scholarly journals Renal Denervation After Symplicity HTN-3 – Back to Basics. Review of the Evidence

2014 ◽  
Vol 9 (2) ◽  
pp. 110 ◽  
Author(s):  
Alexandre Persu ◽  
Fadl Elmula M Fadl Elmula ◽  
Yu Jin ◽  
Ingrid Os ◽  
Sverre E Kjeldsen ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Resistant Hypertension ◽  
Antihypertensive Drugs ◽  
Controlled Trial ◽  
Blood Pressure Reduction ◽  
Renal Sympathetic Denervation ◽  
Drug Adherence ◽  
Regression To The Mean ◽  
Blood Pressure Lowering Effect ◽  
Blood Pressure Elevation

Renal sympathetic denervation (RDN) has been proposed as a new treatment modality in patients with apparent treatment resistant hypertension, a condition defined as office blood pressure elevation despite prescription of at least three antihypertensive drugs including a diuretic. However, the impressive fall in blood pressure reported after RDN in Symplicity HTN-2, the first randomised study, and multiple observational studies has not been confirmed in the US sham-controlled trial Symplicity HTN-3 and four subsequent prospective randomised studies, all published or presented in 2014. The blood pressure reduction documented in earlier studies may be largely due to non-specific effects such as improvement of drug adherence in initially poorly adherent patients (Hawthorne effect), placebo effect and regression to the mean. The overall blood pressure lowering effect of RDN seems rather limited and the characteristics of true responders remain largely unknown. Accordingly, RDN is not ready for clinical practice. In most patients with apparent drug-resistant hypertension, drug monitoring and subsequent improvement of drug adherence may prove more effective and cost-beneficial to achieve blood pressure control. In the meantime, research should aim at identifying characteristics of those few patients adherent to drug treatment and with true resistant hypertension who may respond to RDN.

Non-pharmacological methods in the treatment of resistant hypertension

Folia Medica ◽  
2012 ◽  
Vol 54 (2) ◽  
pp. 5-12 ◽  
Author(s):  
Kostadin N. Kichukov ◽  
Hristo V. Dimitrov ◽  
Lora K. Nikolova ◽  
Ivo S. Petrov ◽  
Maria P. Tokmakova
Keyword(s):  
Blood Pressure ◽  
Resistant Hypertension ◽  
Renal Denervation ◽  
Antihypertensive Drugs ◽  
Adult Population ◽  
Clinical Problem ◽  
Renal Sympathetic Denervation ◽  
Great Promise ◽  
Long Term Effects ◽  
Blood Pressure Targets

ABSTRACT INTRODUCTION: Arterial hypertension is the most common chronic cardiovascular disease affecting about 25% of the adult population. Meta-analyses have demonstrated a linear relationship between blood pressure and the risk of cardiovascular events. Resistant hypertension defined as failure to reach blood pressure targets despite treatment with three antihypertensive drugs including a diuretic represents a serious clinical problem. It has been estimated that it affects between 8.9% and 12.8% of all treated hypertensive subjects. In resistant hypertension the optimal blood pressure is illusive despite very well tailored therapy. OBJECTIVE: Management of resistant hypertension is exactly the fi eld where blood pressurecontrolling non-pharmacological methods fi t best. The present article aims at throwing light on these methods’ principles of action, on who the target patient groups are and the respective results. Two methods are especially reviewed here: the carotid barorefl ex stimulation and the transcatheter renal sympathetic denervation. Current results from the use of renal denervation suggest stable effi ciency of the method, the results becoming signifi cant 6 months after the procedure is applied and sustained for two years in the follow-up. As much as 90% of the treated patients respond to the procedure. The transcatheter renal denervation is associated with only 2.61% of procedural complications. The barorefl ex carotid stimulation, too, is known to produce a stable effect on blood pressure: the effect become obvious at 12 months in 88% of the treated subjects. The neurologic complications associated with the procedure are reported to occur in 4.4% of cases. CONCLUSION: The present review article clearly demonstrates that non-pharmacological methods for treatment of resistant hypertension show great promise despite some open questions concerning their long term effects and procedural safety.

