Cardiovascular Risk Reduction After Renal Denervation According to Time in Therapeutic Systolic Blood Pressure Range

Cost-effectiveness analysis of radiofrequency renal denervation for uncontrolled hypertension in Canada

AIMS

Catheter-based radiofrequency renal denervation (RF RDN) is an interventional treatment for uncontrolled hypertension. This analysis explored the therapy's lifetime cost-effectiveness in a Canadian healthcare setting.

MATERIALS AND METHODS

A decision-analytic Markov model was used to project health events, costs, and quality-adjusted life years over a lifetime horizon. Seven primary health states were modeled, including hypertension alone, stroke, myocardial infarction (MI), other symptomatic coronary artery disease, heart failure (HF), end-stage renal disease (ESRD), and death. Multivariate risk equations and a meta-regression of hypertension trials informed transition probabilities. Contemporary clinical evidence from the SPYRAL HTN-ON MED trial informed the base case treatment effect (-4.9 mmHg change in office systolic blood pressure (oSBP) observed vs. sham control). Costs were sourced from published literature. A 1.5% discount rate was applied to costs and effects, and the resulting incremental cost-effectiveness ratio (ICER) was evaluated against a willingness-to-pay threshold of $50,000 per QALY gained. Extensive scenario and sensitivity analyses were performed.

RESULTS

Over 10 years, RF RDN resulted in relative risk reduction in clinical events (0.80 for stroke, 0.88 for MI, and 0.72 for HF). Under the base case assumptions, RF RDN was found to add 0.51 (15.81 vs. 15.30) QALYs at an incremental cost of $6,031 ($73,971 vs. $67,040) over a lifetime, resulting in an ICER of $11,809 per QALY gained. Cost-effectiveness findings were found robust in sensitivity analyses, with the 95% confidence interval for the ICER based on 10,000 simulations ranging from $4,489 to $22,587 per QALY gained.

LIMITATIONS AND CONCLUSION

Model projections suggest RF RDN, under assumed maintained treatment effect, is a cost-effective treatment strategy for uncontrolled hypertension in the Canadian healthcare system based on meaningful reductions in clinical events.

Renal-Cardiac Crosstalk in the Pathogenesis and Progression of Heart Failure

Chronic kidney disease (CKD) represents a global health issue with a high socioeconomic impact. Beyond a progressive decline of kidney function, patients with CKD are at increased risk of cardiovascular diseases, including heart failure (HF) and sudden cardiac death. HF in CKD can manifest both as HF with reduced ejection fraction and HF with preserved ejection fraction, with the latter further increasing in relative importance in the more advanced stages of CKD. Typical cardiac remodeling characteristics in uremic cardiomyopathy include left ventricular hypertrophy, myocardial fibrosis, cardiac electrical dysregulation, capillary rarefaction, and microvascular dysfunction, which are triggered by increased cardiac preload, cardiac afterload, and preload and afterload-independent factors. The pathophysiological mechanisms underlying cardiac remodeling in CKD are multifactorial and include neurohormonal activation (with increased activation of the renin-angiotensin-aldosterone system, the sympathetic nervous system, and mineralocorticoid receptor signaling), cardiac steroid activation, mitochondrial dysfunction, inflammation, innate immune activation, and oxidative stress. Furthermore, disturbances in cardiac metabolism and calcium homeostasis, macrovascular and microvascular dysfunction, increased cellular profibrotic responses, the accumulation of uremic retention solutes, and mineral and bone disorders also contribute to cardiovascular disease and HF in CKD. Here, we review the current knowledge of HF in CKD, including the clinical characteristics and pathophysiological mechanisms revealed in animal studies. We also elaborate on the detrimental impact of comorbidities of CKD on HF using hypertension as an example and discuss the clinical characteristics of hypertensive heart disease and the genetic predisposition. Overall, this review aims to increase the understanding of HF in CKD to support future research and clinical translational approaches for improved diagnosis and therapy of this vulnerable patient population.

Ambulatory blood pressure monitoring, European guideline targets, and cardiovascular outcomes: an individual patient data meta-analysis

BACKGROUND AND AIMS

Hypertension is the predominant modifiable cardiovascular risk factor. This cohort study assessed the association of risk with the percentage of time that the ambulatory blood pressure (ABP) is within the target range (PTTR) proposed by the 2024 European Society of Cardiology (ESC) guidelines for blood pressure (BP) management.

METHODS

In a person-level meta-analysis of 14 230 individuals enrolled in 14 population cohorts, systolic and diastolic ABPs were combined to assess 24-h, daytime, and nighttime PTTR with thresholds for non-elevated ABP set at <115/65, <120/70, and <110/60 mmHg, respectively.

RESULTS

Median 24-h PTTR was 18% (interquartile range 5-33) corresponding to 4.3 h (1.2-7.9). Over 10.9 years (median), deaths (N = 3117) and cardiovascular endpoints (N = 2265) decreased across increasing 24-h PTTR quartiles from 21.3 to 16.1 and from 20.3 to 11.3 events per 1000 person-years. The standardized multivariable-adjusted hazard ratios for 24-h PTTR were 0.57 (95% confidence interval 0.46-0.71) for mortality and 0.30 (0.23-0.39) for cardiovascular endpoints. Analyses of daytime and nighttime ABP, cardiovascular mortality, coronary endpoints and stroke, and subgroups produced confirmatory results. The 2024 ESC non-elevated 24-h PTTR, compared with the 2018 ESC/European Society of Hypertension non-hypertensive 24-h PTTR, shortened the interval required to reduce relative risk for adverse outcomes from 60% to 18% (14.4-4.3 h). Office BP, compared with 24-h PTTR, misclassified most participants with regard to BP control.

CONCLUSIONS

Longer time that ABP is within the 2024 ESC target range is associated with reduced adverse outcomes; PTTR derived from ABP refines risk prediction and compared with office BP avoids misclassification of individuals with regard to BP control.

Time in Target Range for Blood Pressure and Adverse Health Outcomes: A Systematic Review

BACKGROUND

Blood pressure (BP) time in target range (TTR) reflects the proportion of time that BP measurement is within a specified target range. We aim to summarize the evidence for relationships between TTR and adverse health outcomes.

METHODS

Seven databases were searched. After quality assessment and data extraction, meta-analyses were performed to generate pooled estimates of the association (hazard ratios) between TTR and health outcomes. Primary outcomes were all-cause mortality and cardiovascular death. Secondary outcomes included major adverse cardiovascular events, myocardial infarction, stroke, heart failure, atrial fibrillation, and adverse kidney events.

RESULTS

In all, 21 studies were included, mostly rated at low risk of bias. TTR was defined by systolic BP (SBP) in 15 studies and by both SBP and diastolic BP in 6 studies. Per SD increase of TTR was associated with significantly decreased risks of all-cause mortality (110-130 mm Hg SBP TTR: hazard ratios, 0.85 [95% CI, 0.82-0.89]; 120-140 mm Hg SBP TTR: 0.81 [95% CI, 0.70-0.94]; and 70-80 mm Hg diastolic BP TTR: 0.88 [95% CI, 0.83-0.93]), cardiovascular death (110-130 mm Hg SBP TTR: 0.83 [95% CI, 0.78-0.87]; 120-140 mm Hg SBP TTR: 0.76 [95% CI, 0.65-0.89]; and 70-80 mm Hg diastolic BP TTR: 0.85 [95% CI, 0.80-0.90]), major adverse cardiovascular events (120-140 mm Hg SBP TTR: 0.76 [95% CI, 0.70-0.83]), and heart failure (110-130 mm Hg SBP TTR: 0.84 [95% CI, 0.76-0.93] and 120-140 mm Hg SBP TTR: 0.78 [95% CI, 0.68-0.89]). However, there was not sufficient support for the association of TTR with myocardial infarction, stroke, atrial fibrillation, or adverse kidney events.

