1
|
Christophides T, Somaschini A, Demarchi A, Cornara S, Androulaki M, Androulakis E. New Drugs and Interventional Strategies for the Management of Hypertension. Curr Pharm Des 2021; 27:1396-1406. [PMID: 33155904 DOI: 10.2174/1381612826666201106091527] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Accepted: 09/16/2020] [Indexed: 11/22/2022]
Abstract
Essential hypertension is an important cause of cardiovascular morbidity and mortality worldwide with significant clinical and economic implications. The field of antihypertensive treatment already numbers numerous agents and classes of drugs. However, patients are still developing uncontrolled hypertension. Hence there is a continuous need for novel agents with good tolerability. Advances in this field are focusing both on pharmacotherapy, with the developments in traditional and non-traditional targets, as well as interventional techniques such as renal denervation and baroreflex activation therapy. It is likely that future strategies may involve a tailored approach to the individual patient, with genetic modulation playing a key role.
Collapse
|
2
|
Abstract
In the past decade, efforts to improve blood pressure control have looked beyond conventional approaches of lifestyle modification and drug therapy to embrace interventional therapies. Based upon animal and human studies clearly demonstrating a key role for the sympathetic nervous system in the etiology of hypertension, the newer technologies that have emerged are predominantly aimed at neuromodulation of peripheral nervous system targets. These include renal denervation, baroreflex activation therapy, endovascular baroreflex amplification therapy, carotid body ablation, and pacemaker-mediated programmable hypertension control. Of these, renal denervation is the most mature, and with a recent series of proof-of-concept trials demonstrating the safety and efficacy of radiofrequency and more recently ultrasound-based renal denervation, this technology is poised to become available as a viable treatment option for hypertension in the foreseeable future. With regard to baroreflex activation therapy, endovascular baroreflex amplification, carotid body ablation, and programmable hypertension control, these are developing technologies for which more human data are required. Importantly, central nervous system control of the circulation remains a poorly understood yet vital component of the hypertension pathway and mandates further investigation. Technology to improve blood pressure control through deep brain stimulation of key cardiovascular control territories is, therefore, of interest. Furthermore, alternative nonsympathomodulatory intervention targeting the hemodynamics of the circulation may also be worth exploring for patients in whom sympathetic drive is less relevant to hypertension perpetuation. Herein, we review the aforementioned technologies with an emphasis on the preclinical data that underpin their rationale and the human evidence that supports their use.
Collapse
Affiliation(s)
- Felix Mahfoud
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University, Homburg, Germany (F.M.)
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology (MIT), Cambridge, MA (F.M.)
| | - Markus P Schlaich
- Dobney Hypertension Centre, School of Medicine-Royal Perth Hospital Unit, The University of Western Australia, Australia (M.S.)
- Departments of Cardiology (M.S.), Royal Perth Hospital, Australia
- Nephrology (M.S.), Royal Perth Hospital, Australia
- Neurovascular Hypertension and Kidney Disease Laboratory, Baker Heart and Diabetes Institute, Melbourne, Australia (M.S.)
| | - Melvin D Lobo
- William Harvey Research Institute and Barts NIHR Cardiovascular Biomedical Research Centre, Queen Mary University of London, United Kingdom (M.D.L.)
- Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom (M.D.L.)
| |
Collapse
|
3
|
Sultan S, Mustafa MKE, Barrett N, Hynes N. Midterm complications of ROX arteriovenous coupler device, managed by targeted endovascular repair: a case report. EUROPEAN HEART JOURNAL-CASE REPORTS 2020; 4:1-5. [PMID: 32974488 DOI: 10.1093/ehjcr/ytaa185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 03/19/2020] [Accepted: 05/29/2020] [Indexed: 11/13/2022]
Abstract
Background Resistant and uncontrolled hypertension prominently amplifies the risk of end-stage renal disease and fatal cardiovascular events. Therapeutic inertia, despite maximum tolerated anti-hypertensive medications, puts patients at high risk, thus non-pharmacologic therapies have been proposed. The ROX arteriovenous coupler (ROX, Medical Inc., San Clemente, CA, USA), initially developed for treatment of chronic obstructive pulmonary disease, exploits the biomechanical effects of diverting arterial blood into a low-resistance, high-compliance venous segment, thereby decreasing arterial vascular resistance and blood pressure (BP). Case summary A 76-year-old male, non-smoker and non-diabetic with resistant primary hypertension presented to our institution with disabling claudication, lower limb swelling and right hip pain. He had concomitant saccular abdominal aortic and right iliac aneurysms. He had previously undergone renal denervation on two separate occasions yet continued to require increasing anti-hypertensive medications. He subsequently had an insertion of an ROX coupler device between his right external iliac artery and vein after failure of insertion into his left iliac system. He developed right hip and buttock pain and consequently underwent a total hip replacement and subsequent revision, which did not alleviate his symptoms. Ankle-brachial indices were reduced to 0.70 on the right limb and normal on the left. Insertion of the ROX coupler device was reversed with concomitant endovascular aortic repair. Discussion There is no clear consensus on reversal of the ROX coupler device. Endovascular aortic repair reversal of the ROX coupler device in this case was safe, effective, and improved symptoms including patient's BP control and limb symptoms.
Collapse
Affiliation(s)
- Sherif Sultan
- Department of Vascular and Endovascular Surgery, Western Vascular Institute, University Hospital Galway, Newcastle Road District, National University of Ireland, Galway H91 YXH6, Ireland.,Department of Vascular Surgery and Endovascular Surgery, Galway Clinic, Royal College of Surgeons in Ireland and National University of Ireland Galway affiliated Hospital, Doughiska, Galway H91 HHTO, Ireland
| | - Mohamed K E Mustafa
- Department of Vascular and Endovascular Surgery, Western Vascular Institute, University Hospital Galway, Newcastle Road District, National University of Ireland, Galway H91 YXH6, Ireland
| | - Nora Barrett
- Department of Vascular and Endovascular Surgery, Western Vascular Institute, University Hospital Galway, Newcastle Road District, National University of Ireland, Galway H91 YXH6, Ireland
| | - Niamh Hynes
- Department of Vascular Surgery and Endovascular Surgery, Galway Clinic, Royal College of Surgeons in Ireland and National University of Ireland Galway affiliated Hospital, Doughiska, Galway H91 HHTO, Ireland
| |
Collapse
|
4
|
Mensa Sorato M, Davari M, Kebriaeezadeh A, Naderi N, Sarrafzadegan N, Shibru T, Nikfar S, Arero AG. Cost-effectiveness of Interventional therapies for management of Treatment-resistant hypertension: systematic review of pharmacoeconomic studies. JOURNAL OF PHARMACEUTICAL HEALTH SERVICES RESEARCH 2020. [DOI: 10.1111/jphs.12384] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Abstract
Background
Treatment resistant hypertension (TRH) is defined as uncontrolled blood pressure (>140/90 mm Hg) after treatment with the intensified dose of three standard antihypertensive drugs. Management of TRH involves addition of fourth line drugs on standard care or interventional therapies (Renal denervation, Baroreceptor activation, Central venous anastomosis). However, evidence concerning cost-effectiveness of interventional therapies is inconclusive. Objective: This systematic review was conducted to extract the level of evidence on cost-effectiveness of interventional therapies for TRH.