scholarly journals Resistant Hypertension and Cardiorenovascular Risk

2017 ◽  
Vol 15 (1) ◽  
pp. 6-9 ◽  
Author(s):  
Ingrid Prkacin ◽  
Petra Vrdoljak ◽  
Gordana Cavric ◽  
Damir Vazanic ◽  
Petra Pervan ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Resistant Hypertension ◽  
Antihypertensive Drugs ◽  
Sodium Intake ◽  
Cardiovascular Prevention ◽  
Lifestyle Changes ◽  
Renal Sympathetic Denervation ◽  
Mineralocorticoid Receptor Antagonist ◽  
Obstructive Sleep ◽  
Modifiable Factors

AbstractStudies have documented independent contribution of sympathetic activation to the cardiovascular disease continuum. Hypertension is one of the leading modifiable factors. Most if not all the benefit of antihypertensive treatment depends on blood pressure lowering, regardless how it is obtained. Resistant hypertension is defined as blood pressure that remains uncontrolled in spite of the concurrent use of three antihypertensive drugs of different classes. Ideally, one of the three drugs should be a diuretic, and all drugs should be prescribed at optimal dose amounts. Poor adherence to antihypertensive therapy, undiscovered secondary causes (e.g. obstructive sleep apnea, primary aldosteronism, renal artery stenosis), and lifestyle factors (e.g. obesity, excessive sodium intake, heavy alcohol intake, various drug interactions) are the most common causes of resistant hypertension. Cardio(reno)vascular morbidity and mortality are significantly higher in resistant hypertensive than in general hypertensive population, as such patients are typically presented with a long-standing history of poorly controlled hypertension. Early diagnosis and treatment is needed to avoid further end-organ damage to prevent cardiorenovascular remodeling. Treatment strategy includes lifestyle changes, adding a mineralocorticoid receptor antagonist, treatment adherence in cardiovascular prevention and, in case of failure to control blood pressure, renal sympathetic denervation or baroreceptor activation therapy. The comparative outcomes in resistant hypertension deserve better understanding. In this review, the most current approaches to resistant hypertension and cardiovascular risk based on the available literature evidence will be discussed.

Criteria for selecting patients with resistant hypertension for a renal sympathetic denervation

2016 ◽  
Vol 88 (8) ◽  
pp. 14-18 ◽  
Author(s):  
T M Ripp ◽  
T Yu Rebrova ◽  
V F Mordovin ◽  
S A Afanasiev ◽  
S E Pekarsky ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Radiofrequency Ablation ◽  
Resistant Hypertension ◽  
Antihypertensive Drugs ◽  
Sympathetic Denervation ◽  
Erythrocyte Membranes ◽  
Renal Sympathetic Denervation ◽  
Endovascular Radiofrequency Ablation ◽  
Renal Sympathetic ◽  
Observation Results

Aim. To define and develop a procedure that can select patients with resistant hypertension (RH) for a renal sympathetic denervation (RSD) procedure, by being orienting to the specific initial values of β-adrenoreactivity (β-AR) and systolic blood pressure (SBP). Subjects and methods. The analysis included 23 RH patients receiving the maximally tolerable doses of 4 antihypertensive drugs. The investigations involving BP control and a Russian spectrophotometric procedure for determining β-AR in terms of the change in the osmoresistance of erythrocyte membranes (EM) were performed at baseline and 4 and 24 weeks. RSD was carried out using endovascular radiofrequency ablation of the renal arteries. The therapy was not changed during the observation. Results. If SBP was >170 mm Hg and β-AR of EM >40 conditional units (CUs) at baseline, ΔSBP was 17.68±3.24 mm Hg and the efficiency of RSD was 100%. When SBP was

scholarly journals Resistant hypertension improved after 3 months by measuring drug levels to identify non-adherence

2021 ◽  
Vol 42 (Supplement_1) ◽  
Author(s):  
L E J Peeters ◽  
M H W Kappers ◽  
D A Hesselink ◽  
J B Van Der Net ◽  
S C C Hartong ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Resistant Hypertension ◽  
Antihypertensive Drugs ◽  
Controlled Trial ◽  
Blood Pressure Measurement ◽  
Primary Objective ◽  
Therapeutic Drug ◽  
Personalized Feedback ◽  
Drug Levels

