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McGowan M, Kalinoski T. Cortisol-Producing Adrenocortical Carcinoma Presenting with Hypertensive Emergency. Am J Case Rep 2023; 24:e940228. [PMID: 37605388 PMCID: PMC10450997 DOI: 10.12659/ajcr.940228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Revised: 07/17/2023] [Accepted: 07/10/2023] [Indexed: 08/23/2023]
Abstract
BACKGROUND Hypertensive crisis is a relatively common condition often due to uncontrolled essential hypertension, but also potentially driven by one of many possible secondary etiologies. In this report, we detail a case of new-onset resistant hypertension leading to hypertensive emergency complicated by myocardial infarction and congestive heart failure secondary to underlying cortisol-producing metastatic adrenocortical carcinoma. CASE REPORT A 57-year-old woman with no past medical history presented with generalized weakness and weight gain. Her blood pressure was 239/141 with a pulse of 117. Other vital signs were normal. A physical exam was notable for obesity and lower-extremity edema. Initial serum investigations were notable for leukocytosis, hypokalemia, metabolic alkalosis, and elevated troponin and BNP. An ECG showed anterolateral ST depression and left ventricular hypertrophy. A coronary angiogram revealed no coronary artery disease. Her ejection fraction was 25% by echocardiogram. Further investigation revealed severely elevated serum cortisol levels. CT scans were notable for left adrenal mass with evidence of hepatic, lung, and bone metastasis. A liver biopsy confirmed metastatic adrenocortical carcinoma. The patient was started on antihypertensives and a steroidogenesis inhibitor, with improvement in her blood pressure. She received palliative chemotherapy but later elected to pursue hospice care. CONCLUSIONS This report highlights the potential for underlying cortisol excess and adrenocortical carcinoma as a potential secondary etiology of resistant hypertension and hypertensive crisis. Due to the aggressive nature of this tumor, as demonstrated in this patient, a high index of suspicion and prompt attention are required for patients presenting with these clinical manifestations.
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Affiliation(s)
| | - Thomas Kalinoski
- Department of Internal Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
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Carey RM, Calhoun DA, Bakris GL, Brook RD, Daugherty SL, Dennison-Himmelfarb CR, Egan BM, Flack JM, Gidding SS, Judd E, Lackland DT, Laffer CL, Newton-Cheh C, Smith SM, Taler SJ, Textor SC, Turan TN, White WB. Resistant Hypertension: Detection, Evaluation, and Management: A Scientific Statement From the American Heart Association. Hypertension 2019; 72:e53-e90. [PMID: 30354828 DOI: 10.1161/hyp.0000000000000084] [Citation(s) in RCA: 519] [Impact Index Per Article: 103.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Resistant hypertension (RH) is defined as above-goal elevated blood pressure (BP) in a patient despite the concurrent use of 3 antihypertensive drug classes, commonly including a long-acting calcium channel blocker, a blocker of the renin-angiotensin system (angiotensin-converting enzyme inhibitor or angiotensin receptor blocker), and a diuretic. The antihypertensive drugs should be administered at maximum or maximally tolerated daily doses. RH also includes patients whose BP achieves target values on ≥4 antihypertensive medications. The diagnosis of RH requires assurance of antihypertensive medication adherence and exclusion of the "white-coat effect" (office BP above goal but out-of-office BP at or below target). The importance of RH is underscored by the associated risk of adverse outcomes compared with non-RH. This article is an updated American Heart Association scientific statement on the detection, evaluation, and management of RH. Once antihypertensive medication adherence is confirmed and out-of-office BP recordings exclude a white-coat effect, evaluation includes identification of contributing lifestyle issues, detection of drugs interfering with antihypertensive medication effectiveness, screening for secondary hypertension, and assessment of target organ damage. Management of RH includes maximization of lifestyle interventions, use of long-acting thiazide-like diuretics (chlorthalidone or indapamide), addition of a mineralocorticoid receptor antagonist (spironolactone or eplerenone), and, if BP remains elevated, stepwise addition of antihypertensive drugs with complementary mechanisms of action to lower BP. If BP remains uncontrolled, referral to a hypertension specialist is advised.
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Sag AA, Sal O, Kilic Y, Onal EM, Kanbay M. The concept of crosstalk-directed embryological target mining and its application to essential hypertension treatment failures. J Clin Hypertens (Greenwich) 2017; 19:530-533. [PMID: 28224730 DOI: 10.1111/jch.12978] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2016] [Revised: 11/14/2016] [Accepted: 11/19/2016] [Indexed: 01/11/2023]
Abstract
This review aims to introduce the novel concept of embryological target mining applied to interorgan crosstalk network genesis, and applies embryological target mining to multidrug-resistant essential hypertension (a prototype, complex, undertreated, multiorgan systemic syndrome) to uncover new treatment targets and critique why existing strategies fail. Briefly, interorgan crosstalk pathways represent the next frontier for target mining in molecular medicine. This is because stereotyped stepwise organogenesis presents a unique opportunity to infer interorgan crosstalk pathways that may be crucial to discovering novel treatment targets. Insights gained from this review will be applied to patient management in a clinician-directed fashion.
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Affiliation(s)
- Alan Alper Sag
- Division of Interventional Radiology, Department of Radiology, Koç University School of Medicine, Istanbul, Turkey
| | - Oguzhan Sal
- School of Medicine, Koç University, Istanbul, Turkey
| | - Yagmur Kilic
- School of Medicine, Koç University, Istanbul, Turkey
| | | | - Mehmet Kanbay
- Division of Nephrology, Department of Internal Medicine, Koç University School of Medicine, Istanbul, Turkey
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Karanasos A, Van Mieghem N, Bergmann MW, Hartman E, Ligthart J, van der Heide E, Heeger CH, Ouhlous M, Zijlstra F, Regar E, Daemen J. Multimodality Intra-Arterial Imaging Assessment of the Vascular Trauma Induced by Balloon-Based and Nonballoon-Based Renal Denervation Systems. Circ Cardiovasc Interv 2016; 8:e002474. [PMID: 26156150 DOI: 10.1161/circinterventions.115.002474] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Renal denervation is a new treatment considered for several possible indications. As new systems are introduced, the incidence of acute renal artery wall injury with relation to the denervation method is unknown. We investigated the acute repercussion of renal denervation on the renal arteries of patients treated with balloon-based and nonballoon-based denervation systems by quantitative angiography, intravascular ultrasound, and optical coherence tomography (OCT). METHODS AND RESULTS Twenty-five patients (50 renal arteries) underwent bilateral renal denervation with 5 different systems, 3 of which balloon-based (Paradise [n=5], Oneshot [n=6], and Vessix V2 [n=5)]) and 2 nonballoon-based (Symplicity [n=6] and EnligHTN [n=3]). Analysis included quantitative angiography and morphometric intravascular ultrasound measurements pre and post procedure and assessment of vascular trauma (dissection, edema, or thrombus) by OCT after denervation. A significant reduction in lumen size by quantitative angiography and intravascular ultrasound was observed in nonballoon denervation but not in balloon denervation. By postdenervation OCT, dissection was seen in 14 arteries (32.6%). The percentage of frames with dissection was higher in balloon-based denervation catheters. Thrombus and edema were detected in 35 (81.4%) and 32 (74.4%) arteries, respectively. In arteries treated with balloon-based denervation that had dissection by OCT, the balloon/artery ratio was higher (1.24 [1.17-1.32] versus 1.10 [1.04-1.18]; P<0.01). CONCLUSIONS A varying extent of vascular injury was observed after renal denervation in all systems; however, different patterns were identified in balloon-based and in nonballoon-based denervation systems. In balloon denervation, the presence of dissections by OCT was associated with a higher balloon/artery ratio.