Method
We systematically searched articles written in English language since January 2000 to January 2020 from the following databases: PubMed/Medline, Ovid/Medline, Embase, Scopus, Web of Science, Google scholar and other relevant sources.
Key findings
Twelve pharmacoeconomic studies were included in this systematic review. Renal denervation (RDN) is the most commonly studied intervention therapy for treatment of TRH. Participants included in the study vary from age 18-99 years. The incremental cost-effectiveness ratio (ICER) of RDN ranged from $1,709.84 per QALY gained in Netherlands to 66,380.3 per QALY gained in Australia. RDN was cost-effective in high-risk patients in UK, Australia, Canada, Netherlands, USA, Germany, Russia and Korea. The cost-effectiveness was influenced by the magnitude of effect of RDN on systolic blood pressure, the rate of RDN nonresponders, and the procedure costs of RDN and assumption of long-term time horizon. However, the ICER of RDN in Mexico was above MXN$ 139,000 GDP/capita of the country. The ICER of implantable carotid body stimulator was $64,400 per QALYs gained. The cost-effectiveness of baroreceptor activation didn’t improve with age.
Conclusion
Overall cost-effectiveness of interventional therapies for treatment of TRH was inconclusive based on the current available evidence. Therefore, strong clinical trials and pharmacoeconomic evaluations from different perspectives in various candidate populations are needed to generate adequate clinical and cost-effectiveness evidence for using interventional therapies in treatment of treatment resistant hypertension.
Collapse
Affiliation(s)
- Mende Mensa Sorato
- Department of Pharmacy, Arba Minch University College of Medicine and Health Sciences, Tehran, Iran
| | - Majid Davari
- Department of Pharmacoeconomics and Pharmaceutical Administration, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Abbas Kebriaeezadeh
- Department of Pharmacoeconomics and Pharmaceutical Administration, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Nasim Naderi
- Rajaie Cardiovascular Medical and Research Center, Tehran, Iran
| | | | - Tamiru Shibru
- College of Medicine and Health Sciences, Arba Minch University, Arba Minch, Ethiopia
| | - Shekoufeh Nikfar
- Department of Pharmacoeconomics and Pharmaceutical Administration, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Amanuel Godana Arero
- Students' Scientific Research Center, Tehran University of Medical sciences, Tehran, Iran
| |
Collapse
|
5
|
Kobalava ZD, Konradi AO, Nedogoda SV, Shlyakhto EV, Arutyunov GP, Baranova EI, Barbarash OL, Boitsov SA, Vavilova TV, Villevalde SV, Galyavich AS, Glezer MG, Grineva EN, Grinstein YI, Drapkina OM, Zhernakova YV, Zvartau NE, Kislyak OA, Koziolova NA, Kosmacheva ED, Kotovskaya YV, Libis RA, Lopatin YM, Nebiridze DV, Nedoshivin AO, Ostroumova OD, Oschepkova EV, Ratova LG, Skibitsky VV, Tkacheva ON, Chazova IE, Chesnikova AI, Chumakova GA, Shalnova SA, Shestakova MV, Yakushin SS, Yanishevsky SN. Arterial hypertension in adults. Clinical guidelines 2020. ACTA ACUST UNITED AC 2020. [DOI: 10.15829/1560-4071-2020-3-3786] [Citation(s) in RCA: 164] [Impact Index Per Article: 41.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Arterial hypertension in adults. Clinical guidelines 2020
Collapse
|
6
|
Jeong S, Kwon H, Kim JY, Kim YH, Kwon TW, Lee JB, Cho YP, Han DJ. Effect of arteriovenous access closure and timing on kidney function in kidney transplant recipients. PLoS One 2019; 14:e0226309. [PMID: 31826011 PMCID: PMC6905568 DOI: 10.1371/journal.pone.0226309] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 11/22/2019] [Indexed: 11/28/2022] Open
Abstract
This study aimed to determine whether the closure of a functioning arteriovenous (AV) access affects the estimated glomerular filtration rate (eGFR) and to compare outcomes according to the timing of AV access closure after kidney transplantation (KT). From 2009 to 2015, medical records were retrospectively reviewed for 142 kidney transplant recipients (KTRs) who underwent AV access closure. The 142 KTRs were categorized into three groups: AV access closure was performed within 6 months after KT in Group 1 (n = 45), at 6–12 months after KT in Group 2 (n = 49), and at 12–24 months after KT in Group 3 (n = 48). The baseline (at the time of AV access closure) and follow-up eGFR values during the 3-year follow-up period were compared. Linear mixed model analysis revealed no significant association between longitudinally observed eGFR values and the amount of time elapsed after AV access closure in the study population (P = 0.36). There was no significant association between 3-year eGFR values and the timing of AV access closure (P = 0.58). In conclusion, after successful KT, AV access closure did not affect the eGFR significantly, and the timing of AV access closure was not significantly associated with outcomes.
Collapse
Affiliation(s)
- Seonjeong Jeong
- Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Hyunwook Kwon
- Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Jee Yeon Kim
- Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Young Hoon Kim
- Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Tae-Won Kwon
- Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Jung Bok Lee
- Department of Clinical Epidemiology and Biostatistics, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Yong-Pil Cho
- Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
- * E-mail:
| | - Duck Jong Han
- Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| |
Collapse
|
7
|
Clemmer JS, Pruett WA, Hester RL, Lohmeier TE. Preeminent role of the cardiorenal axis in the antihypertensive response to an arteriovenous fistula: an in silico analysis. Am J Physiol Heart Circ Physiol 2019; 317:H1002-H1012. [PMID: 31469293 DOI: 10.1152/ajpheart.00354.2019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Percutaneous creation of a small central arteriovenous (AV) fistula is currently being evaluated for the treatment of uncontrolled hypertension (HT). Although the mechanisms that contribute to the antihypertensive effects of the fistula are unclear, investigators have speculated that chronic blood pressure (BP) lowering may be due to 1) reduced total peripheral resistance (TPR), 2) increased secretion of atrial natriuretic peptide (ANP), and/or 3) suppression of renal sympathetic nerve activity (RSNA). We used an established integrative mathematical model of human physiology to investigate these possibilities from baseline conditions that mimic sympathetic overactivity and impaired renal function in patients with resistant HT. After a small fistula was stimulated, there were sustained increases in cardiac output, atrial pressures, and plasma ANP concentration (3-fold), without suppression of RSNA; at 8 wk, BP was reduced 14 mmHg along with a 32% fall in TPR. In contrast, when this simulation was repeated while clamping ANP at baseline BP decreased only 4 mmHg, despite a comparable fall in TPR. Furthermore, when chronic resetting of atrial mechanoreceptors was prevented during the fistula, RSNA decreased 7%, and along with the same threefold increase in ANP, BP fell 19 mmHg. This exaggerated fall in BP occurred with a similar decrease in TPR when compared with the above simulations. These findings suggest that ANP, but not TPR, is a key determinant of long-term BP lowering after the creation of an AV fistula and support a contribution of suppressed RSNA if resetting of the atrial-renal reflex is truly incomplete.NEW & NOTEWORTHY The mechanisms that contribute to the antihypertensive effects of a small arteriovenous (AV) fistula comparable to the size used by the ROX coupler currently in clinical trials are unclear and not readily testable in clinical or experimental studies. The integrative mathematical model of human physiology used in the current study provides a tool for understanding key causal relationships that account for blood pressure (BP) lowering and for testing competing hypotheses. The findings from the simulations suggest that after creation of a small AV fistula increased ANP secretion plays a critical role in mediating long-term reductions in BP. Measurement of natriuretic peptide levels in hypertensive patients implanted with the ROX coupler would provide one critical test of this hypothesis.