CONCLUSIONS

Higher TTR was associated with reduced risks of all-cause mortality, cardiovascular death, major adverse cardiovascular events, and heart failure, highlighting the importance of sustained BP control in clinical practice.

REGISTRATION

URL: https://www.crd.york.ac.uk/PROSPERO/; Unique identifier: CRD42023486437.

In these cases, I treat hypertension with renal ablation

Systemic arterial hypertension is one of the leading causes of mortality and morbidity worldwide. Despite therapeutic advancements, a significant proportion of hypertensive patients fail to achieve adequate blood pressure control. Renal denervation (RDN) is emerging as an innovative and minimally invasive procedure to treat hypertension by modulating the renal sympathetic nervous system. Recent clinical trials, including SYMPLICITY HTN-3, SPYRAL HTN-OFF MED, and RADIANCE-HTN SOLO, have shown variable results, influenced by patient selection and study design. The latest 2024 ESC guidelines on systemic arterial hypertension recommend RDN as a therapeutic option in selected cases, especially in patients with resistant hypertension not adequately controlled by pharmacological therapy. However, the response to this approach varies according to individual pathophysiology and the level of sympathetic activation. This article highlights how RDN, performed using ultrasound or radiofrequency technologies, may represent a breakthrough for difficult-to-treat patients, bridging current therapeutic gaps and reducing long-term cardiovascular risk. Finally, it emphasizes the importance of a multi-disciplinary assessment to maximize the benefits of the procedure.

World Stroke Organization and World Hypertension League position statement on hypertension control strategies in prevention and management of stroke

BACKGROUND AND PURPOSE

The goal of this consensus is to provide a comprehensive set of recommendations in regard to hypertension control strategies for the prevention and management of stroke. This document is intended for prehospital care providers, physicians, allied health professionals, and hospital administrators and healthcare policymakers.

METHODS

Members of the writing group were representatives of the World Stroke Organization and World Hypertension League. The writing group reviewed articles searched from PubMed and Google Scholar using selected search strings. The document was sent to 12 peer reviewers. The writing group considered the feedback from peer reviewers and made revisions accordingly. Every member of the writing group gave their approval of the final document.

RESULTS

This article details the various techniques for blood pressure (BP) measurement, BP classification, BP and stroke risk, antihypertensive drug therapy for the primary and secondary prevention of stroke, choice of antihypertensive drug therapy, optimal BP targets, non-drug approaches to the prevention of stroke through BP lowering, BP management separately for acute ischemic stroke and spontaneous intracerebral hemorrhage, and the implementation of BP prevention, treatment, and control in the community.

CONCLUSION

This article provides general recommendations based on currently available evidence to guide healthcare practitioners caring for adults with hypertension for the prevention and management of stroke. Future studies are needed to better define approaches to hypertension control in the community and high-risk groups.

Home blood pressure stability score is associated with better cardiovascular prognosis: data from the nationwide prospective J-HOP study

A home blood pressure (BP)-centered strategy is emerging as the optimal approach to achieve adequate BP control in individuals with hypertension, but a simple cardiovascular risk score based on home BP level and variability is lacking. This study used prospective data from the Japan Morning Surge-Home Blood Pressure (J-HOP) extended study to develop a simple home BP stability score for the prediction of cardiovascular risk. The J-HOP extended study included 4070 participants (mean age 64.9 years) who measured home BP three times in the morning and evening for 14 days at baseline. During the mean 6.3-year follow-up, there were 260 cardiovascular events. A home BP stability score was calculated based on the average of morning and evening systolic BP (SBP; MEave), and three home BP variability metrics: average real variability (average absolute difference between successive measurements); average peak (average of the highest three SBP values for each individual), and time in therapeutic range (proportion of time spent with MEave home SBP 100-135 mmHg). There was a curvilinear association between the home BP stability score and the risk of cardiovascular events. Compared with individuals in the optimal home SBP stability score group (9-10 points), those in the very high-risk group (0 points) had significantly higher cardiovascular event risk during follow-up (adjusted hazard ratio 3.97, 95% confidence interval 2.22-7.09; p < 0.001), independent of age, sex, medication, cardiovascular risk factors, and office BP. These data show the potential for a simple home BP-based score to predict cardiovascular event risk in people with hypertension.

Impact of expected blood pressure reduction on patient preferences for pharmaceutical and renal denervation treatment

BACKGROUND

Effective patient-centered care requires an adequate understanding of patient preferences for different therapeutic options. We modelled patient preference for blood pressure (BP) management by pharmaceutical or interventional treatments such as renal denervation in patients with different profiles of uncontrolled hypertension.

METHODS

Modeling was based on the findings from a previously conducted quantitative discrete choice experiment (DCE). The likelihood of selecting either an interventional treatment option or additional antihypertensive medication option was calculated for three patient profiles that represent the range of patients with hypertension commonly encountered in clinical practice: treatment-naive, patients with uncontrolled BP while on one to three antihypertensive medications, and patients with drug-resistant hypertension. Variables in the preference model were treatment attributes from the DCE study: expected reduction in office SBP with each treatment, duration of treatment effect, risk of reversible drug side effects from drugs, and risk of temporary pain and/or bruising or vascular injury from interventions. Values of the variables were derived from published clinical studies or expert opinion.

RESULTS

The model predicted that the likelihood of choosing an intervention over initiating pharmacotherapy was 17.2% for previously untreated patients, 23.7% for patients with moderate hypertension currently on pharmacotherapy, and 41.8% for patients with drug-resistant hypertension. The dominant variable driving preference in these models was the expected BP reduction. Patient preferences for intervention are greater when drug nonadherence or increased SBP reduction at 3 vs. 1 year are included in the model. Baseline BP, drug side effects, or risks of the procedure had little influence on decisions.

CONCLUSION

Modeling using patient preference weights predicts that a substantial minority of patients favor an interventional treatment such as renal denervation over initiation or escalation of medications. Awareness of a patient's interest in device-based versus pharmaceutical strategies should inform the shared decision-making process for hypertension treatment.

Renal denervation for hypertension

Innovative therapies for hypertension are desperately needed given the rising prevalence and falling rates of control of hypertension despite an abundance of available medical therapies. Procedural interventions lower blood pressure without depending on adherence to medications, and endovascular renal denervation (RDN) is the interventional procedure with the best evidence base for the treatment of hypertension. After nearly two decades of study, with major refinements to devices, technique and trial design, two different systems for RDN received approval from the FDA in late 2023 for the treatment of hypertension. These decisions were based on a portfolio of sham-controlled clinical trials demonstrating efficacy and safety of both radiofrequency and ultrasound RDN in treating patients across the spectrum of hypertension, including patients with mild disease taking no or one medication as well as those with moderate and truly resistant hypertension. In this Review, we begin by summarizing the background and scope of the global problem of hypertension control and explore the evolution and mechanism of RDN. We then detail early studies and randomized clinical trials demonstrating the efficacy and safety of RDN procedures, review international statements, and provide practical guidance on patient selection and implementation of RDN, including the crucial aspects of building a hypertension team and of involving patients in shared decision-making.

