:125-135. [PMID: 34910287 PMCID: PMC8942929 DOI: 10.1007/s40292-021-00495-1] [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: 11/03/2021] [Accepted: 11/30/2021] [Indexed: 11/07/2022] Open
Abstract
With chronic kidney disease (CKD) being a global arising health problem, strategies for delaying kidney disease progression and reducing the high cardiovascular risk inherent to CKD, are the main objectives of the actual management of patients with kidney diseases. In these patients, the control of arterial hypertension is essential, as high blood pressure (BP) is a strong determinant of worst cardiovascular and renal outcomes. Achieving target blood pressures recommended by international guidelines is mandatory and often demands a multiple levels management, including several pharmacological and lifestyle measures. Even in the presence of adequate BP control, the residual cardiovascular risk remains high. In this respect, the recent demonstration that novel agents such as sodium glucose transporter 2 (SGLT2) inhibitors or the new non-steroidal mineralocorticoid antagonist finerenone can retard the progression of kidney diseases and reduce cardiovascular mortality on top of standard of care treatment with renin-angiotensin system inhibitors represent enormous progresses. These studies also demonstrate that cardiovascular and renal protection can be obtained beyond blood pressure control. Other promising novelties are still to come such as renal denervation and endothelin receptor antagonists in the setting of diabetic and non-diabetic kidney diseases. In the present review, we shall discuss the classic and the new aspects for the management of hypertension in CKD, integrating the new data from recent clinical studies.
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Affiliation(s)
- Aikaterini Damianaki
- Service of Nephrology and Hypertension, University Hospital, Rue du Bugnon 17, 1011, Lausanne, Switzerland
| | - Erietta Polychronopoulou
- Service of Nephrology and Hypertension, University Hospital, Rue du Bugnon 17, 1011, Lausanne, Switzerland
| | - Gregoire Wuerzner
- Service of Nephrology and Hypertension, University Hospital, Rue du Bugnon 17, 1011, Lausanne, Switzerland.,Hypertension Research Foundation, Saint-Légier, Switzerland
| | - Michel Burnier
- Service of Nephrology and Hypertension, University Hospital, Rue du Bugnon 17, 1011, Lausanne, Switzerland. .,Hypertension Research Foundation, Saint-Légier, Switzerland.
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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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Kandzari DE. Mirror, Mirror on the Wall: Who Is the Fairest Meta-Analysis of All? JACC Cardiovasc Interv 2021; 14:2625-2628. [PMID: 34743929 DOI: 10.1016/j.jcin.2021.10.014] [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] [Received: 09/30/2021] [Accepted: 10/14/2021] [Indexed: 10/19/2022]
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Ogoyama Y, Tada K, Abe M, Nanto S, Shibata H, Mukoyama M, Kai H, Arima H, Kario K. Effects of renal denervation on blood pressures in patients with hypertension: a systematic review and meta-analysis of randomized sham-controlled trials. Hypertens Res 2021; 45:210-220. [PMID: 34657140 DOI: 10.1038/s41440-021-00761-8] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 09/06/2021] [Accepted: 09/12/2021] [Indexed: 12/20/2022]
Abstract
The efficacy of renal denervation has been controversial, but recent randomized sham-controlled trials demonstrated significant blood pressure reductions after renal denervation in patients with hypertension. We conducted a systematic review and updated meta-analysis to evaluate the effects of renal denervation on ambulatory and office blood pressures in patients with hypertension. Databases were searched up to 25 May 2021 to identify randomized, sham-controlled trials of renal denervation. The primary endpoint was change in 24 h ambulatory systolic blood pressure with renal denervation versus sham control. The secondary endpoints were daytime and nighttime systolic blood pressure, and office systolic blood pressure. A sub-analysis determined outcomes by medication, procedure, and device. From nine trials, 1555 patients with hypertension were randomized to undergo renal denervation (n = 885) or a sham procedure (n = 670). At 2-6 months after treatment, renal denervation significantly reduced 24 h ambulatory systolic blood pressure by 3.31 mmHg (95% confidence interval: -4.69, -1.94) compared with the sham procedure (p < 0.001). Renal denervation also reduced daytime SBP by 3.53 mmHg (-5.28, -1.78; p < 0.001), nighttime SBP by 3.20 mmHg (-5.46, -0.94; p = 0.006), and office SBP by 5.25 mmHg (-7.09, -3.40; p < 0.001) versus the sham control group. There were no significant differences in the magnitude of blood pressure reduction between first- and second-generation trials, between devices, or with or without medication. These data from randomized sham-controlled trials showed that renal denervation significantly reduced all blood pressure metrics in medicated or unmedicated patients with hypertension, including resistant/uncontrolled hypertension. Future trials should investigate the long-term efficacy and safety of renal denervation.