Collapse
Affiliation(s)
- John S Clemmer
- Department of Physiology and Biophysics, University of Mississippi Medical Center, Jackson, Mississippi
| | - W Andrew Pruett
- Department of Physiology and Biophysics, University of Mississippi Medical Center, Jackson, Mississippi
| | - Robert L Hester
- Department of Physiology and Biophysics, University of Mississippi Medical Center, Jackson, Mississippi.,John D. Bower School of Population Health, University of Mississippi Medical Center, Jackson, Mississippi
| | - Thomas E Lohmeier
- Department of Physiology and Biophysics, University of Mississippi Medical Center, Jackson, Mississippi
| |
Collapse
|
8
|
Eysenck W, van Zalen J, Freemantle N, Lloyd G, Furniss S, Sulke N. The hemodynamic effects of a central iliac arteriovenous anastomosis at 6 months in patients with resistant and uncontrolled hypertension. J Clin Hypertens (Greenwich) 2019; 21:1399-1405. [PMID: 31347773 DOI: 10.1111/jch.13646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Revised: 06/27/2019] [Accepted: 07/08/2019] [Indexed: 11/27/2022]
Abstract
A central iliac arteriovenous anastomosis, termed the "coupler" (ROX Medical), results in a significant reduction in blood pressure (BP) in hypertensive patients. This study assessed functional and hemodynamic changes induced by the device. Twenty-one patients with resistant and/or uncontrolled hypertension underwent stress echocardiography and cardiopulmonary exercise testing (CPET) at baseline and 6 months post-coupler implantation. End points were selected to best evaluate cardiac function including Doppler stroke volume (SV), septal and lateral E/E', and right ventricular systolic velocity S' (RV S'). CPET VO2 peak demonstrated total cardiopulmonary performance. SV increased from 76.4 SD12.2 mL to 92.1 SD22.7 mL 6 months post-coupler insertion; P = .002. No changes in RV S', septal or lateral E/E', or VO2 peak were observed. Five patients experienced increased diuretic requirement ≥3 times baseline. RV S' fell from 19.0 SD1.87 cm/s to 16.80 SD3.43 cm/s in these patients (P > .05). A significant increase in SV 6 months post-coupler insertion was observed. In patients with increased diuretic requirement, the device was associated with a lower RV S' suggesting occult RV dysfunction as the mechanism of this pre-specified adverse outcome.
Collapse
Affiliation(s)
- William Eysenck
- Cardiology Research Department, Eastbourne General Hospital, East Sussex, UK
| | - Jet van Zalen
- Cardiology Research Department, Eastbourne General Hospital, East Sussex, UK
| | - Nick Freemantle
- Institute of Clinical Trials and Methodology, University College London, London, UK
| | - Guy Lloyd
- Heart Valve Clinic & Echocardiography Laboratory, Barts Heart Centre, St Bartholomew's Hospital, London, UK.,William Harvey Research Institute, QMUL, London, UK.,Institute of Cardiovascular Sciences, UCL, London, UK
| | - Stephen Furniss
- Cardiology Research Department, Eastbourne General Hospital, East Sussex, UK
| | - Neil Sulke
- Cardiology Research Department, Eastbourne General Hospital, East Sussex, UK
| |
Collapse
|
9
|
Lu Y, Deng Y, Liu W, Jiang M, Bai G. Searching for calcium antagonists for hypertension disease therapy from Moutan Cortex, using bioactivity integrated UHPLC-QTOF-MS. PHYTOCHEMICAL ANALYSIS : PCA 2019; 30:456-463. [PMID: 30859657 DOI: 10.1002/pca.2828] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Revised: 01/29/2019] [Accepted: 02/02/2019] [Indexed: 06/09/2023]
Abstract
INTRODUCTION Calcium channel blockers (CCBs) are currently the most commonly used drugs for the treatment of hypertension. Moutan Cortex (MC), a traditional Chinese herb, has been found to have an anti-hypertensive effect. However, its potential mechanisms in the regulation of intracellular calcium concentration ([Ca2+ ]i ) remain poorly understood. OBJECTIVE The main objective of this work was to identify the potential calcium antagonists from MC and study their molecular mechanisms. METHODS Ultra-high performance liquid chromatography-quadrupole-time-of-fight-mass spectrometry (UHPLC-QTOF-MS) analysis combined with a dual-luciferase reporter assay was utilised to systematically screen the calcium antagonistic active ingredients in the methanol extract of MC. Additionally, the molecular mechanism of these compounds was further studied using live-cell imaging analysis with the calcium ion (Ca2+ ) probe dye fluo-4/AM to monitor changes in [Ca2+ ]i . RESULTS Three monoterpenoids (paeoniflorin, benzoylpaeoniflorin and mudanpioside C), one phenolic acid (paeonol) and one gallotannin (1,2,3,4,6-O-pentagalloylglucose) were screened out as potential calcium antagonists in MC. Among them, the calcium antagonistic activity of benzoylpaeoniflorin, mudanpioside C and 1,2,3,4,6-O-pentagalloylglucose is first reported. Additionally, paeoniflorin, benzoylpaeoniflorin, mudanpioside C and paeonol can effectively block voltage-operated Ca2+ channels (VOCCs) to exert calcium antagonism, while 1,2,3,4,6-O-pentagalloylglucose plays a role in blocking inositol 1,4,5-trisphosphate receptors (IP3Rs). CONCLUSION This work indicated that the anti-hypertensive efficacy of MC acted through multiple components selectively antagonising multiple cell signalling pathways to regulate [Ca2+ ]i . Furthermore, they could be considered as a reference standard for controlling the quality of Chinese medicinal materials.
