Resistant hypertension: Renal denervation or pharmacovigilance? Insights from a renal denervation screening program

Abstract

Background. With emerging new therapeutic concepts including renal denervation (RDN), there is a renewed interest in resistant hypertension (ResH). Among patients suspected of having ResH, a definitive diagnosis needs to be established.Objectives. This study presents observations from a standardized single-center screening program for RDN candidates, including medical therapy modification and reassessment.Material and methods. All patients referred to our center for RDN underwent a standardized screening protocol. Candidates were recruited from among patients receiving no less than 3 antihypertensive drugs, including diuretics with office blood pressure (BP) >140/90 mm Hg. The assessment included 2 measurements of BP and ambulatory BP monitoring (ABPM). If needed, pharmacotherapy was intensified and the diagnosis of ResH was reconfirmed after 6 weeks. If ResH was persistent, patients were hospitalized with repeated ABPM on day 4. Further, renal CT-angio was performed and a multidisciplinary team discussed the patients' suitability for RDN. Results.A total of 87 patients with a ResH diagnosis were referred for RDN. Mean office BP was 159/92 (±7.0/6.5) mm Hg and mean ABPM was 154/90 (±9.0/4.8) mm Hg. The initial medication included angiotensin convertase inhibitors (ACE-I, 78%), angiotensin receptor blockers (12%), β-blockers (85%), calcium channel blockers (36%), and diuretics (93%). During the 18 months of the RDN program, 5 patients underwent RDN and 2 further had ineligible renal anatomy. A new diagnosis of secondary hypertension was made in 21 patients. However, in 59 patients, BP control was achieved after optimization of medical therapy, with a mean ABPM of 124/74 mm Hg. The final treatment included ACE-I (100%), β-blockers (92%), indapamide (94%), amlodipine (72%), and spironolactone (61%). Medication in most of these patients (88%) included single-pill triple combination (52.5%) or double combination (35.6%). Conclusions.Patients with elevated BP screened for RDN require a rigorous diagnostic workup. Up to 2/3 of patients can be managed with strict pharmacotherapy compliance and pharmaceutical intensification, including single-pill combinations and improved drug compliance. Hasty use of RDN may be a result of poor drug optimization and/or compliance. It does remain a viable treatment option in thoroughly vetted ResH patients.

A Japan nationwide web‐based survey of estimation on patients for renal denervation based on blood pressure level and the number of antihypertensives (J‐NEEDs survey)

“…Further, when all uncontrolled hypertensive patients included, the estimate soared to 58.0‐fold and 36.4‐fold. As hypertensive patients would need to be carefully screened for RDN by assessing BP control level using 24‐h ambulatory BP monitoring to detect daytime and nocturnal hypertension, confirming adherence to the prescribed antihypertensives, excluding secondary hypertension, and determining the appropriateness of renal artery anatomy, a multidisciplinary approach is necessary for the appropriate application of RDN 36 . Although the actual number of hypertensive patients who eventually undergo RDN would be much less than the estimate, further consideration will be crucial in the adoption of RDN as a standard of care.…”