Novel approaches to define responders to interventional treatment in hypertension: insights from the SPYRAL HTN-OFF and HTN-ON MED trials

Multiple sham-controlled clinical trials have demonstrated significant reductions in both office and 24-h blood pressure (BP) following radiofrequency renal denervation (RDN) in the uncontrolled hypertension population. Notably, the blood pressure response varies widely within individual participants, thus showing a clinical need to identify potential RDN "responders" prior to the procedure. Despite multiple analytic efforts, no single parameter, aside from baseline blood pressure, has been consistently associated with BP reduction following RDN. However, this failure may be due to limitations in empiric definitions of responders. Indeed, commonly applied responder definitions based on the difference between two point-in-time BP measurements are fraught due to visit-to-visit variability in office and 24-h blood pressure endpoints. Several factors should be considered to develop a more clinically useful operational definition of procedural response including relative changes in office and 24-h BP, consideration of the temporal response to RDN, as well as adjustment for baseline BP. The current evidence may provide incentives for future expert consensus to precisely define responders to hypertension treatments.

Cost-effectiveness of catheter-based radiofrequency renal denervation for the treatment of uncontrolled hypertension: an analysis for the UK based on recent clinical evidence

AIMS

Catheter-based radiofrequency renal denervation (RF RDN) has recently been approved for clinical use in the European Society of Hypertension guidelines and by the US Food and Drug Administration. This study evaluated the lifetime cost-effectiveness of RF RDN using contemporary evidence.

METHODS AND RESULTS

A decision-analytic model based on multivariate risk equations projected clinical events, quality-adjusted life years (QALYs), and costs. The model consisted of seven health states: hypertension alone, myocardial infarction (MI), other symptomatic coronary artery disease, stroke, heart failure (HF), end-stage renal disease, and death. Risk reduction associated with changes in office systolic blood pressure (oSBP) was estimated based on a published meta-regression of hypertension trials. The base case effect size of -4.9 mmHg oSBP (observed vs. sham control) was taken from the SPYRAL HTN-ON MED trial of 337 patients. Costs were based on National Health Service England data. The incremental cost-effectiveness ratio (ICER) was evaluated against the UK National Institute for Health and Care Excellence (NICE) cost-effectiveness threshold of £20 000-30 000 per QALY gained. Extensive scenario and sensitivity analyses were conducted, including the ON-MED subgroup on three medications and pooled effect sizes. RF RDN resulted in a relative risk reduction in clinical events over 10 years (0.80 for stroke, 0.88 for MI, 0.72 for HF), with an increase in health benefit over a patient's lifetime, adding 0.35 QALYs at a cost of £4763, giving an ICER of £13 482 per QALY gained. Findings were robust across tested scenarios.

CONCLUSION

Catheter-based radiofrequency RDN can be a cost-effective strategy for uncontrolled hypertension in the UK, with an ICER substantially below the NICE cost-effectiveness threshold.

Cost-Effectiveness of Radiofrequency Renal Denervation for Uncontrolled Hypertension in Japan

Radiofrequency renal denervation (RF RDN) is a novel therapy for uncontrolled hypertension. In the recent sham-controlled SPYRAL HTN-ON MED study, office-based systolic blood pressure (oSBP) and nighttime BP were reduced significantly. This study examined the cost-effectiveness of RF RDN in the context of the Japanese healthcare system based on this latest clinical evidence. Clinical events, costs, and quality-adjusted life-years (QALYs) were projected using a decision-analytic Markov model adjusted to Japanese incidence data. Risk reduction in clinical events from changes in oSBP was calculated based on a published meta-regression of 47 trials of intentional hypertension treatment. Demographics and results from the SPYRAL HTN-ON MED trial (oSBP effect size -4.9 mmHg vs. sham) were utilized in the base case analysis. Additional scenarios were explored including the potential added benefit of improved night-time control. Costs were sourced from claims data and published literature. The incremental cost-effectiveness ratio (ICER) was evaluated against a cost-effectiveness threshold of ¥5 000 000 per QALY gained. RF RDN was projected to reduce clinical events (10-year relative risks: 0.80 for stroke, 0.88 for myocardial infarction, and 0.75 for heart failure). Over lifetime, RF RDN added 0.36 QALYs at the incremental cost of ¥923 723, resulting in an ICER of ¥2 565 236 per QALY gained. Under the assumption of added night-time benefit, the ICER decreased to ¥2 155 895 per QALY. Cost-effectiveness findings were robust across all tested scenarios. The findings of this model-based analysis suggest that RF RDN can provide meaningful clinical event reductions and is a cost-effective treatment option in the Japanese healthcare system.

Association Between Systolic Blood Pressure Time in Target Range Indices and Adverse Cardiovascular Outcomes

Background

There is no consensus on optimal time points or systolic blood pressure (SBP) ranges for calculating SBP time in target range (TTR).

Objectives

The purpose of this study was to examine the association between various SBP TTR metrics and long-term major adverse cardiovascular events (MACEs).

Methods

This post hoc analysis of SPRINT (Systolic Blood Pressure Intervention Trial) included participants with complete SBP records and excluded those with events in the initial 2 years. SBP TTR indices were calculated using 3 distinct time points and 3 SBP ranges. The SBP TTR index was the percentage of BP segments within the target SBP ranges. MACE, a composite of heart attack, stroke, heart failure, and cardiovascular death, was the primary outcome.

Results

The study included 7,134 participants, of which 280 had a MACE. The median follow-up was 3.91 years. The SBP TTR 110-140 mm Hg in the initial 3 months (3-month TTR 110-140) had the optimal association with incident MACEs (HR per SD increase: 0.898 [95% CI: 0.788-1.022], relative informativeness = 24,398%). Furthermore, a cutoff value of 0.65 for 3-month TTR 110 to 140 index was identified by threshold saturation analysis and used to evaluate early SBP control. No difference in MACE was seen between different mean SBP subgroups in those with good early control (3-month TTR >0.65) (P = 0.88), but in those with poor early control (3-month TTR ≤0.65), a higher mean SBP of 130 to 140 mm Hg was related to increased MACEs risk (P = 0.019).

Conclusions

In nondiabetic hypertensive patients, the 3-month TTR 110 to 140 mm Hg index was independently associated with 2-year MACEs. A cutoff of TTR index as 0.65 indicated that the patient was within BP target range 65% of the time, combined with mean SBP, could potentially be used as a metric for early control stability and late cardiovascular risks. (Systolic Blood Pressure Intervention Trial [SPRINT]; NCT01206062).

Consensus statement on renal denervation by the Joint Committee of Japanese Society of Hypertension (JSH), Japanese Association of Cardiovascular Intervention and Therapeutics (CVIT), and the Japanese Circulation Society (JCS)

This is the first consensus statement of the Joint Committee on Renal Denervation of the Japanese Society of Hypertension (JSH)/Japanese Association of Cardiovascular Intervention and Therapeutics (CVIT)/Japanese Circulation Society (JCS). The consensus is that the indication for renal denervation (RDN) is resistant hypertension or "conditioned" uncontrolled hypertension, with high office and out-of-office blood pressure (BP) readings despite appropriate lifestyle modification and antihypertensive drug therapy. "Conditioned" uncontrolled hypertension is defined as having one of the following: 1) inability to up-titrate antihypertensive medication due to side effects, the presence of complications, or reduced quality of life. This includes patients who are intolerant of antihypertensive drugs; or 2) comorbidity at high cardiovascular risk due to increased sympathetic nerve activity, such as orthostatic hypertension, morning hypertension, nocturnal hypertension, or sleep apnea (unable to use continuous positive airway pressure), atrial fibrillation, ventricular arrythmia, or heart failure. RDN should be performed by the multidisciplinary Hypertension Renal Denervation Treatment (HRT) team, led by specialists in hypertension, cardiovascular intervention and cardiology, in specialized centers validated by JSH, CVIT, and JCS. The HRT team reviews lifestyle modifications and medication, and the patient profile, then determines the presence of an indication of RDN based on shared decision making with each patient. Once approval for real-world clinical use in Japan, however, the joint RDN committee will update the indication and treatment implementation guidance as appropriate (annually if necessary) based on future real-world evidence.