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Affiliation(s)
- Antonios Karanasos
- From the Department of Interventional Cardiology, Thoraxcenter, Erasmus Medical Center (A.K., N.V.M., E.H., J.L., E.v.d.H., F.Z., E.R., J.D.), Department of Radiology (M.O.), Rotterdam, The Netherlands; and Department of Interventional Cardiology, St. Georg Asklepios Klinik, Hamburg, Germany (M.W.B., C.-H.H.)
| | - Nicolas Van Mieghem
- From the Department of Interventional Cardiology, Thoraxcenter, Erasmus Medical Center (A.K., N.V.M., E.H., J.L., E.v.d.H., F.Z., E.R., J.D.), Department of Radiology (M.O.), Rotterdam, The Netherlands; and Department of Interventional Cardiology, St. Georg Asklepios Klinik, Hamburg, Germany (M.W.B., C.-H.H.)
| | - Martin W Bergmann
- From the Department of Interventional Cardiology, Thoraxcenter, Erasmus Medical Center (A.K., N.V.M., E.H., J.L., E.v.d.H., F.Z., E.R., J.D.), Department of Radiology (M.O.), Rotterdam, The Netherlands; and Department of Interventional Cardiology, St. Georg Asklepios Klinik, Hamburg, Germany (M.W.B., C.-H.H.)
| | - Eline Hartman
- From the Department of Interventional Cardiology, Thoraxcenter, Erasmus Medical Center (A.K., N.V.M., E.H., J.L., E.v.d.H., F.Z., E.R., J.D.), Department of Radiology (M.O.), Rotterdam, The Netherlands; and Department of Interventional Cardiology, St. Georg Asklepios Klinik, Hamburg, Germany (M.W.B., C.-H.H.)
| | - Jurgen Ligthart
- From the Department of Interventional Cardiology, Thoraxcenter, Erasmus Medical Center (A.K., N.V.M., E.H., J.L., E.v.d.H., F.Z., E.R., J.D.), Department of Radiology (M.O.), Rotterdam, The Netherlands; and Department of Interventional Cardiology, St. Georg Asklepios Klinik, Hamburg, Germany (M.W.B., C.-H.H.)
| | - Elco van der Heide
- From the Department of Interventional Cardiology, Thoraxcenter, Erasmus Medical Center (A.K., N.V.M., E.H., J.L., E.v.d.H., F.Z., E.R., J.D.), Department of Radiology (M.O.), Rotterdam, The Netherlands; and Department of Interventional Cardiology, St. Georg Asklepios Klinik, Hamburg, Germany (M.W.B., C.-H.H.)
| | - Christian-H Heeger
- From the Department of Interventional Cardiology, Thoraxcenter, Erasmus Medical Center (A.K., N.V.M., E.H., J.L., E.v.d.H., F.Z., E.R., J.D.), Department of Radiology (M.O.), Rotterdam, The Netherlands; and Department of Interventional Cardiology, St. Georg Asklepios Klinik, Hamburg, Germany (M.W.B., C.-H.H.)
| | - Mohamed Ouhlous
- From the Department of Interventional Cardiology, Thoraxcenter, Erasmus Medical Center (A.K., N.V.M., E.H., J.L., E.v.d.H., F.Z., E.R., J.D.), Department of Radiology (M.O.), Rotterdam, The Netherlands; and Department of Interventional Cardiology, St. Georg Asklepios Klinik, Hamburg, Germany (M.W.B., C.-H.H.)
| | - Felix Zijlstra
- From the Department of Interventional Cardiology, Thoraxcenter, Erasmus Medical Center (A.K., N.V.M., E.H., J.L., E.v.d.H., F.Z., E.R., J.D.), Department of Radiology (M.O.), Rotterdam, The Netherlands; and Department of Interventional Cardiology, St. Georg Asklepios Klinik, Hamburg, Germany (M.W.B., C.-H.H.)
| | - Evelyn Regar
- From the Department of Interventional Cardiology, Thoraxcenter, Erasmus Medical Center (A.K., N.V.M., E.H., J.L., E.v.d.H., F.Z., E.R., J.D.), Department of Radiology (M.O.), Rotterdam, The Netherlands; and Department of Interventional Cardiology, St. Georg Asklepios Klinik, Hamburg, Germany (M.W.B., C.-H.H.)
| | - Joost Daemen
- From the Department of Interventional Cardiology, Thoraxcenter, Erasmus Medical Center (A.K., N.V.M., E.H., J.L., E.v.d.H., F.Z., E.R., J.D.), Department of Radiology (M.O.), Rotterdam, The Netherlands; and Department of Interventional Cardiology, St. Georg Asklepios Klinik, Hamburg, Germany (M.W.B., C.-H.H.).
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Thomas G, Xie D, Chen HY, Anderson AH, Appel LJ, Bodana S, Brecklin CS, Drawz P, Flack JM, Miller ER, Steigerwalt SP, Townsend RR, Weir MR, Wright JT, Rahman M. Prevalence and Prognostic Significance of Apparent Treatment Resistant Hypertension in Chronic Kidney Disease: Report From the Chronic Renal Insufficiency Cohort Study. Hypertension 2015; 67:387-96. [PMID: 26711738 DOI: 10.1161/hypertensionaha.115.06487] [Citation(s) in RCA: 108] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Accepted: 11/03/2015] [Indexed: 11/16/2022]
Abstract
The association between apparent treatment resistant hypertension (ATRH) and clinical outcomes is not well studied in chronic kidney disease. We analyzed data on 3367 hypertensive participants in the Chronic Renal Insufficiency Cohort (CRIC) to determine prevalence, associations, and clinical outcomes of ATRH in nondialysis chronic kidney disease patients. ATRH was defined as blood pressure ≥140/90 mm Hg on ≥3 antihypertensives, or use of ≥4 antihypertensives with blood pressure at goal at baseline visit. Prevalence of ATRH was 40.4%. Older age, male sex, black race, diabetes mellitus, and higher body mass index were independently associated with higher odds of having ATRH. Participants with ATRH had a higher risk of clinical events than participants without ATRH-composite of myocardial infarction, stroke, peripheral arterial disease, congestive heart failure (CHF), and all-cause mortality (hazard ratio [95% confidence interval], 1.38 [1.22-1.56]); renal events (1.28 [1.11-1.46]); CHF (1.66 [1.38-2.00]); and all-cause mortality (1.24 [1.06-1.45]). The subset of participants with ATRH and blood pressure at goal on ≥4 medications also had higher risk for composite of myocardial infarction, stroke, peripheral arterial disease, CHF, and all-cause mortality (hazard ratio [95% confidence interval], (1.30 [1.12-1.51]) and CHF (1.59 [1.28-1.99]) than those without ATRH. ATRH was associated with significantly higher risk for CHF and renal events only among those with estimated glomerular filtration rate ≥30 mL/min per 1.73 m(2). Our findings show that ATRH is common and associated with high risk of adverse outcomes in a cohort of patients with chronic kidney disease. This underscores the need for early identification and management of patients with ATRH and chronic kidney disease.