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Affiliation(s)
- Yukako Ogoyama
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Tochigi, Japan
| | - Kazuhiro Tada
- Division of Nephrology and Rheumatology, Department of Internal Medicine, Faculty of Medicine, Fukuoka University, Fukuoka, Japan.,Department of Preventive Medicine and Public Health, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Makiko Abe
- Department of Preventive Medicine and Public Health, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Shinsuke Nanto
- Department of Cardiovascular Medicine, Nishinomiya Municipal Central Hospital, Hyogo, Japan
| | - Hirotaka Shibata
- Department of Endocrinology, Metabolism, Rheumatology and Nephrology, Faculty of Medicine, Oita University, Oita, Japan
| | - Masashi Mukoyama
- Department of Nephrology, Kumamoto University Graduate School of Medical Sciences, Kumamoto, Japan
| | - Hisashi Kai
- Department of Cardiology, Kurume University Medical Center, Fukuoka, Japan
| | - Hisatomi Arima
- Department of Preventive Medicine and Public Health, Faculty of Medicine, Fukuoka University, Fukuoka, Japan.
| | - Kazuomi Kario
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Tochigi, Japan.
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Kandzari DE, Townsend RR, Bakris G, Basile J, Bloch MJ, Cohen DL, East C, Ferdinand KC, Fisher N, Kirtane A, Lee DP, Puckrein G, Rader F, Vassalotti JA, Weber MA, Willis K, Secemsky E. Renal denervation in hypertension patients: Proceedings from an expert consensus roundtable cosponsored by SCAI and NKF. Catheter Cardiovasc Interv 2021; 98:416-426. [PMID: 34343406 DOI: 10.1002/ccd.29884] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 07/15/2021] [Indexed: 12/19/2022]
Affiliation(s)
- David E Kandzari
- Interventional Cardiology, Piedmont Heart Institute, Atlanta, Georgia, USA
| | - Raymond R Townsend
- Hypertension, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - George Bakris
- Hypertension, University of Chicago Medicine, Chicago, Illinois, USA
| | - Jan Basile
- Cardiology, Medical University of South Carolina and Ralph H. Johnson VA Medical Center to Medical University of South Carolina, Charleston, South Carolina, USA
| | - Michael J Bloch
- Vascular Care, Renown Institute for Heart and Vascular Health, University of Nevada, Reno School of Medicine, Reno, Nevada, USA
| | - Debbie L Cohen
- Hypertension, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Cara East
- Cardiology, Baylor Heart & Vascular Hospital, Dallas, Texas, USA
- Vascular Intervention, Soltero CV Research Center, Texas A&M College of Medicine
| | - Keith C Ferdinand
- Preventive Cardiology, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Naomi Fisher
- Hypertension, Harvard Medical School and Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Ajay Kirtane
- Interventional Vascular Therapy, Columbia University Irving Medical Center, New York, New York, USA
| | - David P Lee
- Interventional Cardiology, Stanford University, Stanford, California, USA
| | - Gary Puckrein
- The National Minority Quality Forum, Washington, District of Columbia, USA
| | - Florian Rader
- Hypertension Center, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Joseph A Vassalotti
- Clinical Professor, Icahn School of Medicine at Mount Sinai, National Kidney Foundation, New York, New York, USA
| | - Michael A Weber
- Cardiovascular Medicine, SUNY Downstate Medical Center, New York, New York, USA
| | - Kerry Willis
- National Kidney Foundation, New York, New York, USA
| | - Eric Secemsky
- Vascular Intervention, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
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Azizi M, Daemen J, Lobo MD, Mahfoud F, Sharp ASP, Schmieder RE, Wang Y, Saxena M, Lurz P, Sayer J, Bloch MJ, Basile J, Weber MA, Rump LC, Levy T, Sapoval M, Sanghvi K, Rader F, Fisher NDL, Gosse P, Abraham J, Claude L, Barman NC, McClure CK, Liu Y, Kirtane AJ. 12-Month Results From the Unblinded Phase of the RADIANCE-HTN SOLO Trial of Ultrasound Renal Denervation. JACC Cardiovasc Interv 2021; 13:2922-2933. [PMID: 33357531 DOI: 10.1016/j.jcin.2020.09.054] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 09/04/2020] [Accepted: 09/08/2020] [Indexed: 12/01/2022]
Abstract
