Optimum and stepped care standardised antihypertensive treatment with or without renal denervation for resistant hypertension (DENERHTN): a multicentre, open-label, randomised controlled trial

BACKGROUND

Conflicting blood pressure-lowering effects of catheter-based renal artery denervation have been reported in patients with resistant hypertension. We compared the ambulatory blood pressure-lowering efficacy and safety of radiofrequency-based renal denervation added to a standardised stepped-care antihypertensive treatment (SSAHT) with the same SSAHT alone in patients with resistant hypertension.

METHODS

The Renal Denervation for Hypertension (DENERHTN) trial was a prospective, open-label randomised controlled trial with blinded endpoint evaluation in patients with resistant hypertension, done in 15 French tertiary care centres specialised in hypertension management. Eligible patients aged 18-75 years received indapamide 1·5 mg, ramipril 10 mg (or irbesartan 300 mg), and amlodipine 10 mg daily for 4 weeks to confirm treatment resistance by ambulatory blood pressure monitoring before randomisation. Patients were then randomly assigned (1:1) to receive either renal denervation plus an SSAHT regimen (renal denervation group) or the same SSAHT alone (control group). The randomisation sequence was generated by computer, and stratified by centres. For SSAHT, after randomisation, spironolactone 25 mg per day, bisoprolol 10 mg per day, prazosin 5 mg per day, and rilmenidine 1 mg per day were sequentially added from months two to five in both groups if home blood pressure was more than or equal to 135/85 mm Hg. The primary endpoint was the mean change in daytime systolic blood pressure from baseline to 6 months as assessed by ambulatory blood pressure monitoring. The primary endpoint was analysed blindly. The safety outcomes were the incidence of acute adverse events of the renal denervation procedure and the change in estimated glomerular filtration rate from baseline to 6 months. This trial is registered with ClinicalTrials.gov, number NCT01570777.

FINDINGS

Between May 22, 2012, and Oct 14, 2013, 1416 patients were screened for eligibility, 106 of those were randomly assigned to treatment (53 patients in each group, intention-to-treat population) and 101 analysed because of patients with missing endpoints (48 in the renal denervation group, 53 in the control group, modified intention-to-treat population). The mean change in daytime ambulatory systolic blood pressure at 6 months was -15·8 mm Hg (95% CI -19·7 to -11·9) in the renal denervation group and -9·9 mm Hg (-13·6 to -6·2) in the group receiving SSAHT alone, a baseline-adjusted difference of -5·9 mm Hg (-11·3 to -0·5; p=0·0329). The number of antihypertensive drugs and drug-adherence at 6 months were similar between the two groups. Three minor renal denervation-related adverse events were noted (lumbar pain in two patients and mild groin haematoma in one patient). A mild and similar decrease in estimated glomerular filtration rate from baseline to 6 months was observed in both groups.

INTERPRETATION

In patients with well defined resistant hypertension, renal denervation plus an SSAHT decreases ambulatory blood pressure more than the same SSAHT alone at 6 months. This additional blood pressure lowering effect may contribute to a reduction in cardiovascular morbidity if maintained in the long term after renal denervation.

FUNDING

French Ministry of Health.

Perindopril/indapamide combination in the first-line treatment of hypertension and end-organ protection

This article examines evidence-based findings in the literature on the efficacy of perindopril 2 mg/indapamide 0.625 mg, a first-line, low-dose antihypertensive drug combination. In regulatory Phase II and III trials, perindopril/indapamide significantly lowered blood pressure compared with other first-line therapies (atenolol, losartan and irbesartan). This was also the case in STRAtegies of Treatment in Hypertension: Evaluation, a postregistration study versus current monotherapies and stepped-care therapy with different classes of antihypertensive agents. The efficacy/safety ratio (both clinical and with regard to laboratory parameters) of perindopril/indapamide was good. Perindopril/indapamide provides additional antihypertensive efficacy compared with each component used alone and with current monotherapies, with major efficacy on systolic blood pressure, an important predictor of cardiovascular risk. It also reduces pulse pressure, an independent cardiovascular risk factor, large-vessel arterial stiffness and microcirculatory alterations. The fixed dosage of a once-daily tablet, ensures optimal ease of use and enhances patient compliance. Perindopril/indapamide also reduces target organ damage in patients at high cardiovascular risk, such as patients with cardiac hypertrophy and Type 2 diabetics with albuminuria. These benefits, together with the good efficacy/tolerability ratio, fulfill the requirements of the European Society of Hypertension and of the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure guidelines for low-dose, first-line combination therapy in hypertension.