Collapse
Affiliation(s)
- Yujie Lu
- State Key Laboratory of Medicinal Chemical Biology, College of Pharmacy and Tianjin Key Laboratory of Molecular Drug Research, Nankai University, Tianjin, P. R. China
| | - Yanfang Deng
- State Key Laboratory of Medicinal Chemical Biology, College of Pharmacy and Tianjin Key Laboratory of Molecular Drug Research, Nankai University, Tianjin, P. R. China
| | - Wenjuan Liu
- State Key Laboratory of Medicinal Chemical Biology, College of Pharmacy and Tianjin Key Laboratory of Molecular Drug Research, Nankai University, Tianjin, P. R. China
| | - Min Jiang
- State Key Laboratory of Medicinal Chemical Biology, College of Pharmacy and Tianjin Key Laboratory of Molecular Drug Research, Nankai University, Tianjin, P. R. China
| | - Gang Bai
- State Key Laboratory of Medicinal Chemical Biology, College of Pharmacy and Tianjin Key Laboratory of Molecular Drug Research, Nankai University, Tianjin, P. R. China
| |
Collapse
|
10
|
A sluice to normotension? J Hypertens 2018; 36:2314-2315. [PMID: 30379786 DOI: 10.1097/hjh.0000000000001926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
11
|
2018 ESC/ESH Guidelines for the management of arterial hypertension: The Task Force for the management of arterial hypertension of the European Society of Cardiology and the European Society of Hypertension: The Task Force for the management of arterial hypertension of the European Society of Cardiology and the European Society of Hypertension. J Hypertens 2018; 36:1953-2041. [PMID: 30234752 DOI: 10.1097/hjh.0000000000001940] [Citation(s) in RCA: 1809] [Impact Index Per Article: 301.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
: Document reviewers: Guy De Backer (ESC Review Co-ordinator) (Belgium), Anthony M. Heagerty (ESH Review Co-ordinator) (UK), Stefan Agewall (Norway), Murielle Bochud (Switzerland), Claudio Borghi (Italy), Pierre Boutouyrie (France), Jana Brguljan (Slovenia), Héctor Bueno (Spain), Enrico G. Caiani (Italy), Bo Carlberg (Sweden), Neil Chapman (UK), Renata Cifkova (Czech Republic), John G. F. Cleland (UK), Jean-Philippe Collet (France), Ioan Mircea Coman (Romania), Peter W. de Leeuw (The Netherlands), Victoria Delgado (The Netherlands), Paul Dendale (Belgium), Hans-Christoph Diener (Germany), Maria Dorobantu (Romania), Robert Fagard (Belgium), Csaba Farsang (Hungary), Marc Ferrini (France), Ian M. Graham (Ireland), Guido Grassi (Italy), Hermann Haller (Germany), F. D. Richard Hobbs (UK), Bojan Jelakovic (Croatia), Catriona Jennings (UK), Hugo A. Katus (Germany), Abraham A. Kroon (The Netherlands), Christophe Leclercq (France), Dragan Lovic (Serbia), Empar Lurbe (Spain), Athanasios J. Manolis (Greece), Theresa A. McDonagh (UK), Franz Messerli (Switzerland), Maria Lorenza Muiesan (Italy), Uwe Nixdorff (Germany), Michael Hecht Olsen (Denmark), Gianfranco Parati (Italy), Joep Perk (Sweden), Massimo Francesco Piepoli (Italy), Jorge Polonia (Portugal), Piotr Ponikowski (Poland), Dimitrios J. Richter (Greece), Stefano F. Rimoldi (Switzerland), Marco Roffi (Switzerland), Naveed Sattar (UK), Petar M. Seferovic (Serbia), Iain A. Simpson (UK), Miguel Sousa-Uva (Portugal), Alice V. Stanton (Ireland), Philippe van de Borne (Belgium), Panos Vardas (Greece), Massimo Volpe (Italy), Sven Wassmann (Germany), Stephan Windecker (Switzerland), Jose Luis Zamorano (Spain).The disclosure forms of all experts involved in the development of these Guidelines are available on the ESC website www.escardio.org/guidelines.
Collapse
|
12
|
Williams B, Mancia G, Spiering W, Agabiti Rosei E, Azizi M, Burnier M, Clement DL, Coca A, de Simone G, Dominiczak A, Kahan T, Mahfoud F, Redon J, Ruilope L, Zanchetti A, Kerins M, Kjeldsen SE, Kreutz R, Laurent S, Lip GYH, McManus R, Narkiewicz K, Ruschitzka F, Schmieder RE, Shlyakhto E, Tsioufis C, Aboyans V, Desormais I. 2018 ESC/ESH Guidelines for the management of arterial hypertension. Eur Heart J 2018; 39:3021-3104. [PMID: 30165516 DOI: 10.1093/eurheartj/ehy339] [Citation(s) in RCA: 5688] [Impact Index Per Article: 948.0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
|
13
|
Wei FF, Zhang ZY, Huang QF, Staessen JA. Diagnosis and management of resistant hypertension: state of the art. Nat Rev Nephrol 2018; 14:428-441. [DOI: 10.1038/s41581-018-0006-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
|
14
|
|
15
|
Vanderweckene P, Weekers L, Lancellotti P, Jouret F. Controversies in the management of the haemodialysis-related arteriovenous fistula following kidney transplantation. Clin Kidney J 2017; 11:406-412. [PMID: 29992020 PMCID: PMC6007507 DOI: 10.1093/ckj/sfx113] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Accepted: 08/28/2017] [Indexed: 01/27/2023] Open
Abstract
Arteriovenous fistula (AVF) is regarded as the best vascular access for chronic haemodialysis (HD). Still, AVF inherently causes significant haemodynamic changes. Although the necessity for vascular access despite its putative cardiovascular complications favours AVF creation in patients under chronic HD, one may question whether sustaining a functional AVF after successful kidney transplantation extends the haemodynamic threat. Small prospective series suggest that AVF ligation causes rapid and sustained reduction in left ventricular hypertrophy. Still, the benefits of such a cardiac remodelling in long-terms of cardiovascular morbi-mortality still need to be proven. Furthermore, the elevation of diastolic blood pressure and arterial stiffness caused by AVF ligation may blunt the expected cardio-protection. Finally, the closure of a functioning AVF may accelerate the decline of kidney graft function. As a whole, the current management of a functioning AVF in kidney transplant recipients remains controversial and does not rely on strong evidence-based data. The individual risk of graft dysfunction and a return to chronic HD also needs to be balanced. Careful pre-operative functional assessments, including cardio-pulmonary testing and estimated glomerular filtration rate slope estimation, may help better selection of who might benefit the most from AVF closure. Large-scale prospective, ideally multi-centric, trials are essentially needed.