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Affiliation(s)
- George Thomas
- From the Department of Nephrology and Hypertension, Cleveland Clinic, OH (G.T.); Departments of Medicine (R.R.T.) and Biostatistics and Epidemiology (A.H.A., D.X., H.-Y.C.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Departments of Medicine (L.J.A., E.R.M.) and Epidemiology (L.J.A.), Johns Hopkins University, Baltimore, MD; Department of Nephrology, Ochsner Medical Center, New Orleans, LA (S.B.); Department of Medicine, University of Illinois at Chicago (C.B.); Department of Medicine, University of Minnesota, Minneapolis (P.D.); Hypertension Section, Division of General Medicine, Department of Medicine, Southern Illinois University, Springfield (J.M.F.); Division of Nephrology and Hypertension, St John Hospital and Medical Center, Detroit, MI (S.P.S.); Department of Medicine, University of Maryland School of Medicine, Baltimore (M.R.W.); Department of Medicine, Case Western Reserve University, University Hospitals Case Medical Center, Louis Stokes Cleveland VA Medical Center Cleveland, OH (J.T.W., M.R.)
| | - Dawei Xie
- From the Department of Nephrology and Hypertension, Cleveland Clinic, OH (G.T.); Departments of Medicine (R.R.T.) and Biostatistics and Epidemiology (A.H.A., D.X., H.-Y.C.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Departments of Medicine (L.J.A., E.R.M.) and Epidemiology (L.J.A.), Johns Hopkins University, Baltimore, MD; Department of Nephrology, Ochsner Medical Center, New Orleans, LA (S.B.); Department of Medicine, University of Illinois at Chicago (C.B.); Department of Medicine, University of Minnesota, Minneapolis (P.D.); Hypertension Section, Division of General Medicine, Department of Medicine, Southern Illinois University, Springfield (J.M.F.); Division of Nephrology and Hypertension, St John Hospital and Medical Center, Detroit, MI (S.P.S.); Department of Medicine, University of Maryland School of Medicine, Baltimore (M.R.W.); Department of Medicine, Case Western Reserve University, University Hospitals Case Medical Center, Louis Stokes Cleveland VA Medical Center Cleveland, OH (J.T.W., M.R.)
| | - Hsiang-Yu Chen
- From the Department of Nephrology and Hypertension, Cleveland Clinic, OH (G.T.); Departments of Medicine (R.R.T.) and Biostatistics and Epidemiology (A.H.A., D.X., H.-Y.C.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Departments of Medicine (L.J.A., E.R.M.) and Epidemiology (L.J.A.), Johns Hopkins University, Baltimore, MD; Department of Nephrology, Ochsner Medical Center, New Orleans, LA (S.B.); Department of Medicine, University of Illinois at Chicago (C.B.); Department of Medicine, University of Minnesota, Minneapolis (P.D.); Hypertension Section, Division of General Medicine, Department of Medicine, Southern Illinois University, Springfield (J.M.F.); Division of Nephrology and Hypertension, St John Hospital and Medical Center, Detroit, MI (S.P.S.); Department of Medicine, University of Maryland School of Medicine, Baltimore (M.R.W.); Department of Medicine, Case Western Reserve University, University Hospitals Case Medical Center, Louis Stokes Cleveland VA Medical Center Cleveland, OH (J.T.W., M.R.)
| | - Amanda H Anderson
- From the Department of Nephrology and Hypertension, Cleveland Clinic, OH (G.T.); Departments of Medicine (R.R.T.) and Biostatistics and Epidemiology (A.H.A., D.X., H.-Y.C.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Departments of Medicine (L.J.A., E.R.M.) and Epidemiology (L.J.A.), Johns Hopkins University, Baltimore, MD; Department of Nephrology, Ochsner Medical Center, New Orleans, LA (S.B.); Department of Medicine, University of Illinois at Chicago (C.B.); Department of Medicine, University of Minnesota, Minneapolis (P.D.); Hypertension Section, Division of General Medicine, Department of Medicine, Southern Illinois University, Springfield (J.M.F.); Division of Nephrology and Hypertension, St John Hospital and Medical Center, Detroit, MI (S.P.S.); Department of Medicine, University of Maryland School of Medicine, Baltimore (M.R.W.); Department of Medicine, Case Western Reserve University, University Hospitals Case Medical Center, Louis Stokes Cleveland VA Medical Center Cleveland, OH (J.T.W., M.R.)
| | - Lawrence J Appel
- From the Department of Nephrology and Hypertension, Cleveland Clinic, OH (G.T.); Departments of Medicine (R.R.T.) and Biostatistics and Epidemiology (A.H.A., D.X., H.-Y.C.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Departments of Medicine (L.J.A., E.R.M.) and Epidemiology (L.J.A.), Johns Hopkins University, Baltimore, MD; Department of Nephrology, Ochsner Medical Center, New Orleans, LA (S.B.); Department of Medicine, University of Illinois at Chicago (C.B.); Department of Medicine, University of Minnesota, Minneapolis (P.D.); Hypertension Section, Division of General Medicine, Department of Medicine, Southern Illinois University, Springfield (J.M.F.); Division of Nephrology and Hypertension, St John Hospital and Medical Center, Detroit, MI (S.P.S.); Department of Medicine, University of Maryland School of Medicine, Baltimore (M.R.W.); Department of Medicine, Case Western Reserve University, University Hospitals Case Medical Center, Louis Stokes Cleveland VA Medical Center Cleveland, OH (J.T.W., M.R.)
| | - Shirisha Bodana
- From the Department of Nephrology and Hypertension, Cleveland Clinic, OH (G.T.); Departments of Medicine (R.R.T.) and Biostatistics and Epidemiology (A.H.A., D.X., H.-Y.C.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Departments of Medicine (L.J.A., E.R.M.) and Epidemiology (L.J.A.), Johns Hopkins University, Baltimore, MD; Department of Nephrology, Ochsner Medical Center, New Orleans, LA (S.B.); Department of Medicine, University of Illinois at Chicago (C.B.); Department of Medicine, University of Minnesota, Minneapolis (P.D.); Hypertension Section, Division of General Medicine, Department of Medicine, Southern Illinois University, Springfield (J.M.F.); Division of Nephrology and Hypertension, St John Hospital and Medical Center, Detroit, MI (S.P.S.); Department of Medicine, University of Maryland School of Medicine, Baltimore (M.R.W.); Department of Medicine, Case Western Reserve University, University Hospitals Case Medical Center, Louis Stokes Cleveland VA Medical Center Cleveland, OH (J.T.W., M.R.)
| | - Carolyn S Brecklin
- From the Department of Nephrology and Hypertension, Cleveland Clinic, OH (G.T.); Departments of Medicine (R.R.T.) and Biostatistics and Epidemiology (A.H.A., D.X., H.-Y.C.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Departments of Medicine (L.J.A., E.R.M.) and Epidemiology (L.J.A.), Johns Hopkins University, Baltimore, MD; Department of Nephrology, Ochsner Medical Center, New Orleans, LA (S.B.); Department of Medicine, University of Illinois at Chicago (C.B.); Department of Medicine, University of Minnesota, Minneapolis (P.D.); Hypertension Section, Division of General Medicine, Department of Medicine, Southern Illinois University, Springfield (J.M.F.); Division of Nephrology and Hypertension, St John Hospital and Medical Center, Detroit, MI (S.P.S.); Department of Medicine, University of Maryland School of Medicine, Baltimore (M.R.W.); Department of Medicine, Case Western Reserve University, University Hospitals Case Medical Center, Louis Stokes Cleveland VA Medical Center Cleveland, OH (J.T.W., M.R.)