Normotensive incidentally discovered pheochromocytomas display specific biochemical, cellular, and molecular characteristics

CONTEXT

A number of incidentally discovered pheochromocytomas are not associated with hypertension. The characteristics of normotensive incidentally discovered pheochromocytomas (NIPs) are poorly known.

OBJECTIVE

The purpose of this work was to assess the clinical, hormonal, histological, and molecular features of NIPs.

DESIGN

This was a retrospective cohort recruited from 2001 to 2011 in 2 tertiary care medical departments.

PATIENTS AND METHODS

Clinical, biological, and radiological investigations performed in 96 consecutive patients with sporadic unilateral pheochromocytomas were examined; 47 patients had overt pheochromocytomas responsible for hypertension. Among the patients with incidental pheochromocytomas, 28 had hypertension and 21 were normotensive (NIPs). A total of 62 tumors were examined to determine the Pheochromocytoma of the Adrenal Gland Scale Score, and 29 were studied for the expression of 16 genes involved in chromaffin cell function.

RESULTS

Tumor size and metaiodobenzylguanidine (MIBG) scintigraphy results were similar for hypertensive pheochromocytomas (HPs) and NIPs. Patients with NIPs displayed reduced summed levels of urinary catecholamines and metanephrines and, more specifically, reduced levels of adrenaline and metadrenaline compared with those of patients with HPs (P < .001). Urinary metanephrines had 98% diagnostic sensitivity in patients with HPs and only 75% in patients with NIPs (P < .01). Tumor diameter positively correlated with the total amount of urinary concentrations of metanephrines in patients with HPs (P < .001) but not in patients with NIPs. NIPs displayed global decreased chromaffin gene expression (reaching significance for 5 of them) and 2 corresponding proteins (phenylethanolamine N-methyltransferase and secretogranin II) and a significant increase in the cellularity, mitotic activity, and presence of atypical mitosis (P < .05).

CONCLUSIONS

NIPs differ from pheochromocytomas responsible for hypertension and display features of altered chromaffin differentiation. These tumors may be misdiagnosed with the use of the usual biological diagnostic tools.

Phasing-in plasma metanephrines determination

OBJECTIVES

We set up plasma normetanephrine (pNMA) and metanephrine (pMA) assays as they demonstrated their usefulness for diagnosing phaeochromocytomas. Our scope is to describe some practical laboratory aspects and the clinical relevance of these assays in our endocrinological or cardiological departments.

METHODS

We retrospectively reviewed the results of MA from a population of in- and outpatients over a 7-year period. Subjects (n=2536) from endocrinological or cardiological departments were investigated (66 phaeochromocytomas). Urinary NMA (uNMA) and pNMA, and urinary MA (uMA) and pMA were assayed by HPLC with electrochemical detection.

RESULTS

pNMA and pMA assays are now more frequently requested than uNMA and uMA. This changed our laboratory work load with improved delivery, sensitivity and reliability of plasma assays as well as reduced apparatus maintenance time. The pNMA and pMA upper reference limits (URLs) of subjects with no phaeochromocytoma were 1040 and 430 pmol/l respectively. Sensitivity and specificity based on receiver operating characteristic curves optimal points were 83 and 93% for pNMA at 972 pmol/l and 67 and 98% for pMA at 638 pmol/l. Sensitivity and specificity of paired tests of pMA (positive test: at least one analyte above its URLs) were 100 and 91% respectively.

CONCLUSION

The very low concentration of analytes requires a sustained very good apparatus analytical sensitivity. This can be obtained in an up-to-date laboratory. In terms of clinical performances, assays in plasma or urine are equivalent. Depending on local preferences, populations, strategies or departments, requests for one or the other assay may sustain the need for specifically defined reference ranges.

Impaired baroreflex sensitivity and the risks of new-onset ambulatory hypertension, in an elderly population-based study

BACKGROUND

Impairment of the autonomic nervous system activity may be involved in the development of hypertension. Yet the prognostic values of heart rate variability and baroreflex sensitivity in the risk of new-onset ambulatory hypertension have not been investigated. We sought to assess the relationship between heart rate variability and baroreflex sensitivity parameters and ambulatory hypertension in a community-dwelling elderly cohort.

METHODS

Normotensive subjects were selected from the PROOF study cohort, including 1011 subjects aged 65 years at baseline. The autonomic nervous system activity was assessed through 24-hour heart rate variability and 15-minute spontaneous baroreflex sensitivity at baseline. Incident hypertension was defined with the 24-hour, day-time and night-time ambulatory blood pressure measurements and antihypertensive treatment use, at two-years of follow-up.