[Cost-effectiveness analysis of radiofrequency renal denervation for uncontrolled hypertension in Spain]

Introduction and objectives

Radiofrequency (RF) renal denervation (RDN) has been shown to be a safe and effective treatment option for patients with uncontrolled hypertension. This analysis sought to explore the cost-effectiveness of this therapy in Spain.

Methods

A decision-analytic Markov model projected clinical events, quality-adjusted life years (QALY) and costs over the patients' lifetime. Treatment effectiveness in the base case analysis was informed by the change in office systolic blood pressure observed in the full cohort of the SPYRAL HTN-ON MED trial (-4.9 mmHg vs sham control). Alternate scenarios were calculated for effect sizes reported in the HTN-ON MED subcohort of patients on 3 antihypertensive medications treated outside the United States, the HTN-OFF MED trial, and the Global SYMPLICITY Registry high-risk and very high-risk cohorts. The analysis was conducted from the Spanish National Health System perspective and a willingness-to-pay a threshold of 25000 per QALY gained was considered.

Results

RF RDN therapy resulted in clinical event reductions (10-year relative risk 0.80 for stroke, 0.88 for myocardial infarction, and 0.72 for heart failure) and a lifetime gain of 0.35 (13.99 vs 13.63) QALYs. Incremental lifetime costs were 5335 (26 381 vs 21 045), resulting in an incremental cost-effectiveness ratio of 15 057 per QALY gained. Cost-effectiveness was further improved among all the other clinical evidence scenarios.

Conclusions

The results of this study suggest that RF RDN can provide a cost-effective alternative in the treatment of uncontrolled hypertension in Spain.

Consensus statement on renal denervation by the Joint Committee of Japanese Society of Hypertension (JSH), Japanese Association of Cardiovascular Intervention and Therapeutics (CVIT), and the Japanese Circulation Society (JCS)

This is the first consensus statement of the Joint Committee on Renal Denervation of the Japanese Society of Hypertension (JSH)/Japanese Association of Cardiovascular Intervention and Therapeutics (CVIT)/Japanese Circulation Society (JCS). The consensus is that the indication for renal denervation (RDN) is resistant hypertension or "conditioned" uncontrolled hypertension, with high office and out-of-office blood pressure (BP) readings despite appropriate lifestyle modification and antihypertensive drug therapy. "Conditioned" uncontrolled hypertension is defined as having one of the following: (1) inability to up-titrate antihypertensive medication due to side effects, the presence of complications, or reduced quality of life. This includes patients who are intolerant of antihypertensive drugs; or (2) comorbidity at high cardiovascular risk due to increased sympathetic nerve activity, such as orthostatic hypertension, morning hypertension, nocturnal hypertension, or sleep apnea (unable to use continuous positive airway pressure), atrial fibrillation, ventricular arrythmia, or heart failure. RDN should be performed by the multidisciplinary Hypertension Renal Denervation Treatment (HRT) team, led by specialists in hypertension, cardiovascular intervention and cardiology, in specialized centers validated by JSH, CVIT, and JCS. The HRT team reviews lifestyle modifications and medication, and the patient profile, then determines the presence of an indication of RDN based on shared decision making with each patient. Once approval for real-world clinical use in Japan, however, the joint RDN committee will update the indication and treatment implementation guidance as appropriate (annually if necessary) based on future real-world evidence.

Does renal denervation require cardiovascular outcome-driven data?

Hypertension is a major driver of cardiovascular disease with a prevalence of 32-34% in adults worldwide. This poses a formidable unmet challenge for healthcare systems, highlighting the need for enhanced treatment strategies. Since 2017, eight major sham-controlled randomised controlled trials have examined the effectiveness and safety of renal denervation (RDN) as therapy for BP control. Although most trials demonstrated a reduction in systolic 24-hour/daytime ambulatory BP compared to control groups, open to discussion is whether major adverse cardiovascular events (MACE)-driven RDN trials are necessary or whether the proof of BP reduction as a surrogate for better cardiovascular outcomes is sufficient. We conducted an analysis of the statistical methods used in various trials to assess endpoint definitions and determine the necessity for MACE-driven outcome data. Such comprehensive analysis provides further evidence to confidently conclude that RDN significantly reduces blood pressure compared to sham controls. Importantly, this enables the interpolation of RDN trial endpoints with other studies that report on outcome data, such as pharmacological trials which demonstrate a significant reduction in MACE risk with a decrease in BP. Moreover, limitations associated with directly evaluating outcome data further support the use of BP as a surrogate endpoint. For example, conducting lengthier trials with larger numbers of participants to ensure robust statistical power presents a substantial challenge to evaluating outcome data. Thus, in light of the crucial need to tackle hypertension, there are notable advantages of considering BP as a surrogate for outcome data.

Time in therapeutic range and risk of preeclampsia in chronic hypertensive pregnant women

Pregnancy Hypertensive Disorders (PHD), particularly Preeclampsia (PE), are significant contributors to maternal-fetal morbidity and mortality, with chronic arterial hypertension (CH) being a major risk factor. The prevalence of CH has risen alongside obesity and advanced maternal age. While antihypertensive treatment mitigates adverse pregnancy outcomes, the duration of effective blood pressure (BP) control, termed Time in Therapeutic Range (TTR), has not been extensively studied in pregnant women. TTR, reflecting the proportion of time BP remains within target ranges, predicts long-term cardiovascular and renal events in the general population but remains unexplored in pregnancy. This study investigates the association between TTR, assessed through office BP (OBP) and ambulatory BP monitoring (ABPM), and PE development in pregnant women with CH. In a retrospective longitudinal study, data from 166 pregnant women with HA referred to our hospital analyzed. BP was measured using OBP and ABPM from 10 weeks of gestation, with TTR calculated as the percentage of visits where BP remained within target ranges. The study defined four TTR control groups: 0%, 33%, 50-66%, and 100%. Results showed that 28% of the participants developed PE, with a higher incidence correlating with lower TTR in ABPM. TTR in ABPM was a significant predictor of PE risk, with the best-controlled group (100% TTR) demonstrating a 92% reduced risk compared to those with 0% TTR. The agreement between OBP and ABPM TTR was low, emphasizing the importance of ABPM for accurate BP monitoring in pregnancy. This study indicates that integrating ABPM for TTR assessment in high-risk pregnancies has the potential to reduce maternal and fetal complications.

What are the ideal metrics for assessing the quality of long-term stabilized "perfect" 24-h BP control after renal denervation?

A significant number of individuals being treated for hypertension still have uncontrolled blood pressure (BP). In Japan, renal denervation (RDN) is being introduced into clinical practice as an adjunctive treatment for hypertension that is uncontrolled despite adequate lifestyle changes and maximal antihypertensive drug therapy. The pivotal SPYRAL ON-MED trial showed that there was a significant reduction in trough office and nighttime ambulatory BP values in the RDN group compared with sham control group, although 24-h and daytime BP values were not significantly different between the two groups. The trough office BP measurement (taken before morning antihypertensive dosing) is similar to guideline recommendations for taking morning home BP before taking the morning antihypertensive drug dose. Recent guidelines recommend the measurement of nighttime BP because nighttime BP is a stronger predictor of cardiovascular event risk than daytime BP. It is particularly important to assess nighttime BP in medicated individuals with hypertension because the up- or down-titration of antihypertensive drug dosing is primarily based on office and daytime BPs in clinical practice. This means that there may be significant risk relating to nocturnal hypertension during longer follow-up. Because RDN results in persistent, "always-on" 24-h BP-lowering effects, the best BP metrics to assess the potential benefit of RDN are nighttime BP (determined using home or ambulatory BP monitoring) and morning BP (determined using home BP monitoring or morning trough office BP measurement). The variability of office, home, and ambulatory BP values is another important metric to assess the quality of RDN-related BP lowering.