| | - Paul Drawz
- From the Department of Nephrology and Hypertension, Cleveland Clinic, OH (G.T.); Departments of Medicine (R.R.T.) and Biostatistics and Epidemiology (A.H.A., D.X., H.-Y.C.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Departments of Medicine (L.J.A., E.R.M.) and Epidemiology (L.J.A.), Johns Hopkins University, Baltimore, MD; Department of Nephrology, Ochsner Medical Center, New Orleans, LA (S.B.); Department of Medicine, University of Illinois at Chicago (C.B.); Department of Medicine, University of Minnesota, Minneapolis (P.D.); Hypertension Section, Division of General Medicine, Department of Medicine, Southern Illinois University, Springfield (J.M.F.); Division of Nephrology and Hypertension, St John Hospital and Medical Center, Detroit, MI (S.P.S.); Department of Medicine, University of Maryland School of Medicine, Baltimore (M.R.W.); Department of Medicine, Case Western Reserve University, University Hospitals Case Medical Center, Louis Stokes Cleveland VA Medical Center Cleveland, OH (J.T.W., M.R.)
| | - John M Flack
- From the Department of Nephrology and Hypertension, Cleveland Clinic, OH (G.T.); Departments of Medicine (R.R.T.) and Biostatistics and Epidemiology (A.H.A., D.X., H.-Y.C.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Departments of Medicine (L.J.A., E.R.M.) and Epidemiology (L.J.A.), Johns Hopkins University, Baltimore, MD; Department of Nephrology, Ochsner Medical Center, New Orleans, LA (S.B.); Department of Medicine, University of Illinois at Chicago (C.B.); Department of Medicine, University of Minnesota, Minneapolis (P.D.); Hypertension Section, Division of General Medicine, Department of Medicine, Southern Illinois University, Springfield (J.M.F.); Division of Nephrology and Hypertension, St John Hospital and Medical Center, Detroit, MI (S.P.S.); Department of Medicine, University of Maryland School of Medicine, Baltimore (M.R.W.); Department of Medicine, Case Western Reserve University, University Hospitals Case Medical Center, Louis Stokes Cleveland VA Medical Center Cleveland, OH (J.T.W., M.R.)
| | - Edgar R Miller
- From the Department of Nephrology and Hypertension, Cleveland Clinic, OH (G.T.); Departments of Medicine (R.R.T.) and Biostatistics and Epidemiology (A.H.A., D.X., H.-Y.C.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Departments of Medicine (L.J.A., E.R.M.) and Epidemiology (L.J.A.), Johns Hopkins University, Baltimore, MD; Department of Nephrology, Ochsner Medical Center, New Orleans, LA (S.B.); Department of Medicine, University of Illinois at Chicago (C.B.); Department of Medicine, University of Minnesota, Minneapolis (P.D.); Hypertension Section, Division of General Medicine, Department of Medicine, Southern Illinois University, Springfield (J.M.F.); Division of Nephrology and Hypertension, St John Hospital and Medical Center, Detroit, MI (S.P.S.); Department of Medicine, University of Maryland School of Medicine, Baltimore (M.R.W.); Department of Medicine, Case Western Reserve University, University Hospitals Case Medical Center, Louis Stokes Cleveland VA Medical Center Cleveland, OH (J.T.W., M.R.)
| | - Susan P Steigerwalt
- From the Department of Nephrology and Hypertension, Cleveland Clinic, OH (G.T.); Departments of Medicine (R.R.T.) and Biostatistics and Epidemiology (A.H.A., D.X., H.-Y.C.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Departments of Medicine (L.J.A., E.R.M.) and Epidemiology (L.J.A.), Johns Hopkins University, Baltimore, MD; Department of Nephrology, Ochsner Medical Center, New Orleans, LA (S.B.); Department of Medicine, University of Illinois at Chicago (C.B.); Department of Medicine, University of Minnesota, Minneapolis (P.D.); Hypertension Section, Division of General Medicine, Department of Medicine, Southern Illinois University, Springfield (J.M.F.); Division of Nephrology and Hypertension, St John Hospital and Medical Center, Detroit, MI (S.P.S.); Department of Medicine, University of Maryland School of Medicine, Baltimore (M.R.W.); Department of Medicine, Case Western Reserve University, University Hospitals Case Medical Center, Louis Stokes Cleveland VA Medical Center Cleveland, OH (J.T.W., M.R.)
| | - Raymond R Townsend
- From the Department of Nephrology and Hypertension, Cleveland Clinic, OH (G.T.); Departments of Medicine (R.R.T.) and Biostatistics and Epidemiology (A.H.A., D.X., H.-Y.C.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Departments of Medicine (L.J.A., E.R.M.) and Epidemiology (L.J.A.), Johns Hopkins University, Baltimore, MD; Department of Nephrology, Ochsner Medical Center, New Orleans, LA (S.B.); Department of Medicine, University of Illinois at Chicago (C.B.); Department of Medicine, University of Minnesota, Minneapolis (P.D.); Hypertension Section, Division of General Medicine, Department of Medicine, Southern Illinois University, Springfield (J.M.F.); Division of Nephrology and Hypertension, St John Hospital and Medical Center, Detroit, MI (S.P.S.); Department of Medicine, University of Maryland School of Medicine, Baltimore (M.R.W.); Department of Medicine, Case Western Reserve University, University Hospitals Case Medical Center, Louis Stokes Cleveland VA Medical Center Cleveland, OH (J.T.W., M.R.)
| | - Matthew R Weir
- From the Department of Nephrology and Hypertension, Cleveland Clinic, OH (G.T.); Departments of Medicine (R.R.T.) and Biostatistics and Epidemiology (A.H.A., D.X., H.-Y.C.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Departments of Medicine (L.J.A., E.R.M.) and Epidemiology (L.J.A.), Johns Hopkins University, Baltimore, MD; Department of Nephrology, Ochsner Medical Center, New Orleans, LA (S.B.); Department of Medicine, University of Illinois at Chicago (C.B.); Department of Medicine, University of Minnesota, Minneapolis (P.D.); Hypertension Section, Division of General Medicine, Department of Medicine, Southern Illinois University, Springfield (J.M.F.); Division of Nephrology and Hypertension, St John Hospital and Medical Center, Detroit, MI (S.P.S.); Department of Medicine, University of Maryland School of Medicine, Baltimore (M.R.W.); Department of Medicine, Case Western Reserve University, University Hospitals Case Medical Center, Louis Stokes Cleveland VA Medical Center Cleveland, OH (J.T.W., M.R.)
| | - Jackson T Wright
- From the Department of Nephrology and Hypertension, Cleveland Clinic, OH (G.T.); Departments of Medicine (R.R.T.) and Biostatistics and Epidemiology (A.H.A., D.X., H.-Y.C.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Departments of Medicine (L.J.A., E.R.M.) and Epidemiology (L.J.A.), Johns Hopkins University, Baltimore, MD; Department of Nephrology, Ochsner Medical Center, New Orleans, LA (S.B.); Department of Medicine, University of Illinois at Chicago (C.B.); Department of Medicine, University of Minnesota, Minneapolis (P.D.); Hypertension Section, Division of General Medicine, Department of Medicine, Southern Illinois University, Springfield (J.M.F.); Division of Nephrology and Hypertension, St John Hospital and Medical Center, Detroit, MI (S.P.S.); Department of Medicine, University of Maryland School of Medicine, Baltimore (M.R.W.); Department of Medicine, Case Western Reserve University, University Hospitals Case Medical Center, Louis Stokes Cleveland VA Medical Center Cleveland, OH (J.T.W., M.R.)