OBJECTIVES This study reports the 12-month results of the RADIANCE-HTN (A Study of the ReCor Medical Paradise System in Clinical Hypertension) SOLO trial following unblinding of patients at 6 months. BACKGROUND The blood pressure (BP)-lowering efficacy and safety of endovascular ultrasound renal denervation (RDN) in the absence (2 months) and presence (6 months) of antihypertensive medications were previously reported. METHODS Patients with daytime ambulatory BP ≥135/85 mm Hg after 4 weeks off medication were randomized to RDN (n = 74) or sham (n = 72) and maintained off medication for 2 months. A standardized medication escalation protocol was instituted between 2 and 5 months (blinded phase). Between 6 and 12 months (unblinded phase), patients received antihypertensive medications at physicians' discretion. Outcomes at 12 months included medication burden, change in daytime ambulatory systolic BP (dASBP) and office or home systolic BP (SBP), visit-to-visit variability in SBP, and safety. RESULTS Sixty-five of 74 RDN patients and 67 of 72 sham patients had 12-month dASBP measurements. The proportion of patients on ≥2 medications (27.7% vs. 44.8%; p = 0.041), the number of medications (0 vs. 1.4; p = 0.015), and defined daily dose (1.4 vs. 2.2; p = 0.007) were less with RDN versus sham. The decrease in dASBP from baseline in the RDN group (-16.5 ± 12.9 mm Hg) remained stable at 12 months. The RDN versus sham adjusted difference at 12 months was -2.3 mm Hg (95% confidence interval [CI]: -5.9 to 1.3 mm Hg; p = 0.201) for dASBP, -6.3 mm Hg (95% CI: -11.1 to -1.5 mm Hg; p = 0.010) for office SBP, and -3.4 mm Hg (95% CI: -6.9 to 0.1 mm Hg; p = 0.062) for home SBP. Visit-to-visit variability in SBP was smaller in the RDN group. No renal artery injury was detected on computed tomographic or magnetic resonance angiography. CONCLUSIONS Despite unblinding, the BP-lowering effect of RDN was maintained at 12 months with fewer prescribed medications compared with sham.
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Affiliation(s)
- Michel Azizi
- Université de Paris, Paris, France; AP-HP, Hôpital Européen Georges-Pompidou, Hypertension Department and DMU CARTE, Paris, France; INSERM, CIC1418, Paris, France.
| | - Joost Daemen
- Erasmus Medical Center, University Medical Center Rotterdam, Department of Cardiology, Rotterdam, the Netherlands
| | - Melvin D Lobo
- Barts NIHR Biomedical Research Centre, William Harvey Research Institute, Queen Mary University of London, London, 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, Massachusetts, USA
| | - Andrew S P Sharp
- University Hospital of Wales, Cardiff and University of Exeter, Exeter, United Kingdom
| | - Roland E Schmieder
- Nephrology and Hypertension, University Hospital Erlangen, Friedrich Alexander University, Erlangen, Germany
| | - Yale Wang
- Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Manish Saxena
- 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
| | - Jeremy Sayer
- The Essex Cardiothoracic Centre, Essex, United Kingdom
| | - Michael J Bloch
- Department of Medicine, University of Nevada School of Medicine, Vascular Care, Renown Institute of Heart and Vascular Health, Reno, Nevada, USA
| | - Jan Basile
- Seinsheimer Cardiovascular Health Program, Medical University of South Carolina, Ralph H. Johnson VA Medical Center, Charleston, South Carolina, USA
| | - Michael A Weber
- Division of Cardiovascular Medicine, State University of New York, Downstate Medical Center, New York, New York, USA
| | - Lars C Rump
- University Clinic Dusseldorf, Dusseldorf, Germany
| | - Terry Levy
- Royal Bournemouth Hospital, Dorset, United Kingdom
| | - Marc Sapoval
- Université de Paris, Paris, France; AP-HP, Hôpital Européen Georges-Pompidou, Hypertension Department and DMU CARTE, Paris, France; INSERM, CIC1418, Paris, France
| | - Kintur Sanghvi
- Deborah Heart & Lung Center, Brown Mills, New Jersey, USA
| | - Florian Rader
- Cedars-Sinai Heart Institute, Los Angeles, California, USA
| | | | | | | | | | | | | | - Yuyin Liu
- The Baim Institute for Clinical Research, Boston, Massachusetts, USA
| | - Ajay J Kirtane
- Columbia University Medical Center/NewYork-Presbyterian Hospital and the Cardiovascular Research Foundation, New York, New York, USA
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Cai X, Shen Y, Yang Y, Wang W, Qian L, Cai J, Chi R, Yu S, Li K, Wei Z, Chen T, Fei Y, Han Y, Chen X, Liu M, Liu Y, Wang D, Jiang M, Li YG. Renal Denervation by Noninvasive Stereotactic Radiotherapy Induces Persistent Reduction of Sympathetic Activity in a Hypertensive Swine Model. J Am Heart Assoc 2021; 10:e020068. [PMID: 34369204 PMCID: PMC8475062 DOI: 10.1161/jaha.120.020068] [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] [Indexed: 11/23/2022]
Abstract