Collapse
Affiliation(s)
- Pauline Vanderweckene
- Divisions of Nephrology and Cardiology, Department of Internal Medicine, University of Liège Hospital (ULg CHU), Liège, Belgium
| | - Laurent Weekers
- Divisions of Nephrology and Cardiology, Department of Internal Medicine, University of Liège Hospital (ULg CHU), Liège, Belgium
| | - Patrizio Lancellotti
- Divisions of Nephrology and Cardiology, Department of Internal Medicine, University of Liège Hospital (ULg CHU), Liège, Belgium
- Groupe Interdisciplinaire de Génoprotéomique Appliquée (GIGA), Cardiovascular Sciences, University of Liège, Liège, Belgium
| | - François Jouret
- Divisions of Nephrology and Cardiology, Department of Internal Medicine, University of Liège Hospital (ULg CHU), Liège, Belgium
- Groupe Interdisciplinaire de Génoprotéomique Appliquée (GIGA), Cardiovascular Sciences, University of Liège, Liège, Belgium
- Correspondence and offprint requests to: François Jouret; E-mail:
| |
Collapse
|
16
|
Weekers L, Vanderweckene P, Pottel H, Castanares-Zapatero D, Bonvoisin C, Hamoir E, Maweja S, Krzesinski JM, Delanaye P, Jouret F. The closure of arteriovenous fistula in kidney transplant recipients is associated with an acceleration of kidney function decline. Nephrol Dial Transplant 2017; 32:196-200. [PMID: 27798197 DOI: 10.1093/ndt/gfw351] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Accepted: 08/24/2016] [Indexed: 11/14/2022] Open
Abstract
Background The creation of arteriovenous fistula (AVF) may retard chronic kidney disease progression in the general population. Conversely, the impact of AVF closure on renal function in kidney transplant recipients (KTRs) remains unknown. Methods From 2007 to 2013, we retrospectively categorized 285 KTRs into three groups: no AVF (Group 0, n = 90), closed AVF (Group 1, n = 114) and left-open AVF (Group 2, n = 81). AVF closure occurred at 653 ± 441 days after kidney transplantation (KTx), with a thrombosis:ligation ratio of 19:95. Estimated glomerular filtration rate (eGFR) was determined using the Modification of Diet in Renal Disease equation. Linear mixed models calculated the slope and intercept of eGFR decline versus time, starting at 3 months post-KTx, with a median follow-up of 1807 days (95% confidence interval 1665-2028). Results The eGFR slope was less in Group 1 (-0.081 mL/min/month) compared with Group 0 (-0.183 mL/min/month; P = 0.03) or Group 2 (-0.164 mL/min/month; P = 0.09). Still, the eGFR slope significantly deteriorated after (-0.159 mL/min/month) versus before (0.038 mL/min/month) AVF closure (P = 0.03). Study periods before versus after AVF closure were balanced to a mean of 13.5 and 12.5 months, respectively, with at least 10 observations per patient ( n = 99). Conclusions In conclusion, a significant acceleration of eGFR decline is observed over the 12 months following the closure of a functioning AVF in KTRs.
Collapse
Affiliation(s)
- Laurent Weekers
- Division of Nephrology, Department of Internal Medicine, University of Liège Hospital (ULg CHU), Liège, Belgium
| | - Pauline Vanderweckene
- Division of Nephrology, Department of Internal Medicine, University of Liège Hospital (ULg CHU), Liège, Belgium
| | - Hans Pottel
- KU Leuven Kulak, Department of Public Health and Primary Care, University of Leuven, Kortrijk, Belgium
| | - Diego Castanares-Zapatero
- Intensive Care Unit, Cliniques universistaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium
| | - Catherine Bonvoisin
- Division of Nephrology, Department of Internal Medicine, University of Liège Hospital (ULg CHU), Liège, Belgium
| | - Etienne Hamoir
- Division of Abdominal Surgery and Transplantation, Department of Surgery, University of Liège Hospital (ULg CHU), Liège, Belgium
| | - Sylvie Maweja
- Division of Abdominal Surgery and Transplantation, Department of Surgery, University of Liège Hospital (ULg CHU), Liège, Belgium
| | - Jean-Marie Krzesinski
- Division of Nephrology, Department of Internal Medicine, University of Liège Hospital (ULg CHU), Liège, Belgium
| | - Pierre Delanaye
- Division of Nephrology, Department of Internal Medicine, University of Liège Hospital (ULg CHU), Liège, Belgium
| | - François Jouret
- Division of Nephrology, Department of Internal Medicine, University of Liège Hospital (ULg CHU), Liège, Belgium.,Groupe Interdisciplinaire de Génoprotéomique Appliquée (GIGA), Cardiovascular Sciences, University of Liège, Liège, Belgium
| |
Collapse
|
17
|
Abstract
Hypertension continues to be a major contributor to global morbidity and mortality, fuelled by an abundance of patients with uncontrolled blood pressure despite the multitude of pharmacological options available. This may occur as a consequence of true resistant hypertension, through an inability to tolerate current pharmacological therapies, or non-adherence to antihypertensive medication. In recent years, there has been a rapid expansion of device-based therapies proposed as novel non-pharmacological approaches to treating resistant hypertension. In this review, we discuss seven novel devices—renal nerve denervation, baroreflex activation therapy, carotid body ablation, central iliac arteriovenous anastomosis, deep brain stimulation, median nerve stimulation, and vagal nerve stimulation. We highlight how the devices differ, the varying degrees of evidence available to date and upcoming trials. This review also considers the possible factors that may enable appropriate device selection for different hypertension phenotypes.
Collapse
Affiliation(s)
- Fu L Ng
- Barts BP Centre of Excellence, Barts Heart Centre, St Bartholomew's Hospital, W Smithfield, London, EC1A 7BE, UK.,Barts NIHR Cardiovascular Biomedical Research Unit, Charterhouse Square, William Harvey Research Institute, Queen Mary University London, London, EC1M 6BQ, UK
| | - Manish Saxena
- Barts BP Centre of Excellence, Barts Heart Centre, St Bartholomew's Hospital, W Smithfield, London, EC1A 7BE, UK.,Barts NIHR Cardiovascular Biomedical Research Unit, Charterhouse Square, William Harvey Research Institute, Queen Mary University London, London, EC1M 6BQ, UK
| | - Felix Mahfoud
- Department of Internal Medicine, Cardiology, Angiology, Intensive Care Medicine, Saarland University Hospital, Homburg/Saar, Germany
| | - Atul Pathak
- Department of Cardiovascular Medicine, Hypertension and Heart Failure Unit, Health Innovation Lab (Hi-Lab) Clinique Pasteur, Toulouse, France
| | - Melvin D Lobo
- Barts BP Centre of Excellence, Barts Heart Centre, St Bartholomew's Hospital, W Smithfield, London, EC1A 7BE, UK. .,Barts NIHR Cardiovascular Biomedical Research Unit, Charterhouse Square, William Harvey Research Institute, Queen Mary University London, London, EC1M 6BQ, UK.