| | - Mahboob Rahman
- From the Department of Nephrology and Hypertension, Cleveland Clinic, OH (G.T.); Departments of Medicine (R.R.T.) and Biostatistics and Epidemiology (A.H.A., D.X., H.-Y.C.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Departments of Medicine (L.J.A., E.R.M.) and Epidemiology (L.J.A.), Johns Hopkins University, Baltimore, MD; Department of Nephrology, Ochsner Medical Center, New Orleans, LA (S.B.); Department of Medicine, University of Illinois at Chicago (C.B.); Department of Medicine, University of Minnesota, Minneapolis (P.D.); Hypertension Section, Division of General Medicine, Department of Medicine, Southern Illinois University, Springfield (J.M.F.); Division of Nephrology and Hypertension, St John Hospital and Medical Center, Detroit, MI (S.P.S.); Department of Medicine, University of Maryland School of Medicine, Baltimore (M.R.W.); Department of Medicine, Case Western Reserve University, University Hospitals Case Medical Center, Louis Stokes Cleveland VA Medical Center Cleveland, OH (J.T.W., M.R.)
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de Beus E, Bots ML, van Zuilen AD, Wetzels JFM, Blankestijn PJ. Prevalence of Apparent Therapy-Resistant Hypertension and Its Effect on Outcome in Patients With Chronic Kidney Disease. Hypertension 2015; 66:998-1005. [PMID: 26351024 DOI: 10.1161/hypertensionaha.115.05694] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Accepted: 08/06/2015] [Indexed: 12/17/2022]
Abstract
New options recently became available for treatment of uncontrolled blood pressure. Information on the prevalence of therapy-resistant hypertension (TRH) in patients with chronic kidney disease and its consequences is relevant to balance risks and benefits of potential new therapies. Data of 788 patients with chronic kidney disease came from a multicenter study investigating the effect on outcome of an integrated multifactorial approach delivered by nurse practitioners added to usual care versus usual care alone. Blood pressure was measured at the office and during 30 minutes using an automated oscillometric device. Apparent TRH (aTRH) was defined as a blood pressure ≥130/80 mm Hg despite treatment with ≥3 antihypertensive drugs, including a diuretic or treatment with ≥4 antihypertensive drugs. Participants were followed up for the occurrence of myocardial infarction, stroke or cardiovascular mortality (composite cardiovascular end point) and end-stage renal disease. aTRH was present in 34% (office blood pressure) and in 32% (automated measurements). During 5.3 years of follow-up, 17% of patients with aTRH reached a cardiovascular end point and 27% reached end-stage renal disease. aTRH lead to a 1.5-fold higher risk (95% confidence interval, 0.8-3.0) of a cardiovascular end point compared with controlled hypertensives in multivariable-adjusted analysis. aTRH increased end-stage renal disease risk 2.3-fold (95% confidence interval, 1.4-3.7). During 4 years of follow-up, the prevalence of aTRH did not decline in either treatment group. The prevalence of aTRH is high in patients with chronic kidney disease even after optimization of nephrologist care. The presence of TRH is related to a substantially increased risk of renal and cardiovascular outcomes.
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Affiliation(s)
- Esther de Beus
- From the Department of Nephrology and Hypertension (E.d.B., A.D.v.Z., P.J.B.) and Julius Center for Health Sciences and Primary Care (M.L.B.), University Medical Center Utrecht, Utrecht, the Netherlands; and Department of Nephrology, Radboud University Medical Center, Nijmegen, the Netherlands (J.F.M.W.).
| | - Michiel L Bots
- From the Department of Nephrology and Hypertension (E.d.B., A.D.v.Z., P.J.B.) and Julius Center for Health Sciences and Primary Care (M.L.B.), University Medical Center Utrecht, Utrecht, the Netherlands; and Department of Nephrology, Radboud University Medical Center, Nijmegen, the Netherlands (J.F.M.W.)
| | - Arjan D van Zuilen
- From the Department of Nephrology and Hypertension (E.d.B., A.D.v.Z., P.J.B.) and Julius Center for Health Sciences and Primary Care (M.L.B.), University Medical Center Utrecht, Utrecht, the Netherlands; and Department of Nephrology, Radboud University Medical Center, Nijmegen, the Netherlands (J.F.M.W.)
| | - Jack F M Wetzels
- From the Department of Nephrology and Hypertension (E.d.B., A.D.v.Z., P.J.B.) and Julius Center for Health Sciences and Primary Care (M.L.B.), University Medical Center Utrecht, Utrecht, the Netherlands; and Department of Nephrology, Radboud University Medical Center, Nijmegen, the Netherlands (J.F.M.W.)
| | - Peter J Blankestijn
- From the Department of Nephrology and Hypertension (E.d.B., A.D.v.Z., P.J.B.) and Julius Center for Health Sciences and Primary Care (M.L.B.), University Medical Center Utrecht, Utrecht, the Netherlands; and Department of Nephrology, Radboud University Medical Center, Nijmegen, the Netherlands (J.F.M.W.)
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7
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Rosa J, Widimský P, Toušek P, Petrák O, Čurila K, Waldauf P, Bednář F, Zelinka T, Holaj R, Štrauch B, Šomlóová Z, Táborský M, Václavík J, Kociánová E, Branny M, Nykl I, Jiravský O, Widimský J. Randomized comparison of renal denervation versus intensified pharmacotherapy including spironolactone in true-resistant hypertension: six-month results from the Prague-15 study. Hypertension 2014; 65:407-13. [PMID: 25421981 DOI: 10.1161/hypertensionaha.114.04019] [Citation(s) in RCA: 156] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
This prospective, randomized, open-label multicenter trial evaluated the efficacy of catheter-based renal denervation (Symplicity, Medtronic) versus intensified pharmacological treatment including spironolactone (if tolerated) in patients with true-resistant hypertension. This was confirmed by 24-hour ambulatory blood pressure monitoring after excluding secondary hypertension and confirmation of adherence to therapy by measurement of plasma antihypertensive drug levels before enrollment. One-hundred six patients were randomized to renal denervation (n=52), or intensified pharmacological treatment (n=54) with baseline systolic blood pressure of 159±17 and 155±17 mm Hg and average number of drugs 5.1 and 5.4, respectively. A significant reduction in 24-hour average systolic blood pressure after 6 months (-8.6 [95% cofidence interval: -11.8, -5.3] mm Hg; P<0.001 in renal denervation versus -8.1 [95% cofidence interval: -12.7, -3.4] mm Hg; P=0.001 in pharmacological group) was observed, which was comparable in both groups. Similarly, a significant reduction in systolic office blood pressure (-12.4 [95% cofidence interval: -17.0, -7.8] mm Hg; P<0.001 in renal denervation versus -14.3 [95% cofidence interval: -19.7, -8.9] mm Hg; P<0.001 in pharmacological group) was present. Between-group differences in change were not significant. The average number of antihypertensive drugs used after 6 months was significantly higher in the pharmacological group (+0.3 drugs; P<0.001). A significant increase in serum creatinine and a parallel decrease of creatinine clearance were observed in the pharmacological group; between-group difference were borderline significant. The 6-month results of this study confirmed the safety of renal denervation. In conclusion, renal denervation achieved reduction of blood pressure comparable with intensified pharmacotherapy.