Abstract Introduction Identification of non-adherence to antihypertensive drugs is crucial to improve resistant hypertension (RH). For this therapeutic drug monitoring is the most reliable method. Purpose The primary objective of this analysis is to determine whether drug levels measured with a dried blood spot (DBS) method combined with personalized feedback leads to a decrease in prevalence of RH after 3 months due to an increase in adherence. Methods This is a multi-centre single-blinded randomized controlled trial (RHYME-RCT, NL6736). Patients went to an eligibility visit, where DBS sampling and a 24-hour ambulatory blood pressure measurement (ABPM) was performed simultaneously. Patients with a daytime systolic blood pressure (SBP) >135 and/or diastolic blood pressure (DBP) >85 mmHg were randomized to standard treatment (control) or intervention. The intervention was performed by the treating physician and included information on drug levels and a personalized feedback conversation based on a feedback tool. The follow-up period was one year and included visits at 3, 6 and 12 months after the eligibility visit. At each visit an ABPM and DBS were performed. Results A total of 53 patients (mean age of 59±11 years, 78.7% male) with at least three months of follow-up were included. The prevalence of RH decreased from 100% in both arms to 75.0% in the intervention arm (p=0.014, n=24) and 58.6% in the control arm (p=0.001, n=29). No improvements were seen in adherence rates over time. Furthermore, no significant differences were found after three months between the two groups in the degree of RH (p=0.214), SBP (p=0.551) or adherence (p=0.746). Conclusion Measuring blood pressure and drug levels led to a decrease in the prevalence of RH. However, this improvement could not be linked to the actual intervention or improvement of adherence. FUNDunding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): ZonMW

scholarly journals Blood pressure reduction in hypertensive acute ischemic stroke patients does not affect cerebral blood flow

2018 ◽  
Vol 39 (9) ◽  
pp. 1878-1887 ◽  
Author(s):  
Mahesh Kate ◽  
Negar Asdaghi ◽  
Laura C Gioia ◽  
Brian Buck ◽  
Sumit R Majumdar ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Blood Flow ◽  
Cerebral Blood Flow ◽  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Antihypertensive Drugs ◽  
Controlled Trial ◽  
Blood Pressure Reduction ◽  
Stroke Patients ◽  
Before And After

The effect of blood pressure (BP) reduction on cerebral blood flow (CBF) in acute ischemic stroke is unknown. We measured regional CBF with perfusion-weighted MRI before and after BP treatment in a three-armed non-randomized prospective controlled trial. Treatment arm assignment was based on acute mean arterial pressure (MAP). Patients with (MAP) >120 mmHg ( n = 14) were treated with intravenous labetalol and sublingual (SL) nitroglycerin (labetalol group). Those with MAP 100–120 mmHg ( n = 17) were treated with SL nitroglycerin (0.3 mg) (‘NTG Group’) and those with baseline MAP<100 mmHg ( n = 18) were not treated with antihypertensive drugs (untreated group). Forty-nine patients (18 female, mean age 65.3 ± 12.9 years) were serially imaged. Labetalol reduced MAP by 12.5 (5.7–17.7) mmHg, p = 0.0002. MAP remained stable in the NTG (6.0 (0.4–16, p = 0.3) mmHg and untreated groups (−0.3 (−2.3–7.0, p = 0.2) mmHg. The volume of total hypoperfused tissue (CBF<18 ml/100 g/min) did not increase after labetalol (−1.1 ((−6.5)–(−0.2)) ml, p = 0.1), NTG (0 ((−1.5)–4.5) ml, p = 0.72), or no treatment 0.25 ((−10.1)–4.5) ml, p = 0.87). Antihypertensive therapy, based on presenting BP, in acute stroke patients was not associated with an increased volume of total hypoperfused tissue.

