Renal Sympathetic Denervation and Daily Life Blood Pressure in Resistant Hypertension

Parati, Gianfranco; Ochoa, Juan Eugenio; Bilo, Grzegorz

doi:10.1161/circulationaha.113.003892

Cited by 9 publications

(5 citation statements)

References 18 publications

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“…Home BP measurements correlated closely with daytime ambulatory BP monitoring and after month 1 post denervation with office BP measurements. Similar differences between office BP and ambulatory BP reductions have been reported in previously published studies 13,14,18,34 and have been scrutinized, 21,35 but comparisons between office and home measurements have been limited to a small number of patients in Symplicity HTN-1. 13 Small differences are expected and have been reported in the drug treatment literature.…”

Section: Discussionsupporting

confidence: 56%

Catheter-Based Renal Denervation for Resistant Hypertension

et al. 2014

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T he role of the sympathetic nervous system in the development and maintenance of hypertension has long been recognized, 1,2 and for decades, extensive research has demonstrated the effects of renal denervation on hypertension and other disease states. 3,4,5,6,7 It has been well established that kidneys act both as generators and recipients of sympathetic signals 8 transferred bidirectionally through afferent or efferent sympathetic fibers. Both afferent and efferent sympathetic fibers course through the adventitia of the renal artery and are thus amenable to thermal injury using transvascular techniques. 9 Resistant hypertension, defined as uncontrolled hypertension with at least 3 antihypertensive medications, of which one is a diuretic, is an emerging problem with unmet medical needs. Given resistance to drug therapy, activation of sympathetic nervous system, the role of renal nerves in the development of hypertension, and the ease of approach of the sympathetic fibers by catheter-based techniques, resistant hypertension is the optimal candidate for interventional approaches. 10,11,12 Most of the published catheter-based renal denervation studies [13][14][15][16][17][18] used single-tip catheters to achieve renal denervation and demonstrated encouraging but inconsistent results. The first-in-man study, Symplicity HTN-1, 13 demonstrated a small reduction in office blood pressure (BP) early on, which improved with time, thus creating the impression of delayed response after renal denervation. However, published data from these studies present different numbers of patients at different time points, making the results difficult to interpret. The second study, Symplicity HTN-2, 14 was a placebo-controlled but unblinded study that showed a similar pattern of BP reduction as HTN-1, but did not show a placebo effect. In both studies (HTN-1 Abstract-Renal denervation has emerged as a novel approach for the treatment of patients with drug-resistant hypertension. To date, only limited data have been published using multielectrode radiofrequency ablation systems.In this article, we present the 12-month data of EnligHTN I, a first-in-human study using a multielectrode ablation catheter. EnligHTN I enrolled 46 patients (average age, 60±10 years; on average 4.7±1.0 medications) with drugresistant hypertension. Eligible patients were on ≥3 antihypertensive medications and had a systolic blood pressure (BP) ≥160 mm Hg (≥150 mm Hg for diabetics). Bilateral renal artery ablation was performed using a percutaneous femoral approach and standardized techniques. The average baseline office BP was 176/96 mm Hg, average 24-hour ambulatory BP was 150/83 mm Hg, and average home BP was 158/90 mm Hg. The average reductions (mm Hg) at 1, 3, 6, and 12 months were as follows: office: −28/−10, −27/−10, −26/−10, and −27/−11 mm Hg (P<0.001 for all); 24-hour ambulatory: −10/−5, −10/−5, −10/−6 (P<0.001 for all), and −7/−4 for 12 months (P<0.0094). Reductions in home measurements (based on 2-week average) were −9/−4, −8/−5,−10/−7, and −11/−6 mm H...

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Section: Discussionsupporting

confidence: 56%

Catheter-Based Renal Denervation for Resistant Hypertension

et al. 2014

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“…This article was accompanied by an editorial that criticized the results. 51 Figure 4 presents baseline office and 24-hour ambulatory BPs and BP changes after RNA in 5 studies that included both measures. Consistently the ABPM measurements are substantially lower than the office measurements.…”

Section: Rna For Drug-resistant Hypertensionmentioning

confidence: 99%

Renal Nerve Ablation for Resistant Hypertension

et al. 2014

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S ympathetic renal denervation, or renal nerve ablation (RNA), has become the new buzz word in hypertension and interventional cardiology. Recent advances in catheterbased approaches have allowed sympathetic fiber interruption through transvascular techniques that are minimally invasive and can be delivered expeditiously and safely. Radiofrequency (RF) energy sources are currently the preferred modalities, but other sources of energy, such as cryoablation, microwave, high-intensity focus ultrasound, and local neurotoxic agent infusion, are under intense investigation. Results thus far have been encouraging and offer promise for the future. The role of the sympathetic nervous system (SNS) in the development of resistant hypertension and cardiovascular disease has long been known, and a great deal of work has been done through the years trying to explore potential interventions to interrupt the sympathetic influence on systemic vasculature and target organs. In this article we attempt an overview of timedependent interventions on the SNS and examine approaches used in humans and in the many experimental models that offer a better understanding of the role of sympathetic activity in cardiovascular disease. Naturally we focus on methods and techniques addressing sympathetic renal denervation in patients with drug-resistant hypertension, examine the current state of the art, and attempt a look into the future. Historic PerspectiveIn 1889, after meticulous experiments on dogs, Bradford 1 reported that stimulation of dorsal and splanchnic nerves causes changes in blood pressure (BP) and kidney size measured by plethysmography. Whether BP increased or decreased depended on the anatomic area stimulated, as well as the electric impulse frequency, but outcomes were consistent and reproducible. Neurosurgical treatment of hypertension was independently suggested by researchers in 1923. Adson, however, was the first to performed surgical sympathectomy for the treatment of malignant hypertension in 1925.3 During the following years and in the 1930s, Peet in Ann Arbor, Page and Heuer in New York, and Adson, Craig, and Brown from the Mayo Clinic operated and reported on series of patients all experiencing malignant hypertension.4 At the same time, renal decapsulation, which was considered a form of sympathectomy by disrupting the fibers between the capsule and the renal cortex, was being performed to treat unexplained hematuria and perinephritis. Sen 5 reported a significant but not permanent decrease in BP in 85 subjects who underwent decapsulation between 1925 and 1935.Surgical denervation of the kidneys alone was first performed in humans by Papin and Ambard 6 in 1924 in an attempt to relieve intractable pain originating from the kidney. The first case of bilateral sympathetic denervation of the kidney to treat severe essential hypertension was presented in 1934 by Page and Heuer. 7 The patient was a 25-year-old woman who reported easy fatigability and had severe headaches and BP in the range of 208/140 mm Hg. The patient und...

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“…Mahfoud et al combined data from 10 centers without adjusting for differences between centers. Finally, we 2 share the concerns of the editorialist 3 about the disproportionality between the responses in office and ambulatory BPs.…”

Section: To the Editormentioning

confidence: 92%