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Affiliation(s)
- Ján Rosa
- From the 3rd Department of Medicine, Centre for Hypertension, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., O.P., T.Z., R.H., B.Š., Z.Š., J.W.); Cardiocentre, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., P.W., P.T., K.Č., F.B.); Department of Anesthesiology, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (P.W.); Department of Internal Medicine I, University Hospital Olomouc, Czech Republic (M.T., J.V., E.K.); and Cardiocentre, Nemocnice Podlesí, Třinec, Czech Republic (M.B., I.N., O.J.).
| | - Petr Widimský
- From the 3rd Department of Medicine, Centre for Hypertension, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., O.P., T.Z., R.H., B.Š., Z.Š., J.W.); Cardiocentre, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., P.W., P.T., K.Č., F.B.); Department of Anesthesiology, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (P.W.); Department of Internal Medicine I, University Hospital Olomouc, Czech Republic (M.T., J.V., E.K.); and Cardiocentre, Nemocnice Podlesí, Třinec, Czech Republic (M.B., I.N., O.J.)
| | - Petr Toušek
- From the 3rd Department of Medicine, Centre for Hypertension, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., O.P., T.Z., R.H., B.Š., Z.Š., J.W.); Cardiocentre, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., P.W., P.T., K.Č., F.B.); Department of Anesthesiology, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (P.W.); Department of Internal Medicine I, University Hospital Olomouc, Czech Republic (M.T., J.V., E.K.); and Cardiocentre, Nemocnice Podlesí, Třinec, Czech Republic (M.B., I.N., O.J.)
| | - Ondřej Petrák
- From the 3rd Department of Medicine, Centre for Hypertension, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., O.P., T.Z., R.H., B.Š., Z.Š., J.W.); Cardiocentre, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., P.W., P.T., K.Č., F.B.); Department of Anesthesiology, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (P.W.); Department of Internal Medicine I, University Hospital Olomouc, Czech Republic (M.T., J.V., E.K.); and Cardiocentre, Nemocnice Podlesí, Třinec, Czech Republic (M.B., I.N., O.J.)
| | - Karol Čurila
- From the 3rd Department of Medicine, Centre for Hypertension, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., O.P., T.Z., R.H., B.Š., Z.Š., J.W.); Cardiocentre, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., P.W., P.T., K.Č., F.B.); Department of Anesthesiology, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (P.W.); Department of Internal Medicine I, University Hospital Olomouc, Czech Republic (M.T., J.V., E.K.); and Cardiocentre, Nemocnice Podlesí, Třinec, Czech Republic (M.B., I.N., O.J.)
| | - Petr Waldauf
- From the 3rd Department of Medicine, Centre for Hypertension, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., O.P., T.Z., R.H., B.Š., Z.Š., J.W.); Cardiocentre, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., P.W., P.T., K.Č., F.B.); Department of Anesthesiology, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (P.W.); Department of Internal Medicine I, University Hospital Olomouc, Czech Republic (M.T., J.V., E.K.); and Cardiocentre, Nemocnice Podlesí, Třinec, Czech Republic (M.B., I.N., O.J.)
| | - František Bednář
- From the 3rd Department of Medicine, Centre for Hypertension, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., O.P., T.Z., R.H., B.Š., Z.Š., J.W.); Cardiocentre, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., P.W., P.T., K.Č., F.B.); Department of Anesthesiology, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (P.W.); Department of Internal Medicine I, University Hospital Olomouc, Czech Republic (M.T., J.V., E.K.); and Cardiocentre, Nemocnice Podlesí, Třinec, Czech Republic (M.B., I.N., O.J.)
| | - Tomáš Zelinka
- From the 3rd Department of Medicine, Centre for Hypertension, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., O.P., T.Z., R.H., B.Š., Z.Š., J.W.); Cardiocentre, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., P.W., P.T., K.Č., F.B.); Department of Anesthesiology, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (P.W.); Department of Internal Medicine I, University Hospital Olomouc, Czech Republic (M.T., J.V., E.K.); and Cardiocentre, Nemocnice Podlesí, Třinec, Czech Republic (M.B., I.N., O.J.)
| | - Robert Holaj
- From the 3rd Department of Medicine, Centre for Hypertension, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., O.P., T.Z., R.H., B.Š., Z.Š., J.W.); Cardiocentre, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., P.W., P.T., K.Č., F.B.); Department of Anesthesiology, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (P.W.); Department of Internal Medicine I, University Hospital Olomouc, Czech Republic (M.T., J.V., E.K.); and Cardiocentre, Nemocnice Podlesí, Třinec, Czech Republic (M.B., I.N., O.J.)
| | - Branislav Štrauch
- From the 3rd Department of Medicine, Centre for Hypertension, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., O.P., T.Z., R.H., B.Š., Z.Š., J.W.); Cardiocentre, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., P.W., P.T., K.Č., F.B.); Department of Anesthesiology, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (P.W.); Department of Internal Medicine I, University Hospital Olomouc, Czech Republic (M.T., J.V., E.K.); and Cardiocentre, Nemocnice Podlesí, Třinec, Czech Republic (M.B., I.N., O.J.)
| | - Zuzana Šomlóová
- From the 3rd Department of Medicine, Centre for Hypertension, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., O.P., T.Z., R.H., B.Š., Z.Š., J.W.); Cardiocentre, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., P.W., P.T., K.Č., F.B.); Department of Anesthesiology, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (P.W.); Department of Internal Medicine I, University Hospital Olomouc, Czech Republic (M.T., J.V., E.K.); and Cardiocentre, Nemocnice Podlesí, Třinec, Czech Republic (M.B., I.N., O.J.)
| | - Miloš Táborský
- From the 3rd Department of Medicine, Centre for Hypertension, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., O.P., T.Z., R.H., B.Š., Z.Š., J.W.); Cardiocentre, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., P.W., P.T., K.Č., F.B.); Department of Anesthesiology, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (P.W.); Department of Internal Medicine I, University Hospital Olomouc, Czech Republic (M.T., J.V., E.K.); and Cardiocentre, Nemocnice Podlesí, Třinec, Czech Republic (M.B., I.N., O.J.)
| | - Jan Václavík
- From the 3rd Department of Medicine, Centre for Hypertension, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., O.P., T.Z., R.H., B.Š., Z.Š., J.W.); Cardiocentre, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., P.W., P.T., K.Č., F.B.); Department of Anesthesiology, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (P.W.); Department of Internal Medicine I, University Hospital Olomouc, Czech Republic (M.T., J.V., E.K.); and Cardiocentre, Nemocnice Podlesí, Třinec, Czech Republic (M.B., I.N., O.J.)
| | - Eva Kociánová
- From the 3rd Department of Medicine, Centre for Hypertension, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., O.P., T.Z., R.H., B.Š., Z.Š., J.W.); Cardiocentre, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., P.W., P.T., K.Č., F.B.); Department of Anesthesiology, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (P.W.); Department of Internal Medicine I, University Hospital Olomouc, Czech Republic (M.T., J.V., E.K.); and Cardiocentre, Nemocnice Podlesí, Třinec, Czech Republic (M.B., I.N., O.J.)
| | - Marian Branny
- From the 3rd Department of Medicine, Centre for Hypertension, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., O.P., T.Z., R.H., B.Š., Z.Š., J.W.); Cardiocentre, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., P.W., P.T., K.Č., F.B.); Department of Anesthesiology, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (P.W.); Department of Internal Medicine I, University Hospital Olomouc, Czech Republic (M.T., J.V., E.K.); and Cardiocentre, Nemocnice Podlesí, Třinec, Czech Republic (M.B., I.N., O.J.)