Blood Pressure Time in Target Range and its Impact on Clinical Outcomes

PURPOSE OF REVIEW

To examine the concept of time in target range for blood pressure (BP) management, exploring its calculation methods, implications for patient outcomes, and potential use in patient care.

RECENT FINDINGS

Recent post-hoc analyses of clinical trials and observational studies highlight the importance of BP time in target range in predicting cardiovascular outcomes. Higher time in target range correlates with reduced risks of major adverse cardiovascular events including heart failure, stroke, myocardial infarction and all-cause mortality. Additionally, longer time in target range decreases the risk of incident atrial fibrillation and risk of developing dementia. BP time in target range is a novel metric offering valuable insights into BP control and its impact on clinical outcomes. Higher time in target range is consistently associated with better cardiovascular outcomes across various patient populations. However, the clinical application of BP time in target range requires further investigation through prospective clinical trials and real-world studies. Integrating wearable devices for continuous BP monitoring could enhance the practical utility of BP time in target range in hypertension management.

Renal Denervation for the Treatment of Hypertension: A Scientific Statement From the American Heart Association

Hypertension is a leading risk factor for cardiovascular morbidity and mortality. Despite the widespread availability of both pharmacological and lifestyle therapeutic options, blood pressure control rates across the globe are worsening. In fact, only 23% of individuals with high blood pressure in the United States achieve treatment goals. In 2023, the US Food and Drug Administration approved renal denervation, a catheter-based procedure that ablates the renal sympathetic nerves, as an adjunctive treatment for patients in whom lifestyle modifications and antihypertensive medications do not adequately control blood pressure. This approval followed the publication of multiple randomized clinical studies using rigorous trial designs, all incorporating renal angiogram as the sham control. Most but not all of the new generation of trials reached their primary end point, demonstrating modest efficacy of renal denervation in lowering blood pressure across a spectrum of hypertension, from mild to truly resistant. Individual patient responses vary, and further research is needed to identify those who may benefit most. The initial safety profile appears favorable, and multiple ongoing studies are assessing longer-term efficacy and safety. Multidisciplinary teams that include hypertension specialists and adequately trained proceduralists are crucial to ensure that referrals are made appropriately with full consideration of the potential risks and benefits. Incorporating patient preferences and engaging in shared decision-making conversations will help patients make the best decisions given their individual circumstances. Although further research is clearly needed, renal denervation presents a novel treatment strategy for patients with uncontrolled blood pressure.

Ultra-long-term efficacy and safety of catheter-based renal denervation in resistant hypertension: 10-year follow-up outcomes

BACKGROUND

Randomized sham-controlled trials have confirmed the efficacy and safety of catheter-based renal denervation in hypertension. Data on the very long-term effects of renal denervation are scarce.

AIMS

This study evaluates the 10-year safety and efficacy of renal denervation in resistant hypertension.

METHODS

This prospective single-center study included patients with resistant hypertension undergoing radio-frequency renal denervation between 2010 and 2012. Office blood pressure, 24-h ambulatory blood pressure, antihypertensive medication, color duplex sonography, and renal function were assessed after 1-, 2- and 10-years.

RESULTS

Thirty-nine patients completed the 10-year follow-up (mean follow-up duration 9.4 ± 0.7 years). Baseline office and 24-h ambulatory systolic blood pressure were 164 ± 23 mmHg and 153 ± 16 mmHg, respectively. After 10 years, 24-h ambulatory and office systolic blood pressure were reduced by 16 ± 17 mmHg (P < 0.001) and 14 ± 23 mmHg (P = 0.001), respectively. The number of antihypertensive drugs remained unchanged from 4.9 ± 1.4 to 4.5 ± 1.2 drugs (P = 0.087). The estimated glomerular filtration rate declined within the expected range from 69 (95% CI 63 to 74) to 60 mL/min/1.73m2 (95% CI 53 to 68; P < 0.001) through 10-year follow-up. Three renal artery interventions were documented for progression of pre-existing renal artery stenosis in two patients and one patient with new-onset renal artery stenosis. No other adverse events were observed during the follow-up.

CONCLUSION

Renal denervation was safe and sustainedly reduced ambulatory and office blood pressure out to 10 years in patients with resistant hypertension.

Consensus Statement on Renal Denervation by the Joint Committee of Japanese Society of Hypertension (JSH), Japanese Association of Cardiovascular Intervention and Therapeutics (CVIT), and the Japanese Circulation Society (JCS)

This is the first consensus statement of the Joint Committee on Renal Denervation of the Japanese Society of Hypertension (JSH)/Japanese Association of Cardiovascular Intervention and Therapeutics (CVIT)/Japanese Circulation Society (JCS). The consensus is that the indication for renal denervation (RDN) is resistant hypertension or "conditioned" uncontrolled hypertension, with high office and out-of-office blood pressure (BP) readings despite appropriate lifestyle modification and antihypertensive drug therapy. "Conditioned" uncontrolled hypertension is defined as having one of the following: 1) inability to up-titrate antihypertensive medication due to side effects, the presence of complications, or reduced quality of life. This includes patients who are intolerant of antihypertensive drugs; or 2) comorbidity at high cardiovascular risk due to increased sympathetic nerve activity, such as orthostatic hypertension, morning hypertension, nocturnal hypertension, or sleep apnea (unable to use continuous positive airway pressure), atrial fibrillation, ventricular arrythmia, or heart failure. RDN should be performed by the multidisciplinary Hypertension Renal Denervation Treatment (HRT) team, led by specialists in hypertension, cardiovascular intervention and cardiology, in specialized centers validated by JSH, CVIT, and JCS. The HRT team reviews lifestyle modifications and medication, and the patient profile, then determines the presence of an indication of RDN based on shared decision making with each patient. Once approval for real-world clinical use in Japan, however, the joint RDN committee will update the indication and treatment implementation guidance as appropriate (annually if necessary) based on future real-world evidence.

Blood pressure time at target and its prognostic value for cardiovascular outcomes: a scoping review

The proportion of time that blood pressure (BP) readings are at treatment target levels, commonly referred to as time at target or time in therapeutic range (BP-TTR), is emerging as a useful measure for evaluating hypertension management effectiveness and assessing longitudinal BP control. However, method of determination for BP-TTR differs across studies. This review identifies variations in BP-TTR determination methodologies and its potential prognostic value for cardiovascular outcomes. Following PRISMA extension for scoping reviews guidelines, literature was systematically searched in Embase, PubMed, Scopus, Web of Science, and CINAHL. Relevant clinical trials, observational studies, cohort studies, cross-sectional studies, and systematic reviews published in English were screened. Of 369 articles identified, 17 articles were included. Studies differed in the BP targets used (e.g., BP < 140/90 mmHg or 130/80 mmHg; systolic BP within 110-130 mmHg or 120-140 mmHg), BP-TTR measurement duration (range 24 h to 15 years), and calculation method (linear interpolation method, n = 12 [71%]; proportion of BP readings at target, n = 5 [29%]). Regardless of method, studies consistently demonstrated that higher BP-TTR was associated with reduced risk of cardiovascular outcomes. Six of eight studies found the association was independent of mean achieved BP or last measured BP. Despite variation in methods of BP-TTR determination, these studies demonstrated the potential prognostic value of BP-TTR for cardiovascular outcomes beyond current BP control measures. We recommend standardization of BP-TTR methodology, with preference for linear interpolation method when BP measurements are few or less frequent, and proportion of BP readings method when large number of BP readings are available.