| |
Collapse
|
18
|
Lobo MD, Sobotka PA, Pathak A. Interventional procedures and future drug therapy for hypertension. Eur Heart J 2017; 38:1101-1111. [PMID: 27406184 PMCID: PMC5400047 DOI: 10.1093/eurheartj/ehw303] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Revised: 05/09/2016] [Accepted: 06/16/2016] [Indexed: 02/06/2023] Open
Abstract
Hypertension management poses a major challenge to clinicians globally once non-drug (lifestyle) measures have failed to control blood pressure (BP). Although drug treatment strategies to lower BP are well described, poor control rates of hypertension, even in the first world, suggest that more needs to be done to surmount the problem. A major issue is non-adherence to antihypertensive drugs, which is caused in part by drug intolerance due to side effects. More effective antihypertensive drugs are therefore required which have excellent tolerability and safety profiles in addition to being efficacious. For those patients who either do not tolerate or wish to take medication for hypertension or in whom BP control is not attained despite multiple antihypertensives, a novel class of interventional procedures to manage hypertension has emerged. While most of these target various aspects of the sympathetic nervous system regulation of BP, an additional procedure is now available, which addresses mechanical aspects of the circulation. Most of these new devices are supported by early and encouraging evidence for both safety and efficacy, although it is clear that more rigorous randomized controlled trial data will be essential before any of the technologies can be adopted as a standard of care.
Collapse
Affiliation(s)
- Melvin D. Lobo
- Barts BP Centre of Excellence, Barts Heart Centre, St Bartholomew's Hospital, Barts Health NHS Trust, London, UK
- William Harvey Research Institute, Barts NIHR Cardiovascular Biomedical Research Unit, Queen Mary University of London, London, UK
| | - Paul A. Sobotka
- The Ohio State University, Columbus, OH, USA
- ROX Medical, San Clemente, CA, USA
| | - Atul Pathak
- Department of Cardiovascular Medicine, Hypertension and Heart Failure Unit, Health Innovation Lab (Hi-Lab) Clinique Pasteur, Toulouse, France
| |
Collapse
|
19
|
Procedural Reassessment of Radiofrequency Renal Denervation in Resistant Hypertensive Patients. High Blood Press Cardiovasc Prev 2017; 24:187-192. [PMID: 28374154 DOI: 10.1007/s40292-017-0197-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Accepted: 03/27/2017] [Indexed: 10/19/2022] Open
Abstract
INTRODUCTION Recent anatomical and clinical studies have led to the hypothesis that in several cases of failure of response to renal denervation (RDN), the procedure has not been technically correct. AIM To perform procedural reassessment in patients with true resistant hypertension who underwent RDN. METHODS We retrospectively reassessed the procedural technique of RDN in 10 true resistant hypertensive patients, comparing the sites of renal ablations with the knowledge of animal and human post mortem evidences. Procedural ablation technique was assessed in terms of number of ablations for each renal artery and site of ablation (quadrant and distance from renal ostium) by using the radiologic images of each RDN and the number of radiofrequency ablation attempts documented in the reports of each denervation session. RESULTS 10 patients were studied, 9 denervated with Simplicity monoelectrode catheter, 1 with multielectrode balloon technique. Responders to the procedure underwent more ablations and particularly at least a quadrant ablation in one of the kidney arteries, >2 ablations in Dorsal plus Ventral quadrants and in 67% of then >10 ablations were done in superior inferior and ventral quadrants. CONCLUSION This study confirms the importance of a well knowledge of renal artery anatomy and underlines the relevance of the choice of ablation sites in order to obtain a successful RDN procedure.
Collapse
|
20
|
Ott C, Lobo MD, Sobotka PA, Mahfoud F, Stanton A, Cockcroft J, Sulke N, Dolan E, van der Giet M, Hoyer J, Furniss SS, Foran JP, Witkowski A, Januszewicz A, Schoors D, Tsioufis K, Rensing BJ, Saxena M, Scott B, Ng GA, Achenbach S, Schmieder RE. Effect of Arteriovenous Anastomosis on Blood Pressure Reduction in Patients With Isolated Systolic Hypertension Compared With Combined Hypertension. J Am Heart Assoc 2016; 5:JAHA.116.004234. [PMID: 28003251 PMCID: PMC5210451 DOI: 10.1161/jaha.116.004234] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
Background Options for interventional therapy to lower blood pressure (BP) in patients with treatment‐resistant hypertension include renal denervation and the creation of an arteriovenous anastomosis using the ROX coupler. It has been shown that BP response after renal denervation is greater in patients with combined hypertension (CH) than in patients with isolated systolic hypertension (ISH). We analyzed the effect of ROX coupler implantation in patients with CH as compared with ISH. Methods and Results The randomized, controlled, prospective ROX Control Hypertension Study included patients with true treatment‐resistant hypertension (office systolic BP ≥140 mm Hg, average daytime ambulatory BP ≥135/85 mm Hg, and treatment with ≥3 antihypertensive drugs including a diuretic). In a post hoc analysis, we stratified patients with CH (n=31) and ISH (n=11). Baseline office systolic BP (177±18 mm Hg versus 169±17 mm Hg, P=0.163) and 24‐hour ambulatory systolic BP (159±16 mm Hg versus 154±11 mm Hg, P=0.463) did not differ between patients with CH and those with ISH. ROX coupler implementation resulted in a significant reduction in office systolic BP (CH: −29±21 mm Hg versus ISH: −22±31 mm Hg, P=0.445) and 24‐hour ambulatory systolic BP (CH: −14±20 mm Hg versus ISH: −13±15 mm Hg, P=0.672), without significant differences between the two groups. The responder rate (office systolic BP reduction ≥10 mm Hg) after 6 months was not different (CH: 81% versus ISH: 82%, P=0.932). Conclusions Our data suggest that creation of an arteriovenous anastomosis using the ROX coupler system leads to a similar reduction of office and 24‐hour ambulatory systolic BP in patients with combined and isolated systolic hypertension. Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT01642498.