| | - Igor Nykl
- From the 3rd Department of Medicine, Centre for Hypertension, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., O.P., T.Z., R.H., B.Š., Z.Š., J.W.); Cardiocentre, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., P.W., P.T., K.Č., F.B.); Department of Anesthesiology, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (P.W.); Department of Internal Medicine I, University Hospital Olomouc, Czech Republic (M.T., J.V., E.K.); and Cardiocentre, Nemocnice Podlesí, Třinec, Czech Republic (M.B., I.N., O.J.)
| | - Otakar Jiravský
- From the 3rd Department of Medicine, Centre for Hypertension, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., O.P., T.Z., R.H., B.Š., Z.Š., J.W.); Cardiocentre, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., P.W., P.T., K.Č., F.B.); Department of Anesthesiology, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (P.W.); Department of Internal Medicine I, University Hospital Olomouc, Czech Republic (M.T., J.V., E.K.); and Cardiocentre, Nemocnice Podlesí, Třinec, Czech Republic (M.B., I.N., O.J.)
| | - Jiří Widimský
- From the 3rd Department of Medicine, Centre for Hypertension, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., O.P., T.Z., R.H., B.Š., Z.Š., J.W.); Cardiocentre, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., P.W., P.T., K.Č., F.B.); Department of Anesthesiology, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (P.W.); Department of Internal Medicine I, University Hospital Olomouc, Czech Republic (M.T., J.V., E.K.); and Cardiocentre, Nemocnice Podlesí, Třinec, Czech Republic (M.B., I.N., O.J.)
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8
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Hering D, Marusic P, Walton AS, Lambert EA, Krum H, Narkiewicz K, Lambert GW, Esler MD, Schlaich MP. Sustained sympathetic and blood pressure reduction 1 year after renal denervation in patients with resistant hypertension. Hypertension 2014; 64:118-24. [PMID: 24732891 DOI: 10.1161/hypertensionaha.113.03098] [Citation(s) in RCA: 113] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Renal denervation (RDN) reduces muscle sympathetic nerve activity (MSNA) and blood pressure (BP) in resistant hypertension. Although a persistent BP-lowering effect has been demonstrated, the long-term effect on MSNA remains elusive. We investigated whether RDN influences MSNA over time. Office BP and MSNA were obtained at baseline, 3, 6, and 12 months after RDN in 35 patients with resistant hypertension. Office BP averaged 166±22/88±19 mm Hg, despite the use of an average of 4.8±2.1 antihypertensive drugs. Baseline MSNA was 51±11 bursts/min ≈2- to 3-fold higher than the level observed in healthy controls. Mean office systolic and diastolic BP significantly decreased by -12.6±18.3/-6.5±9.2, -16.1±25.6/-8.6±12.9, and -21.2±29.1/-11.1±12.9 mm Hg (P<0.001 for both systolic BP and diastolic BP) with RDN at 3-, 6-, and 12-month follow-up, respectively. MSNA was reduced by -8±12, -6±12, and -6±11 bursts/min (P<0.01) at 3-, 6-, and 12-month follow-up. The reduction in MSNA was maintained, despite a progressive fall in BP over time. No such changes were observed in 7 control subjects at 6-month follow-up. These findings confirm previous reports on the favorable effects of RDN on elevated BP and demonstrate sustained reduction of central sympathetic outflow ≤1-year follow-up in patients with resistant hypertension and high baseline MSNA. These observations are compatible with the hypothesis of a substantial contribution of afferent renal nerve signaling to increased BP in resistant hypertension and argue against a relevant reinnervation at 1 year after procedure.
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Affiliation(s)
- Dagmara Hering
- From the Neurovascular Hypertension and Kidney Disease Laboratory, Baker IDI Heart and Diabetes Institute, Melbourne, Australia (D.H., P.M., E.A.L., G.W.L., M.D.E., M.P.S.); Department of Hypertension and Diabetology, Medical University of Gdansk, Gdańsk, Poland (D.H., K.N.); Heart Centre Alfred Hospital, Melbourne, Australia (A.S.W., H.K., M.D.E., M.P.S.); and Department of Physiology, Faculty of Medicine, Nursing and Health Sciences (E.A.L., G.W.L., M.P.S.) and Department of Epidemiology and Preventive Medicine (H.K.), Monash University, Melbourne, Australia
| | - Petra Marusic
- From the Neurovascular Hypertension and Kidney Disease Laboratory, Baker IDI Heart and Diabetes Institute, Melbourne, Australia (D.H., P.M., E.A.L., G.W.L., M.D.E., M.P.S.); Department of Hypertension and Diabetology, Medical University of Gdansk, Gdańsk, Poland (D.H., K.N.); Heart Centre Alfred Hospital, Melbourne, Australia (A.S.W., H.K., M.D.E., M.P.S.); and Department of Physiology, Faculty of Medicine, Nursing and Health Sciences (E.A.L., G.W.L., M.P.S.) and Department of Epidemiology and Preventive Medicine (H.K.), Monash University, Melbourne, Australia
| | - Antony S Walton
- From the Neurovascular Hypertension and Kidney Disease Laboratory, Baker IDI Heart and Diabetes Institute, Melbourne, Australia (D.H., P.M., E.A.L., G.W.L., M.D.E., M.P.S.); Department of Hypertension and Diabetology, Medical University of Gdansk, Gdańsk, Poland (D.H., K.N.); Heart Centre Alfred Hospital, Melbourne, Australia (A.S.W., H.K., M.D.E., M.P.S.); and Department of Physiology, Faculty of Medicine, Nursing and Health Sciences (E.A.L., G.W.L., M.P.S.) and Department of Epidemiology and Preventive Medicine (H.K.), Monash University, Melbourne, Australia
| | - Elisabeth A Lambert
- From the Neurovascular Hypertension and Kidney Disease Laboratory, Baker IDI Heart and Diabetes Institute, Melbourne, Australia (D.H., P.M., E.A.L., G.W.L., M.D.E., M.P.S.); Department of Hypertension and Diabetology, Medical University of Gdansk, Gdańsk, Poland (D.H., K.N.); Heart Centre Alfred Hospital, Melbourne, Australia (A.S.W., H.K., M.D.E., M.P.S.); and Department of Physiology, Faculty of Medicine, Nursing and Health Sciences (E.A.L., G.W.L., M.P.S.) and Department of Epidemiology and Preventive Medicine (H.K.), Monash University, Melbourne, Australia
| | - Henry Krum
- From the Neurovascular Hypertension and Kidney Disease Laboratory, Baker IDI Heart and Diabetes Institute, Melbourne, Australia (D.H., P.M., E.A.L., G.W.L., M.D.E., M.P.S.); Department of Hypertension and Diabetology, Medical University of Gdansk, Gdańsk, Poland (D.H., K.N.); Heart Centre Alfred Hospital, Melbourne, Australia (A.S.W., H.K., M.D.E., M.P.S.); and Department of Physiology, Faculty of Medicine, Nursing and Health Sciences (E.A.L., G.W.L., M.P.S.) and Department of Epidemiology and Preventive Medicine (H.K.), Monash University, Melbourne, Australia
| | - Krzysztof Narkiewicz