Selected highlights in the updated treatment of hypertension

Hypertension remains the leading international risk factor for cardiovascular disease and premature death but, despite effective treatments, hypertension remains significantly underdiagnosed and undertreated. In the present review paper, we provide a selected update on recent developments of interest in the management of hypertension. We focus on summarizing four topics that we believe are worth highlighting to a clinical audience: (1) the evidence and strong motivation for new lower systolic BP treatment targets; (2) new studies reporting on the efficacy of renal denervation in the management of hypertension; (3) interesting new data to inform the great salt debate; and (4), perhaps most importantly, pioneering new work highlighting the huge potential of multi-disciplinary care in the management of hypertension.

Italian Society of Interventional Cardiology (GISE) and Italian Society of Arterial Hypertension (SIIA) Position Paper on the role of renal denervation in the management of the difficult-to-treat hypertension

Renal denervation (RDN) is a safe and effective strategy for the treatment of difficult to treat hypertension. The blood pressure (BP)-lowering efficacy of RDN is comparable to those of many single antihypertensive medications and it allows to consider the RDN as a valuable option for the treatment of difficult to treat hypertension together with lifestyle modifications and medical therapy. A multidisciplinary team is of pivotal importance from the selection of the patient candidate for the procedure to the post-procedural management. Further studies are needed to investigate the effect of RDN on clinical outcomes and to better identify the predictors of BP response to RDN in order to recognize the patients who are more likely to benefit from the procedure.

The Efficacy of Renal Denervation in Treating Resistant Hypertension: A Systematic Review

Resistant hypertension is blood pressure (BP) that is persistently above target in spite of the maximally tolerated usage of at least three anti-hypertensives simultaneously. The sympathetic nervous system is instrumental in blood pressure (BP) regulation. Renal (sympathetic) denervation involves using ablative energy to disrupt the sympathetic nerves in renal arteries. This systematic review examines the efficacy of this treatment modality. Abiding by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines, we conducted an extensive literature search in five databases, Cochrane Library, Google Scholar, PubMed, PubMed Central (PMC), and ScienceDirect, to retrieve studies that are free, open access, and published in English done within the past four years. Nineteen articles passed critical appraisal. These articles were randomized controlled trials (RCT), a case report, a cross-sectional study, a cohort study, and previous reviews. Renal denervation (RDN) was generally superior to sham control in patients with resistant hypertension for reducing various systolic blood pressure (SBP) measures, including 24-hour ambulatory, daytime, and nighttime SBP. The efficacy was highest in patients whose baseline SBP was higher. BP reduction was sustained for years post-procedure. The procedure had a good safety profile with no severe complications. Future studies should compare the efficacy of different types of renal denervation, such as ethanol ablation versus radiofrequency ablation, and renal denervation against other procedure-based treatment modalities, such as carotid baroreceptor stimulation and transcranial direct current stimulation.

Long-Term Blood Pressure Reductions Following Catheter-Based Renal Denervation: A Systematic Review and Meta-Analysis

BACKGROUND

Renal denervation is a recognized adjunct therapy for hypertension with clinically significant blood pressure (BP)-lowering effects. Long-term follow-up data are critical to ascertain durability of the effect and safety. Aside from the 36-month follow-up data available from randomized control trials, recent cohort analyses extended follow-up out to 10 years. We sought to analyze study-level data and quantify the ambulatory BP reduction of renal denervation across contemporary randomized sham-controlled trials and available long-term follow-up data up to 10 years from observational studies.

METHODS

A systematic review was performed with data from 4 observational studies with follow-up out to 10 years and 2 randomized controlled trials meeting search and inclusion criteria with follow-up data out to 36 months. Study-level data were extracted and compared statistically.

RESULTS

In 2 contemporary randomized controlled trials with 36-month follow-up, an average sham-adjusted ambulatory systolic BP reduction of -12.7±4.5 mm Hg from baseline was observed (P=0.05). Likewise, a -14.8±3.4 mm Hg ambulatory systolic BP reduction was found across observational studies with a mean long-term follow-up of 7.7±2.8 years (range, 3.5-9.4 years; P=0.0051). The observed reduction in estimated glomerular filtration rate across the long-term follow-up was in line with the predicted age-related decline. Antihypertensive drug burden was similar at baseline and follow-up.

CONCLUSIONS

Renal denervation is associated with a significant and clinically meaningful reduction in ambulatory systolic BP in both contemporary randomized sham-controlled trials up to 36 months and observational cohort studies up to 10 years without adverse consequences on renal function.

A European Renal Association (ERA) synopsis for nephrology practice of the 2023 European Society of Hypertension (ESH) Guidelines for the Management of Arterial Hypertension

In June 2023, the European Society of Hypertension (ESH) presented and published the new 2023 ESH Guidelines for the Management of Arterial Hypertension, a document that was endorsed by the European Renal Association (ERA). Following the evolution of evidence in recent years, several novel recommendations relevant to the management of hypertension in patients with chronic kidney disease (CKD) appeared in these Guidelines. These include recommendations for target office blood pressure (BP) <130/80 mmHg in most and against target office BP <120/70 mmHg in all patients with CKD; recommendations for use of spironolactone or chlorthalidone for patients with resistant hypertension with estimated glomerular filtration rate (eGFR) higher or lower than 30 mL/min/1.73 m2, respectively; use of a sodium-glucose cotransporter 2 inhibitor for patients with CKD and estimated eGFR ≥20 mL/min/1.73 m2; use of finerenone for patients with CKD, type 2 diabetes mellitus, albuminuria, eGFR ≥25 mL/min/1.73 m2 and serum potassium <5.0 mmol/L; and revascularization in patients with atherosclerotic renovascular disease and secondary hypertension or high-risk phenotypes if stenosis ≥70% is present. The present report is a synopsis of sections of the ESH Guidelines that are relevant to the daily clinical practice of nephrologists, prepared by experts from ESH and ERA. The sections summarized are those referring to the role of CKD in hypertension staging and cardiovascular risk stratification, the evaluation of hypertension-mediated kidney damage and the overall management of hypertension in patients with CKD.

Ten-year follow-up of very-high risk hypertensive patients undergoing renal sympathetic denervation

OBJECTIVES

Renal denervation (RDN) has been proven to be effective in lowering blood pressure (BP) in patients, but previous studies have had short follow-ups and have not examined the effects of RDN on major cardiovascular outcomes. This study aimed to demonstrate the effectiveness and safety of RDN in the long-term treatment of hypertension and to determine if it has an effect on cardiovascular outcomes.

METHODS

All patients with resistant hypertension who underwent RDN between 2011 and 2015 at Tianjin First Central Hospital were included in the study. Patients were followed up at 1,5 and 10 years and the longest follow-up was 12 years. Data were collected on office BP, home BP, ambulatory BP monitoring (ABPM), renal function, antihypertensive drug regimen, major adverse events (including acute myocardial infarction, stroke, cardiovascular death and all cause death) and safety events.

RESULTS

A total of 60 participants with mean age 50.37 ± 15.19 years (43.33% female individuals) completed long-term follow-up investigations with a mean of 10.02 ± 1.72 years post-RDN. Baseline office SBP and DBP were 179.08 ± 22.05 and 101.17 ± 16.57 mmHg under a mean number of 4.22 ± 1.09 defined daily doses (DDD), with a reduction of -35.93/-14.76 mmHg as compared with baseline estimates ( P  < 0.0001). Compared with baseline, ambulatory SBP and DBP after 10-years follow-up were reduced by 14.31 ± 10.18 ( P  < 0.001) and 9 ± 4.35 ( P  < 0.001) mmHg, respectively. In comparison to baseline, participants were taking fewer antihypertensive medications ( P  < 0.001), and their mean heart rate had decreased ( P  < 0.001). Changes in renal function, as assessed by estimated glomerular filtration rate (eGFR) and creatinine, were within the expected rate of age-related decline. No major adverse events related to the RDN procedure were observed in long-term consequences. All-cause mortality and cardiovascular mortality rates were 10 and 8.34%, respectively, for the 10-year period.