RESULTS

At baseline, 13.7% of subjects developed day-time hypertension, 18.2% developed night-time hypertension and 13.6% developed 24-hour hypertension. Reduced baroreflex sensitivity at baseline was associated with onset of hypertension after adjustment for blood pressure level, C-reactive protein levels and depression score (OR = 0.45 [0.23-0.86]). Indices of heart rate variability were not associated with hypertension onset.

CONCLUSION

Baroreflex sensitivity may represent an intermediate goal for prevention of ambulatory hypertension at early stage.

Autonomic activation during sleep and new-onset ambulatory hypertension in the elderly

BACKGROUND

Sympathetic "overactivity" during night is a well recognized factor of hypertension development in adults. However, the deleterious effect of nocturnal autonomic activation in elderly remains controversial.

METHODS

Subjects, all aged 65 years at baseline, were selected from the PROOF cohort study, a prospective observational cohort of subjects. Exclusion criteria were previous myocardial infarction, stroke, heart failure, type-1 diabetes, atrial fibrillation or anti-arrhythmic drug. Normotensive subjects were selected according to: 24-h ambulatory blood pressure (BP) measurements <135/85 mm Hg, absence of self-report antihypertensive treatment. Autonomic activation during sleep was evaluated from night-time ECG Holter recording. According the %VLFI (Very-Low Frequency component of Interbeat Interval Increment evaluated from heart rate variability analysis). Subjects with new-onset ambulatory hypertension were identified after two years when daytime ambulatory blood pressure was higher than 135/85 mm Hg or when they used an antihypertensive treatment.

RESULTS

Among 428 normotensive subjects at inclusion, 62 (14.5%) were considered as hypertensives after two years. Univariate logistic regression model showed a significant association between abnormal %VLFI (>4%) and new-onset hypertension: OR = 1.78 (1.03-3.07). Male gender, increased body mass index and ambulatory systolic BP were also associated with increased risk of hypertension. After adjustment in the stepwise logistic regression, abnormal %VLFI was associated with an 82% increase in odds of new-onset hypertension, independently of systolic ABPM and body mass index.

CONCLUSION

Repeated autonomic activation during sleep, whatever the origin of the phenomenon, may trigger hypertension development in the elderly.

Atrioventricular conduction in the hypertensive patient: influence of aging, pulse pressure, and arterial stiffness

Atrioventricular (AV) conduction time (PR interval) lengthens with age. Hypertension is often presented as an accelerated aging of the heart and arteries. The principal marker of arterial aging is an increase in arterial stiffness and pulse pressure. We were interested to find out whether parameters of blood pressure and arterial stiffness were related to the PR interval and whether they influenced its long-term progression. We examined factors linked to the PR interval at baseline in a cohort of untreated hypertensive patients including office and 24-hr blood pressure and arterial stiffness (QKD(100-60)). Long-term evolution of the PR interval and related factors were obtained during follow-up of this population. Baseline data were obtained in 1,034 untreated hypertensive patients. At baseline, four variables emerged as significantly and independently correlated with PR interval: Gender, age, weight, and heart rate. During follow-up (137 ± 78 months), 328 of these patients were re-examined. In this group, PR increased from 159 ± 20 to 167 ± 25 msec (p<0.001), a mean alteration of 8 ± 19 msec. This change was correlated with the baseline 24 hr PP (r=0.17, p=0.004) and with the duration of follow-up (r=0.13, p=0.02). In the group with baseline evaluation of arterial stiffness (n=141), QKD(100-60) was correlated with the change in PR interval (r= -0.33, p<0.0001) along with the duration of follow-up (r=0.22, p=0.005). This study shows a link between baseline increased pulse pressure or arterial stiffness with the prolongation of the PR interval with aging. Because this link was observed during follow-up, it is possible that increased arterial stiffness favors the increase in the PR interval with age.

Domestic activities after myocardial infarction. Their impact is underestimated

BACKGROUND

Although aptitude for resumption of work is usually evaluated after myocardial infarction, the return home often entails significant daily obligations whose cardiovascular implications are poorly described and may well be underestimated.

AIM

The aim of this study was to evaluate the consequences of domestic activities on blood pressure and heart rate in patients with recent myocardial infarction

DESIGN

This was an observational study.

SETTING

Inpatients, at the end of a three week period of cardiovascular rehabilitation.