Background We have previously reported the feasibility of noninvasive stereotactic body radiotherapy (SBRT) as a novel approach for renal denervation. Methods and Results Herein, from a translational point of view, we assessed the antihypertensive effect and chronological evolution of SBRT‐induced renal nerve injury within 6 months in a hypertensive swine model. Hypertension was induced in swine by subcutaneous implantation of deoxycorticosterone acetate pellets in combination with a high‐salt diet. A single dose of 25 Gy with SBRT was delivered for renal denervation in 9 swine within 3.4±1.0 minutes. Blood pressure levels at baseline and 1 and 6 months post‐SBRT were comparable to control (n=5), whereas renal norepinephrine was significantly lower at 6 months (P<0.05). Abdominal computed tomography, performed before euthanasia and renal function assessment, remained normal. Standard semiquantitative histological assessment showed that compared with control (1.4±0.4), renal nerve injury was greater at 1 month post‐SBRT (2.3±0.3) and peaked at 6 months post‐SBRT (3.2±0.8) (P<0.05), along with a higher proportion of active caspase‐3–positive nerves (P<0.05). Moreover, SBRT resulted in continuous dysfunction of renal sympathetic nerves and low level of nerve regeneration in 6 months by immunohistochemistry analysis. Conclusions SBRT delivering 25 Gy for renal denervation was safe and related to sustained reduction of sympathetic activity by aggravating nerve damage and inhibiting nerve regeneration up to 6 months; however, its translation to clinical trial should be cautious because of the negative blood pressure response in the deoxycorticosterone acetate–salt hypertensive swine model.
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Affiliation(s)
- Xingxing Cai
- Department of Cardiology Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine China
| | - Yichen Shen
- Department of Oncology Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine China
| | - Yuli Yang
- Department of Cardiology Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine China
| | - Wei Wang
- Department of Oncology Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine China
| | - Li Qian
- Department of Pathology Affiliated Hospital of Nantong University China
| | - Jing Cai
- Department of Radiology Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine China
| | - Runmin Chi
- Department of Radiology Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine China
| | - Shunxuan Yu
- Department of Oncology Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine China
| | - Keke Li
- Department of Oncology Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine China
| | - Zhixing Wei
- Department of Cardiology Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine China
| | - Taizhong Chen
- Department of Cardiology Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine China
| | - Yudong Fei
- Department of Cardiology Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine China
| | - Yaqin Han
- Department of Cardiology Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine China
| | - Xiu Chen
- Department of Cardiology Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine China
| | - Ming Liu
- Department of Radiology Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine China
| | - Yifei Liu
- Department of Pathology Affiliated Hospital of Nantong University China
| | - Dengbin Wang
- Department of Radiology Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine China
| | - Mawei Jiang
- Department of Oncology Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine China
| | - Yi-Gang Li
- Department of Cardiology Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine China
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An Update on Catheter-Based Renal Denervation for the Treatment of Hypertension. CURRENT CARDIOVASCULAR RISK REPORTS 2021. [DOI: 10.1007/s12170-021-00682-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Abstract
This ESH Position Paper 2021 with updated proposed recommendations was deemed necessary after the publication of a set of new pivotal sham-controlled randomized clinical trials (RCTs), which provided important information about the efficacy and safety of endovascular device-based renal denervation (RDN) for hypertension treatment. RDN is effective in reducing or interrupting the sympathetic signals to the kidneys and decreasing whole body sympathetic activity. Five independent, fully completed, sham-controlled RCTs provide conclusive evidence that RDN lowers ambulatory and office blood pressure (BP) to a significantly greater extent than sham treatment. BP-lowering efficacy is evident both in patients with and without concomitant antihypertensive medication. The average decrease of 10 mmHg in office BP is estimated to lower the incidence of cardiovascular events by 25-30%, based on meta-analyses of RCTs using pharmacological treatment. Neither peri-procedural, nor short-term or long-term adverse events or safety signals (available up to 3 years) have been observed. Implementing RDN as an innovative third option in the armamentarium of antihypertensive treatment requires a structured process that ensures the appropriate performance of the endovascular RDN procedure and adequate selection of hypertensive patients. The latter should also incorporate patients' perspective and preference that needs to be respected in a shared decision-making process.
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