CONCLUSION

The BP-lowering effect of RDN was safely sustained for at least 10 years post-procedure. More importantly, to the best of my knowledge, this is the first study to explore cardiovascular and all-cause mortality at 10 years after RDN.

Resistant hypertension: Diagnosis, evaluation, and treatment practical approach

The term RH describes a subgroup of hypertensive patients whose BP is uncontrolled despite the use of at least three antihypertensive drugs in an appropriate combination at optimal or best tolerated doses. True RH is considered when appropriate lifestyle measures and treatment with optimal or best tolerated doses of three or more drugs (a thiazide/thiazide-like diuretic, plus renin-angiotensin system -RAS- blocker and a calcium channel blocker -CCB-) fail to lower office BP to <140/90 mmHg; besides the inadequate BP control should be confirmed by home blood pressure monitoring (HBPM) or 24-hour ambulatory; and evidence of adherence to therapy and exclusion of secondary causes of hypertension are required. RH patients are at a high risk of cardiovascular events and death. RH is associated with a higher prevalence of end-organ damage. When stricter criteria are applied, a reasonable estimate of the prevalence of true RH is 5 % of the total hypertensive population. The predominant hemodynamic pattern appears to be increased systemic vascular resistance and plasma volume with normal or even low cardiac output. We must rule out pseudo-resistance before diagnosing true drug resistance. RH is a therapeutic challenge, and its management includes lifestyle interventions, avoiding nonadherence to treatment, avoiding inertia, appropriate use of antihypertensive drugs based on current evidence, especially long-acting diuretics, and the addition of mineralocorticoid receptor antagonists. RCTs to identify the most protective medical therapy in RH are needed. A series of drugs in different stages of investigation could significantly impact RH treatment in the future.

Renal denervation in the management of hypertension

Arterial hypertension is a global leading cause of cardiovascular, cerebrovascular, and renal disease, as well as mortality. Although pharmacotherapy is safe and effective in lowering blood pressure (BP) and cardiovascular disease risk, BP control remains poor, and the mortality rates associated with high BP have been steadily increasing. Device-based therapies have been investigated to overcome barriers to pharmacotherapy, including non-adherence and low rates of persistence to daily medications. Among these device-based therapies, catheter-based renal denervation (RDN) has been most extensively examined over the past 15 years. In this state-of-the-art article, we summarise the rationale for RDN, review the available evidence, provide recommendations for a safe procedure, and discuss the role of RDN in current guidelines and clinical practice.

Renal sympathetic denervation improves pressure-natriuresis relationship in cardiorenal syndrome: insight from studies with Ren-2 transgenic hypertensive rats with volume overload induced using aorto-caval fistula

The aim was to evaluate the effects of renal denervation (RDN) on autoregulation of renal hemodynamics and the pressure-natriuresis relationship in Ren-2 transgenic rats (TGR) with aorto-caval fistula (ACF)-induced heart failure (HF). RDN was performed one week after creation of ACF or sham-operation. Animals were prepared for evaluation of autoregulatory capacity of renal blood flow (RBF) and glomerular filtration rate (GFR), and of the pressure-natriuresis characteristics after stepwise changes in renal arterial pressure (RAP) induced by aortic clamping. Their basal values of blood pressure and renal function were significantly lower than with innervated sham-operated TGR (p < 0.05 in all cases): mean arterial pressure (MAP) (115 ± 2 vs. 160 ± 3 mmHg), RBF (6.91 ± 0.33 vs. 10.87 ± 0.38 ml.min-1.g-1), urine flow (UF) (11.3 ± 1.79 vs. 43.17 ± 3.24 µl.min-1.g-1) and absolute sodium excretion (UNaV) (1.08 ± 0.27 vs, 6.38 ± 0.76 µmol.min-1.g-1). After denervation ACF TGR showed improved autoregulation of RBF: at lowest RAP level (80 mmHg) the value was higher than in innervated ACF TGR (6.92 ± 0.26 vs. 4.54 ± 0.22 ml.min-1.g-1, p < 0.05). Also, the pressure-natriuresis relationship was markedly improved after RDN: at the RAP of 80 mmHg UF equaled 4.31 ± 0.99 vs. 0.26 ± 0.09 µl.min-1.g-1 recorded in innervated ACF TGR, UNaV was 0.31 ± 0.05 vs. 0.04 ± 0.01 µmol min-1.g-1 (p < 0.05 in all cases). In conclusion, in our model of hypertensive rat with ACF-induced HF, RDN improved autoregulatory capacity of RBF and the pressure-natriuresis relationship when measured at the stage of HF decompensation.

The feasibility, efficacy, and safety of RDN procedure using CO2 angiography through radial artery in severe chronic kidney disease patients

The recent evidence regarding the effectiveness of renal denervation (RDN) in blood pressure control is becoming increasingly substantial. However, many studies have excluded populations with severely impaired kidney function, even though these individuals have a higher prevalence of hypertension compared to the general population, and controlling their blood pressure is more challenging. The effectiveness and safety of RDN in patients with severe chronic kidney disease (CKD) lack strong evidence support. Concerns about worsening kidney function still exist, particularly in patients with CKD stage 5. We conducted an observational study involving 10 patients who were using at least 3 different antihypertensive medications and had an estimated glomerular filtration rate (eGFR) < 45 mL/min/1.73 m2 but had not undergone dialysis. For these patients, we performed RDN via the radial artery approach, with the assistance of carbon dioxide (CO2) angiography. Utilizing this approach, the systolic 24-hour ambulatory blood pressure monitoring did not exhibit a significant decrease at 3 months; however, a significant reduction was observed at 6 months after RDN. We also minimized contrast agent usage, observed no kidney function decline 3 months post-RDN, and experienced no vascular-related complications. Using the radial artery approach and CO2 angiography assistance for RDN may be an effective and safe blood pressure control method for patients with severe kidney impairment.

Neuromodulation interventions in the management of heart failure

Despite remarkable improvements in the management of heart failure (HF), HF remains one of the most rapidly growing cardiovascular condition resulting in a substantial burden on healthcare systems worldwide. In clinical practice, however, a relevant proportion of patients are treated with suboptimal combinations and doses lower than those recommended in the current guidelines. Against this background, it remains important to identify new targets and investigate additional therapeutic options to alleviate symptoms and potentially improve prognosis in HF. Therefore, non-pharmacological interventions targeting autonomic imbalance in HF have been evaluated. This paper aims to review the physiology, available clinical data, and potential therapeutic role of device-based neuromodulation in HF.

Management of Resistant Hypertension

Resistant hypertension (RH) is a severe form of hypertension associated with increased cardiovascular risk. Although true RH affects less than 10% of the patients receiving antihypertensive therapy, the absolute number is high and continues to increase. The workup of these patients requires screening for secondary hypertension and pseudoresistance, including poor adherence to prescribed medicines and the white-coat phenomenon. The treatment of RH consists of lifestyle modifications and pharmacological therapies. Lifestyle modifications include dietary adjustments, weight loss, physical activity, and limiting alcohol consumption; pharmacological therapies include diuretics, mineralocorticoid receptor antagonists, beta blockers, angiotensin receptor-neprilysin inhibitors, and others. Over the last 15 years, interventional approaches have emerged as adjunct treatment options; we highlight catheter-based renal denervation. This review summarizes the rationales and latest clinical evidence and, based thereon, proposes an updated algorithm for the management of RH.