- From the Neurovascular Hypertension and Kidney Disease Laboratory, Baker IDI Heart and Diabetes Institute, Melbourne, Australia (D.H., P.M., E.A.L., G.W.L., M.D.E., M.P.S.); Department of Hypertension and Diabetology, Medical University of Gdansk, Gdańsk, Poland (D.H., K.N.); Heart Centre Alfred Hospital, Melbourne, Australia (A.S.W., H.K., M.D.E., M.P.S.); and Department of Physiology, Faculty of Medicine, Nursing and Health Sciences (E.A.L., G.W.L., M.P.S.) and Department of Epidemiology and Preventive Medicine (H.K.), Monash University, Melbourne, Australia
| | - Gavin W Lambert
- From the Neurovascular Hypertension and Kidney Disease Laboratory, Baker IDI Heart and Diabetes Institute, Melbourne, Australia (D.H., P.M., E.A.L., G.W.L., M.D.E., M.P.S.); Department of Hypertension and Diabetology, Medical University of Gdansk, Gdańsk, Poland (D.H., K.N.); Heart Centre Alfred Hospital, Melbourne, Australia (A.S.W., H.K., M.D.E., M.P.S.); and Department of Physiology, Faculty of Medicine, Nursing and Health Sciences (E.A.L., G.W.L., M.P.S.) and Department of Epidemiology and Preventive Medicine (H.K.), Monash University, Melbourne, Australia
| | - Murray D Esler
- From the Neurovascular Hypertension and Kidney Disease Laboratory, Baker IDI Heart and Diabetes Institute, Melbourne, Australia (D.H., P.M., E.A.L., G.W.L., M.D.E., M.P.S.); Department of Hypertension and Diabetology, Medical University of Gdansk, Gdańsk, Poland (D.H., K.N.); Heart Centre Alfred Hospital, Melbourne, Australia (A.S.W., H.K., M.D.E., M.P.S.); and Department of Physiology, Faculty of Medicine, Nursing and Health Sciences (E.A.L., G.W.L., M.P.S.) and Department of Epidemiology and Preventive Medicine (H.K.), Monash University, Melbourne, Australia
| | - Markus P Schlaich
- From the Neurovascular Hypertension and Kidney Disease Laboratory, Baker IDI Heart and Diabetes Institute, Melbourne, Australia (D.H., P.M., E.A.L., G.W.L., M.D.E., M.P.S.); Department of Hypertension and Diabetology, Medical University of Gdansk, Gdańsk, Poland (D.H., K.N.); Heart Centre Alfred Hospital, Melbourne, Australia (A.S.W., H.K., M.D.E., M.P.S.); and Department of Physiology, Faculty of Medicine, Nursing and Health Sciences (E.A.L., G.W.L., M.P.S.) and Department of Epidemiology and Preventive Medicine (H.K.), Monash University, Melbourne, Australia.
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Witham MD, Ireland S, Houston JG, Gandy SJ, Waugh S, Macdonald TM, Mackenzie IS, Struthers AD. Vitamin D therapy to reduce blood pressure and left ventricular hypertrophy in resistant hypertension: randomized, controlled trial. Hypertension 2014; 63:706-12. [PMID: 24420547 DOI: 10.1161/hypertensionaha.113.02177] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Low 25-hydroxyvitamin D levels are associated with higher prevalent blood pressure. We tested whether high-dose intermittent oral vitamin D therapy could reduce blood pressure and left ventricular mass in patients with hypertension resistant to conventional treatment. We conducted a parallel-group, double-blind, randomized placebo-controlled trial. Patients with supine office blood pressure >140/90 mm Hg on ≥3 antihypertensive agents received 100 000 U oral vitamin D3 or matching placebo every 2 months. Office and 24-hour ambulatory blood pressure, glucose, and cholesterol were measured at baseline, 2, 4, and 6 months; left ventricular mass index was measured by cardiac MRI on a subgroup at baseline and 6 months. The primary outcome was mean 24-hour ambulatory blood pressure at 6 months. A total of 68 participants were randomized, 34 in each group. Mean age was 63 (SD 11) years, mean baseline office blood pressure was 154/84 (13/10) mm Hg, and mean baseline 25-hydroxyvitamin D level was 42 (16) nmol/L. Treatment with vitamin D did not reduce 24-hour ambulatory blood pressure (adjusted treatment effects: systolic, +3 mm Hg; 95% confidence interval, -4 to +11; P=0.33; diastolic, -2 mm Hg; 95% confidence interval, -6 to +2; P=0.29); similar results were seen for office blood pressure. Left ventricular mass index was measured in a subgroup (n=25); no reduction was seen with vitamin D treatment (adjusted treatment effect, +4 g/m(2); 95% confidence interval, 0 to +7; P=0.04). There was no significant change in cholesterol or glucose levels. Thus, 6 months of intermittent, high-dose oral vitamin D3 did not reduce blood pressure or left ventricular mass in patients with resistant hypertension.
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Affiliation(s)
- Miles D Witham
- Ageing and Health, Ninewells Hospital, University of Dundee, Dundee DD1 9SY, United Kingdom.
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10
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Mahfoud F, Ukena C, Schmieder RE, Cremers B, Rump LC, Vonend O, Weil J, Schmidt M, Hoppe UC, Zeller T, Bauer A, Ott C, Blessing E, Sobotka PA, Krum H, Schlaich M, Esler M, Böhm M. Ambulatory blood pressure changes after renal sympathetic denervation in patients with resistant hypertension. Circulation 2013; 128:132-40. [PMID: 23780578 DOI: 10.1161/circulationaha.112.000949] [Citation(s) in RCA: 215] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Catheter-based renal sympathetic denervation (RDN) reduces office blood pressure (BP) in patients with resistant hypertension according to office BP. Less is known about the effect of RDN on 24-hour BP measured by ambulatory BP monitoring and correlates of response in individuals with true or pseudoresistant hypertension. METHODS AND RESULTS A total of 346 uncontrolled hypertensive patients, separated according to daytime ambulatory BP monitoring into 303 with true resistant (office systolic BP [SBP] 172.2±22 mm Hg; 24-hour SBP 154±16.2 mm Hg) and 43 with pseudoresistant hypertension (office SBP 161.2±20.3 mm Hg; 24-hour SBP 121.1±19.6 mm Hg), from 10 centers were studied. At 3, 6, and 12 months follow-up, office SBP was reduced by 21.5/23.7/27.3 mm Hg, office diastolic BP by 8.9/9.5/11.7 mm Hg, and pulse pressure by 13.4/14.2/14.9 mm Hg (n=245/236/90; P for all <0.001), respectively. In patients with true treatment resistance there was a significant reduction with RDN in 24-hour SBP (-10.1/-10.2/-11.7 mm Hg, P<0.001), diastolic BP (-4.8/-4.9/-7.4 mm Hg, P<0.001), maximum SBP (-11.7/-10.0/-6.1 mm Hg, P<0.001) and minimum SBP (-6.0/-9.4/-13.1 mm Hg, P<0.001) at 3, 6, and 12 months, respectively. There was no effect on ambulatory BP monitoring in pseudoresistant patients, whereas office BP was reduced to a similar extent. RDN was equally effective in reducing BP in different subgroups of patients. Office SBP at baseline was the only independent correlate of BP response. CONCLUSIONS RDN reduced office BP and improved relevant aspects of ambulatory BP monitoring, commonly linked to high cardiovascular risk, in patients with true-treatment resistant hypertension, whereas it only affected office BP in pseudoresistant hypertension.
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Affiliation(s)
- Felix Mahfoud
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Kirrberger Str, Geb 40, 66421 Homburg/Saar, Germany.
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