Collapse
Affiliation(s)
- Christian Ott
- Department of Nephrology and Hypertension, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Melvin D Lobo
- William Harvey Research Institute, Barts NIHR Cardiovascular Biomedical Research Unit, Queen Mary University of London, United Kingdom
| | | | - Felix Mahfoud
- Klinik für Innere Medizin III, Universitätsklinikum des Saarlandes, Homburg/Saar, Germany
| | - Alice Stanton
- Molecular and Cellular Therapeutics, Royal College of Surgeons in Ireland Medical School, Dublin, Ireland
| | - John Cockcroft
- Cardiolgy Department, Wales Heart Research Institute, Cardiff, United Kingdom
| | - Neil Sulke
- Cardiology Department, Eastbourne District General Hospital, East Sussex, United Kingdom
| | - Eamon Dolan
- Department of Medicine for the Elderly, Connolly Hospital, Dublin, Ireland
| | - Markus van der Giet
- Department of Endocrinology and Nephrology, Universitätsmedizin Berlin, Berlin, Germany
| | - Joachim Hoyer
- Department of Internal Medicine and Nephrology, Universitätsklinikum Gießen und Marburg GmbH, Marburg, Germany
| | - Stephen S Furniss
- Department of Cardiology, East Sussex Healthcare NHS Trust, East Sussex, United Kingdom
| | - John P Foran
- Cardiac Department, Royal Brompton Hospital, London, United Kingdom.,Cardiolgy Department, St. Helier Hospital, Surrey, United Kingdom
| | | | | | - Danny Schoors
- Department of Cardiology, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | | | - Benno J Rensing
- Department of Cardiology, St. Antonius Ziekenhuis, Nieuwegein, the Netherlands
| | - Manish Saxena
- William Harvey Research Institute, Barts NIHR Cardiovascular Biomedical Research Unit, Queen Mary University of London, United Kingdom
| | - Benjamin Scott
- Department of Cardiology, ZNA - Cardio Middelheim, Antwerp, Belgium
| | - G André Ng
- Department of Cardiovascular Sciences, University of Leicester Glenfield Hospital/NIHR Leicester Cardiovascular Biomedical Research, Leicester, United Kingdom
| | - Stephan Achenbach
- Department of Cardiology, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Roland E Schmieder
- Department of Nephrology and Hypertension, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany
| |
Collapse
|
21
|
Purinergic receptors in the carotid body as a new drug target for controlling hypertension. Nat Med 2016; 22:1151-1159. [PMID: 27595323 DOI: 10.1038/nm.4173] [Citation(s) in RCA: 138] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Accepted: 07/27/2016] [Indexed: 11/09/2022]
Abstract
In view of the high proportion of individuals with resistance to antihypertensive medication and/or poor compliance or tolerance of this medication, new drugs to treat hypertension are urgently needed. Here we show that peripheral chemoreceptors generate aberrant signaling that contributes to high blood pressure in hypertension. We discovered that purinergic receptor P2X3 (P2rx3, also known as P2x3) mRNA expression is upregulated substantially in chemoreceptive petrosal sensory neurons in rats with hypertension. These neurons generate both tonic drive and hyperreflexia in hypertensive (but not normotensive) rats, and both phenomena are normalized by the blockade of P2X3 receptors. Antagonism of P2X3 receptors also reduces arterial pressure and basal sympathetic activity and normalizes carotid body hyperreflexia in conscious rats with hypertension; no effect was observed in rats without hypertension. We verified P2X3 receptor expression in human carotid bodies and observed hyperactivity of carotid bodies in individuals with hypertension. These data support the identification of the P2X3 receptor as a potential new target for the control of human hypertension.
Collapse
|
22
|
Eirin A, Textor SC, Lerman LO. Emerging concepts for patients with treatment-resistant hypertension. Trends Cardiovasc Med 2016; 26:700-706. [PMID: 27381561 DOI: 10.1016/j.tcm.2016.05.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Revised: 05/09/2016] [Accepted: 05/09/2016] [Indexed: 11/15/2022]
Abstract
Treatment-resistant hypertension (TRH) is defined as elevated blood pressure despite treatment with three properly dosed antihypertensive drugs, and is associated with adverse cardiovascular and renal outcomes and increased mortality. Treatment of patients with TRH focuses on maximizing the doses of antihypertensive drugs and adding drugs with complementary mechanisms of action, including a combination of angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers, calcium channel blockers, and thiazide-like diuretics. Randomized clinical trials have demonstrated the efficacy of the mineralocorticoid receptor antagonist spironolactone as a fourth-line therapy for patients with TRH. Other pharmacologic considerations include adding α-blockers, combined α-β-blockers, centrally acting α-agonists, or direct vasodilators. However, a small, but important subset of patients remain hypertensive despite combination regimens with multiple antihypertensive drugs, underscoring the need for novel blood pressure-lowering therapies. Over recent years, alternative approaches for treating TRH have emerged, including agonists of natriuretic peptides, endothelin-receptor antagonists, and additional vasoactive drugs. Lastly, device-based interventions, such as renal denervation or carotid baroreflex activation, may supplement drug therapy for these patients. This review summarizes current knowledge on the management of TRH, with focus on novel therapeutic strategies designed to achieve optimal blood pressure control.
Collapse
Affiliation(s)
- Alfonso Eirin
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
| | - Stephen C Textor
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
| | - Lilach O Lerman
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN.
| |
Collapse
|
23
|
Abstract
Access surgeons will encounter patients with functioning transplants who want to lose their fistula, and every dialysis unit sees patients returning after a failed kidney transplant for whom an old fistula is a readily available lifeline. The decision is straightforward in patients with perfectly functioning transplants and disabling complications of their fistula, or in patients with failing transplants and a good fistula. The challenge is to make this decision in patients with good transplant function and an asymptomatic fistula. Despite improvements in one-year survival of renal grafts, the long-term graft survival has improved modestly. This means about half of the patients with a successful kidney transplant will return to dialysis within 10 years. Use of recently developed risk calculators, based on clinical parameters, may help in the decision process. A high flow fistula can lead to heart failure but most fistulae are well tolerated in asymptomatic patients and the effects of closure of the AVF on the heart are modest. Recent evidence suggests that there may be benefits of a functioning AVF that may need to be considered in this decision process. This article reviews the literature and comes to pragmatic recommendations of what to do with this conundrum.
Collapse
|
24
|
Sulke N, Eysenck W, Badiani S, Furniss S. Structural cure for reflex syncope? BMJ Case Rep 2016; 2016:bcr-2015-213990. [PMID: 26791131 DOI: 10.1136/bcr-2015-213990] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
The ROX Coupler is a device that allows creation of a central arteriovenous anastomosis at the iliac level. The device has been shown to improve exercise capacity in patients with chronic obstructive pulmonary disease and is CE marked for the treatment of resistant and uncontrolled hypertension. Reflex syncope is a challenging clinical condition with limited proven therapeutic options. We describe the resolution of symptoms and tilt table response of a patient who underwent insertion of a ROX Coupler to treat hypertension, and also incidentally had pre-existing vasodepressor syncope.