Photoplethysmography for Assessing Microcirculation in Hypertensive Patients After Taking Antihypertensive Drugs: A Review

High blood pressure (BP) is a common disease and is associated with many chronic diseases. Measuring BP is essential for the treatment and management of many diseases, and therefore there is a growing need for a non-invasive, sleeveless and continuous BP monitoring device. With the development of technology, pulse waveform analysis using photoplethysmography (PPG) has become more feasible for evaluating BP. This study aimed to evaluate the changes of vascular elasticity and blood volume over time by using the characteristic parameters extracted by PPG. We reviewed the latest progress and literature on the observation of capillary network characteristics in hypertensive and non-hypertensive patients by PPG, the influence of different drugs on microcirculation characteristics in hypertensive patients with PPG, and further explored the key relationship between microcirculation and hypertension. We found that the PPG waveform produced by the fingertips of hypertensive patients is very different from that of healthy people, and the PPG waveform changes significantly during diastolic period after antihypertensive treatment. With the rapid development of medical technology, people can get more intuitive microcirculation image data, which provides beneficial help for the comprehensive understanding of hypertension.

Home systolic blood pressure time in therapeutic range and cardiovascular risk: the practitioner-based nationwide J-HOP study extended

Time in therapeutic range (TTR) for office systolic blood pressure (SBP) is an independent predictor of major cardiovascular events. However, the clinical implications of TTR for home SBP have not yet been investigated. This study determined the association between TTR of home SBP and cardiovascular events in individuals with ≥1 cardiovascular risk factor who were enrolled in The Japan Morning Surge-Home Blood Pressure (J-HOP) study. The therapeutic range for home SBP was defined as home SBP of 100-135 mmHg during the 13-day baseline period of the J-HOP study. Participants were divided into subgroups based on quartiles of TTR for home SBP, and the risk of cardiovascular events was determined in each quartile. During a mean 6.3 years of follow-up in 4070 participants (mean age 65 years), cardiovascular events included stroke in 92, coronary artery disease in 119, heart failure in 41 and aortic dissection in 8. The adjusted hazard ratio (95% confidence interval) for the risk of total cardiovascular events in participants with home SBP TTR in the lowest (100%) versus highest quartile (<15.3%) was 1.74 (1.16-2.61); the corresponding hazard ratio for stroke events was 2.11 (1.06-4.21). A 10% decrease in home SBP TTR was associated with a 4% increase in the risk of total cardiovascular events (p = 0.033) and a 9% increase in the risk of stroke (p = 0.004). The significant association seen between home SBP TTR and the occurrence of cardio- and cerebrovascular events highlights the importance of achieving stable reductions in home SBP and minimizing day-by-day home BP variability.Clinical Trial Registration: University Hospital Medical Information Network Clinical Trials Registry, UMIN000000894 (J-HOP study).

Late outcomes of renal denervation are more favourable than early ones: facts or fancies?

Following second-generation randomized trials, there is evidence that renal denervation (RDN) decreases blood pressure (BP), although to a lesser extent than suggested in the initial controlled and observational studies. The recent publication of the 36-month follow-up of the Symplicity HTN-3 trial has raised expectations, suggesting increasing, late benefits of the procedure, despite initially negative results. These findings come after those obtained at 36 months in the sham-controlled trial SPYRAL HTN-ON MED and in the Global Symplicity Registry. However, they are susceptible to biases inherent in observational studies (after unblinding for sham-control) and non-random, substantial attrition of treatment groups at 36 months, and used interpolation of missing BPs. More importantly, in SPYRAL HTN-ON MED and Symplicity HTN-3, long-term BP changes in patients from the initial RDN group were compared with those in a heterogeneous control group, including both control patients who did not benefit from RDN and patients who eventually crossed over to RDN. In crossover patients, the last BP before RDN was imputed to subsequent follow-up. In Symplicity HTN-3, this particular approach led to the claim of increasing long-term benefits of RDN. However, comparison of BP changes in patients from the RDN group and control patients who did not undergo RDN, without imputation of BPs from crossover patients, does not support this view. The good news is that despite the suggestion of sympathetic nerve regrowth after RDN in some animal models, there is no strong signal in favour of a decreasing effect of RDN over time, up to 24 or even 36 months. Still, current data do not support a long-term increase in the effect of RDN and the durability of RDN-related BP reduction remains to be formally demonstrated.

Update on advanced interventional neuromodulatory approaches to lower blood pressure

Herein, we review interventional peripheral neuromodulatory approaches to reduce blood pressure (BP), specifically focusing on catheter-based renal denervation (RDN), as well as the latest data from recent clinical trials underpinning its clinical use. Given the apparent failure of established lifestyle measures and pharmacologic BP-lowering approaches to improve hypertension (HTN) control rates, the past decade has seen remarkable scientific efforts to explore the utility of interventional strategies for BP management. Experimental studies and human clinical trials have demonstrated the crucial role of the sympathetic nervous system in the development and mainenance of HTN - consequently, most recent interventional technologies aimed primarily at modulating neural pathways. Advanced approaches that were rigorously tested in human studies include RDN, endovascular baroreflex amplification, baroreflex activation therapy and cardiac neuromodulation stimulation.Amongst these, RDN is by far the most established technology. With recent robust evidence from clinical trials and real-world data showing the safety and efficacy of both ultrasound and radiofrequency-based approaches, a recent clinical consensus statement of the European Society of Cardiology Council on Hypertension and the European Association of Percutaneous Cardiovascular Interventions concludes that RDN represents an ancillary therapeutic option in patients with uncontrolled resistant HTN confirmed by ambulatory blood pressure measurement and in spite of attention to lifestyle changes and optimised pharmacological treatment. Furthermore, RDN could alos be considered for patienst unlikley to adhere to or tolerate long-term antihypertensive drug treatment. Very recent data indicate long-term safety and efficacy up to 10 years. Appropriate implementation of RDN into clinical practice is now warranted.For all other interventions additional data from adequately designed human studies are required to establish their safety and clinical utility for potential future use in routine practice.

Resistant Hypertension and Related Outcomes in a Cohort of Patients with Cardiorenal Multimorbidity Hospitalized in an Internal Medicine Ward

INTRODUCTION

Resistant hypertension (RH) is characterized by the failure to reach a goal blood pressure despite the administration of three medications at maximally tolerated doses, one of which being a diuretic. RH can be observed in a variety of clinical conditions, such as heart failure and reduced renal function and may confer high cardiovascular risk.

AIM

To evaluate the prevalence of RH and its association with clinical outcomes; the primary outcome was in-hospital mortality and the composite outcome was all-cause of mortality and morbidity in a cohort of patients with cardiorenal multimorbidity hospitalized in an internal medicine ward.

METHODS

We conducted a retrospective analysis of consecutive hypertensive patients with cardiorenal multimorbidity. The composite outcome incorporated all-cause of in-hospital mortality and occurrence of sepsis, pulmonary embolism, acute coronary syndrome, stroke and renal replacement therapy.

RESULTS

We collected data in 141 inpatients with a mean age of 77 years ± 10 (males 65.9 %), estimated glomerular filtration rate of 34 ± 18.6 ml/min with length of stay of 17 ± 12 days. The prevalence of RH was 52.4%. In-hospital mortality was observed in 24 patients (17%) and the composite outcome occurred in 87 patients (61.7%) and among these 74 (85.1%) were patients with RH. Free survival for composite outcome was significantly higher in patients without RH than patients with RH (log rank 7.52, p = 0.006). Resistant hypertension was a risk factor for composite outcome [HR 1.857(C.I. 1.170-2.946, p = 0.009)].

CONCLUSION

In patients with cardiorenal multimorbidity there is a high proportion of RH that represents a risk factor for composite outcome but not for in-hospital mortality.