scholarly journals Novel approaches to treat resistant hypertension

2020 ◽  
Vol 26 (1) ◽  
pp. 10-34
Author(s):  
Aleksandra Cherneva ◽  
Ivo Petrov
Keyword(s):  
Blood Pressure ◽  
Resistant Hypertension ◽  
Antihypertensive Drugs ◽  
Current Knowledge ◽  
Pressure Control ◽  
Uncontrolled Hypertension ◽  
Renal Sympathetic Denervation ◽  
Significant Group ◽  
Arterial Blood ◽  
Optimal Blood Pressure

Treatment-resistant hypertension, or resistant hypertension (RH), is defined as arterial hypertension (AH) despite treatment with three properly dosed antihypertensive drugs, at least one of which is a diuretic. Resistant hypertension is associated with an increased incidence of adverse cardiovascular events, renal impairment, and increased mortality. The main treatment of patients with RH is based on maximizing doses of antihypertensive drugs from different groups and adding drugs with complementary mechanisms of action. Despite the combination treatment involving multiple antihypertensive drugs, a small but significant group of patients remains with uncontrolled hypertension, emphasizing the need to find and put into practice new therapies to lower high arterial blood pressure (BP). Among these new methods of treatment, the most promising is the renal sympathetic denervation, showing positive results with the second generation devices. This review summarizes current knowledge about the treatment of RH, with an emphasis on new therapeutic strategies to achieve optimal blood pressure control.

Abstract P624: Prevalence, Predictors and Comparison of Spironolactone versus Clonidine as a Fourth Drug for Resistant Hypertension: the Resistant Hypertension Optimal Treatment (ReHOT) study

Hypertension ◽  
2016 ◽  
Vol 68 (suppl_1) ◽  
Author(s):  
Eduardo M Krieger ◽  
Luciano F Drager ◽  
Dante M Giorgi ◽  
Alexandre C Pereira ◽  
José A Barreto-Filho ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Primary Endpoint ◽  
Resistant Hypertension ◽  
Blood Pressure Monitoring ◽  
Controlled Trial ◽  
Blood Pressure Reduction ◽  
National Research Council ◽  
Study Entry ◽  
Hypertension Optimal Treatment ◽  
Admixed Population

Background: The prevalence, predictors and the best anti-hypertensive regimen for resistant hypertension (RH) are not well established especially in Countries with multiethnic profile. Our main aim was to compare spironolactone versus clonidine as a fourth drug therapy for patients with RH. Methods: This is a multicentric, randomized controlled trial comprising 26 sites in Brazil that recruited outpatients from a highly admixed population with hypertension stage 2 (≥160/100mmHg) at study entry. Medical therapy adherence was checked by pill counting. Patients with confirmed RH (no office and 24hs ambulatory blood pressure monitoring - ABPM - control despite treatment with 3 drugs including a diuretic for 12 weeks) were randomized to additional 12 weeks treatment with spironolactone (12.5-50mg once daily) or clonidine (0.1-0.3mg twice daily). The primary endpoint was blood pressure (BP) control from both office (<140/90mmHg) and 24hs ABPM (<130/80mmHg). Secondary endpoints included absolute and relative BP reductions in each study arm. Results: A total of 1597 patients were included in the analysis. We found that 14.9% (238 patients) fulfilled the RH criteria. Predictors of true RH include male gender (OR 1.43; CI 1.02-2.00), previous stroke (OR 2.81; CI 1.51-5.06), diabetes (OR 2.09; CI 1.48-2.94) and BP ≥180x110mmHg at study entry (OR 2.53; CI 1.88-3.43). Compared to patients randomized to spironolactone (n=119), those patients randomized to clonidine (n=119) presented similar rate of the primary endpoint (19.8 vs. 24%, respectively; p=0.59). Similarly, no differences were observed between groups in the blood pressure reduction analyzed either by office as well as by 24-h ABPM. No differences in the pill counting monitoring were observed in the groups. Conclusions: Appropriate treatment for stage 2 hypertension under the national universal health care conditions provided blood pressure control in 85% from a highly admixed population. Spironolactone or clonidine displayed comparable BP control as a fourth drug in patients with RH. Funding: Ministry of Health/H. Samaritano, National Research Council, Sao Paulo Research Foundation and Zerbini Foundation.

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