MD Conference Express ESC 2012 - (Page 31)
Renal denervation has been shown to delay/prevent the development of preclinical experimental forms of hypertension. The Renal Denervation in Patients With Uncontrolled Hypertension [Symplicity HTN-2] trial was a prospective, randomized trial in 106 treatmentresistant hypertensive patients with a baseline systolic BP ≥160 mm Hg (≥150 mm Hg for type diabetics) in which catheter-based renal denervation using radio frequency was shown to reduce BP by 32/12 mm Hg at 6 months [Symplicity HTN-2 Investigators et al. Lancet 2010] (Figure 3). Prof. Esler shared new data showing that the effect was still durable after 3 years, with no evidence of atherogenesis, fibrotic stenosis, renal artery aneurysm, deterioration in renal function, or orthostatic or electrolyte disturbances [Lenski M et al. Eur Heart J 2012]. Figure 3. Primary Endpoint: 6-Month Office BP.
Renal Artery Denervation (n=49) Systolic Diastolic Control (n=51) Systolic 1 Diastolic 0
competence. Resting heart rate decreased and heart rate recovery improved after the procedure [Ukena C et al. J Am Coll Cardiol 2011]. In another recent study, renal denervation safely reduced BP, renal resistive index, and the incidence of albuminuria without adversely affecting glomerular filtration rate (GFR) or renal artery structure within 6 months [Mahfoud F et al. Hypertension 2012] and may be equally effective in resistant hypertensive patients with Stage 3/4 chronic kidney disease (mean estimated GFR 31 mL/min/1.73 m2) [Hering D et al. J Am Soc Nephrol 2012]. Keys to good outcomes with renal denervation include good patient selection and a thorough preprocedural work-up. Alberto Cremonesi, MD, Villa Maria Cecilia Hospital, Cotignola, Italy, provided his insight regarding appropriate patient selection for renal denervation. It is important to establish that the patient is truly drugresistant and is not undertreated, non-compliant, or taking other medications/therapies that interfere with BP control. Contributing lifestyle factors (eg, obesity, physical inactivity, excessive alcohol ingestion, high salt intake) should be identified and treated, substances that interfere with BP should be addressed, and patients should also be screened for secondary causes of hypertension. The best treatment modality should maximize pharmacological treatment, which may include maximizing diuretic therapy, combining agents with different mechanisms of action, and using aldosterone antagonists such as spironalactone. Felix Mahfoud, MD, Universitätsklinikum des Saarlandes, Homburg/Saar, Germany, described his catheter-based approach to renal denervation. The renal nerves should receive ≥5 ablations (120 seconds each) separated both longitudinally and rotationally (spacing >5 mm) with ablation occurring distal to proximal. Prof. Mahfoud noted that a secondary rise in BP should not be expected after renal denervation and that the amount of BP reduction correlates to baseline systolic BP. It is best to use office BP to monitor BP changes, confirmed by ambulatory BP, he added. New treatment catheters using radiofrequency energy, new approaches using ultrasound, and chemical denervation are on the horizon. Although renal denervation shows promise as treatment for a variety of conditions, there remain unanswered questions such as its clinical durability, how to explain non-responders, whether its clinical indication can be expanded beyond hypertension, and whether new ablation systems will address anatomical limitations. These questions are likely to be answered by the Symplicity-HTN-3 trial, an ongoing randomized study in >500 hypertensive resistant patients.
Change from Baseline to 6 Months (mm Hg)
10 0 -10 -20 -30 -40 -50 -12
-32
33/11 mm Hg difference between renal artery denervation and control p<0.0001
Reproduced with permission from The Lancet; Symplicity HTN-2 Investigators. Renal sympathetic denervation in patients with treatment-resistant hypertension (The Symplicity HTN-2 Trial): A randomised controlled trial. 2010;376(9756):1903-9.
In addition to significantly reducing BP, a small study suggests denervation may also improve glucose metabolism and insulin sensitivity [Mahfoud F et al. Circulation 2011]. Left ventricular (LV) hypertrophy and diastolic dysfunction are associated with elevated sympathetic activity and increased morbidity and mortality [Redfield MM et al. JAMA 2003; Bombeli M et al. J Hypertens 2009]. New evidence suggests renal denervation may improve LV and diastolic function. Six months after 46 resistant hypertensive patients underwent bilateral renal denervation, the patients experienced a significant reduction in LV mass and improved diastolic function in addition to significant BP reduction [Brandt MC et al. J Am Coll Cardiol 2012]. There is also evidence that renal denervation improves cardiorespiratory response to exercise. In a small study with 37 patients, renal denervation reduced BP during exercise without compromising chronotropic
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Table of Contents for the Digital Edition of MD Conference Express ESC 2012
MD Conference Express ESC 2012
Contents
ESC 2012 Clinical Practice Guidelines
TAVI: 10 Years After the First Case
PARAMOUNT Trial Results
TRILOGY ACS Outcomes
Results from the ALTITUDE Trial
Results of the WOEST Trial
Results from the Aldo-DHF Trial
FAME 2 Results
Results from the IABP-SHOCK II Trial
STEMI Mortality Decreases in France While Some Key Risk Factors Increase
Results from the PURE Study
PURE: Treatment and Control of Hypertension
Genetic Determinants of Variability in Dabigatran Exposure
The RE-LY AF Registry
TRA 2°P-TIMI 50 Results
Rivaroxaban of Benefit in STEMI: ATLAS ACS 2-TIMI 51
Ivabradine Effect on Recurrent Hospitalization for HF
CLARIFY: Similar 1-Year Outcomes for Men and Women with Stable CAD
HPS2-THRIVE Study Results
PRoFESS Study Results
Outcomes from the CARDia Trial
Hypertension
Atrial Fibrillation
Heart Failure
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