POPULATION

Patients with recent myocardial infarction.

METHODS

We studied patients who had benefited from a three-week period of cardiovascular rehabilitation after a myocardial infarction, all treated with beta-blockers. At the end of the rehabilitation period, patients were submitted to a standardized exercise test with measurement of V.O2. They also carried out, on a separate day, four standardized domestic tasks in a random order along with an automated measurement of blood pressure and heart rate.

RESULTS

We included 16 men and 11 women, aged 35 to 74 years. Vacuum cleaning led to a much greater increase in the product of heart rate and systolic blood pressure (DP) than did window cleaning, bathroom cleaning or ironing. It also led to an increase in heart rate to 70-90% of maximum heart rate during the exercise test and 47-65% of the maximal DP on the exercise test. Although the women were more accustomed to these tasks than the men, they did not appear to benefit from any training effect. The average level of DP observed in some patients during domestic tasks was comparable to that of a maximum exercise test indicating that they were not adequately prepared for a return to household activities.

CONCLUSION

Domestic tasks should not be underestimated as they can lead to a significant increase in DP. They tend not to be taken into account in the rehabilitation of patients after a myocardial infarction.

CLINICAL REHABILITATION IMPACT

The traditional methods of rehabilitation are not well adapted for resumption of domestic life, especially for women who are most involved in these activities. We recommend an individual approach involving performance of real life tasks taking account of the personality of the patients, their lifestyle and home environment.

[Surgical excision of subclinical cortisol secreting incidentalomas: Impact on blood pressure, BMI and glucose metabolism]

OBJECTIVES

To compare clinical, vascular and metabolic parameters before and after surgery in patients with subclinical cortisol secreting incidentalomas.

PATIENTS AND METHODS

Eight patients were investigated before and 12 months after removal of the mass on hemodynamic (blood pressure by MAPA procedure), anthropometric (body weight, body mass index), and metabolic parameters (glucose level, HbA(1c)).

RESULTS

In the whole group, 75% of patients displayed decrease in blood pressure (cessation of at least one hypotensive medication) and 33% of them were definitely cured of hypertension. Seventy-one percent of patients lost body weight and 37.5% lost more than 5%. In the whole group of patients, glucose level decreased by 1.1% and medical treatment was discontinuated in two of three diabetic patients.

CONCLUSION

Subclinical cortisol secreting adrenal incidentalomas are associated with cardiovascular risk factors that may be corrected after removal of the mass. Therefore, surgery may be an appropriate choice in patients with subclinical Cushing's syndrome to improve hypertension, body weight and impaired glucose level. Controlled studies comparing surgical treatment to a medical follow-up including optimal cardiovascular risk factors treatment are needed to define the usefulness of surgery in hypertensive patients with subclinical cortisol secreting incidentalomas.

Magnitude of the early morning blood pressure surge in untreated hypertensive patients: a pooled analysis

OBJECTIVES

A post hoc analysis was performed to assess the magnitude of the early morning blood pressure surge (EMBPS), which is associated with peak cardiovascular risk, in untreated hypertensive patients enrolled in two sister studies (Prospective, Randomised Investigation of the Safety and efficacy of MICARDIS vs. ramipril using ambulatory blood pressure monitoring I and II) with identical design.

METHODS

In adults with a mild-to-moderate primary hypertension and no significant comorbidities, 24-h ambulatory blood pressure monitoring was conducted after a 2- to 4-week placebo run-in period and before treatment initiation. Individual blood pressure measurements at 20-min intervals were analysed.

RESULTS

In 1419 hypertensive patients with normal sleeping times, blood pressure displayed a typical circadian rhythm, with a mean EMBPS of 29/24 mmHg. An EMBPS of >or= 25 mmHg was observed in around 60% of patients. The surge was significantly increased with smoking, alcohol consumption, longer sleep, later waking times, and increased blood pressure variability during waking and sleeping. The magnitude of the EMBPS was significantly reduced in Black vs. White patients. The surge was not affected by gender, body mass index or duration of hypertension. Further analysis showed that ethnicity, alcohol consumption and smoking were all found to have a significant impact on surge around waking and age, sleep duration and sleep blood pressure variability were all found to have an effect on the prewake surge.

CONCLUSIONS

In untreated hypertensive patients, the magnitude of the EMBPS is significant when compared with the 24-h mean and is affected by individual patient characteristics. In light of these findings, physicians should understand the importance of 24-h blood pressure control and the modification of certain lifestyle factors as ways of reducing the EMBPS.