Collapse
Affiliation(s)
- Neil Sulke
- Department of Cardiology, Eastbourne District General Hospital, Eastbourne, UK
| | - William Eysenck
- Department of Cardiology, Eastbourne District General Hospital, Eastbourne, UK
| | - Sveeta Badiani
- Department of Cardiology, Eastbourne District General Hospital, Eastbourne, UK
| | - Stephen Furniss
- Department of Cardiology, Eastbourne District General Hospital, Eastbourne, UK
| |
Collapse
|
25
|
Kapil V, Sobotka PA, Saxena M, Mathur A, Knight C, Dolan E, Stanton A, Lobo MD. Central iliac arteriovenous anastomosis for hypertension: targeting mechanical aspects of the circulation. Curr Hypertens Rep 2015; 17:585. [PMID: 26228235 PMCID: PMC4521087 DOI: 10.1007/s11906-015-0585-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Raised blood pressure is the leading attributable risk factor for global morbidity and mortality. Real world data demonstrates that half of treated patients are at elevated cardiovascular risk because of inadequately controlled BP. In addition to pharmacotherapy, certain interventional strategies to reduce blood pressure and cardiovascular risk in hypertension can be considered according to international guidelines. One of the newer technologies entering this field is a proprietary arteriovenous coupler device that forms a fixed flow arteriovenous conduit in the central vasculature. In this review, we examine the development of and rationale for the creation of a central arteriovenous anastomosis in patients with hypertension and review the proposed mechanisms by which it may ameliorate hypertension. We critically review the clinical trial evidence base to date and postulate on future therapeutic directions.
Collapse
Affiliation(s)
- Vikas Kapil
- />Barts BP Centre of Excellence, Barts Heart Centre, St Bartholomew’s Hospital, W Smithfield, London, EC1A 7BE UK
- />William Harvey Research Institute, Barts NIHR Cardiovascular Biomedical Research Unit, Charterhouse Square, Queen Mary University London, London, EC1M 6BQ UK
| | - Paul A. Sobotka
- />Department of Internal Medicine, Division of Cardiovascular Diseases, The Ohio State University, Columbus, OH 43210 USA
- />ROX Medical, 150 Calle Iglesia # A, San Clemente, CA 92672 USA
| | - Manish Saxena
- />Barts BP Centre of Excellence, Barts Heart Centre, St Bartholomew’s Hospital, W Smithfield, London, EC1A 7BE UK
- />William Harvey Research Institute, Barts NIHR Cardiovascular Biomedical Research Unit, Charterhouse Square, Queen Mary University London, London, EC1M 6BQ UK
| | - Anthony Mathur
- />Barts BP Centre of Excellence, Barts Heart Centre, St Bartholomew’s Hospital, W Smithfield, London, EC1A 7BE UK
- />Department of Cardiology, Barts Heart Centre, St Bartholomew’s Hospital, W Smithfield, London, EC1A 7BE UK
| | - Charles Knight
- />Barts BP Centre of Excellence, Barts Heart Centre, St Bartholomew’s Hospital, W Smithfield, London, EC1A 7BE UK
- />Department of Cardiology, Barts Heart Centre, St Bartholomew’s Hospital, W Smithfield, London, EC1A 7BE UK
| | - Eamon Dolan
- />Department of Medicine for the Elderly, Connolly Hospital, Mill Road, Blanchardstown, Dublin 15 Dublin, Ireland
| | - Alice Stanton
- />Molecular and Cellular Therapeutics, Royal College of Surgeons in Ireland Medical School, 123 Saint Stephen’s Green, Dublin 2 Dublin, Ireland
| | - Melvin D. Lobo
- />Barts BP Centre of Excellence, Barts Heart Centre, St Bartholomew’s Hospital, W Smithfield, London, EC1A 7BE UK
- />William Harvey Research Institute, Barts NIHR Cardiovascular Biomedical Research Unit, Charterhouse Square, Queen Mary University London, London, EC1M 6BQ UK
| |
Collapse
|
26
|
Brier TJ, Jain AK, Lobo MD. Central arteriovenous anastomosis for hypertension: it is not all about sympathomodulation. Future Cardiol 2015; 11:503-6. [DOI: 10.2217/fca.15.34] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Tim J Brier
- Barts BP Centre of Excellence, Barts Heart Centre, St Bartholomew's Hospital, Barts Health NHS Trust, London, EC1A 7BE, UK
- William Harvey Research Institute, Centre for Clinical Pharmacology, NIHR Cardiovascular Biomedical Research Unit, Queen Mary University of London, London, E1 4NS, UK
| | - Ajay K Jain
- Department of Cardiology, Barts Health NHS Trust, London, EC1A 7BE, UK
| | - Melvin D Lobo
- Barts BP Centre of Excellence, Barts Heart Centre, St Bartholomew's Hospital, Barts Health NHS Trust, London, EC1A 7BE, UK
- William Harvey Research Institute, Centre for Clinical Pharmacology, NIHR Cardiovascular Biomedical Research Unit, Queen Mary University of London, London, E1 4NS, UK
| |
Collapse
|
27
|
Locatelli F, Zoccali C. Arteriovenous fistula as a nephroprotective intervention in advanced CKD: scientific discovery and explanation, and the evaluation of interventions. Nephrol Dial Transplant 2015; 30:1939-41. [PMID: 26232781 DOI: 10.1093/ndt/gfv281] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Accepted: 06/22/2015] [Indexed: 12/27/2022] Open
Affiliation(s)
| | - Carmine Zoccali
- CNR-IFC Pathophysiology of Renal Diseases and Hypertension Unit, Reggio Calabria, Italy
| |
Collapse
|
28
|
Lobo MD, Sobotka PA, Stanton A, Cockcroft JR, Sulke N, Dolan E, van der Giet M, Hoyer J, Furniss SS, Foran JP, Witkowski A, Januszewicz A, Schoors D, Tsioufis K, Rensing BJ, Scott B, Ng GA, Ott C, Schmieder RE. Central arteriovenous anastomosis for the treatment of patients with uncontrolled hypertension (the ROX CONTROL HTN study): a randomised controlled trial. Lancet 2015; 385:1634-41. [PMID: 25620016 DOI: 10.1016/s0140-6736(14)62053-5] [Citation(s) in RCA: 99] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND Hypertension contributes to cardiovascular morbidity and mortality. We assessed the safety and efficacy of a central iliac arteriovenous anastomosis to alter the mechanical arterial properties and reduce blood pressure in patients with uncontrolled hypertension. METHODS We enrolled patients in this open-label, multicentre, prospective, randomised, controlled trial between October, 2012, and April, 2014. Eligible patients had baseline office systolic blood pressure of 140 mm Hg or higher and average daytime ambulatory blood pressure of 135 mm Hg or higher systolic and 85 mm Hg or higher diastolic despite antihypertensive treatment. Patients were randomly allocated in a 1:1 ratio to undergo implantation of an arteriovenous coupler device plus current pharmaceutical treatment or to maintain current treatment alone (control). The primary endpoint was mean change from baseline in office and 24 h ambulatory systolic blood pressure at 6 months. Analysis was by modified intention to treat (all patients remaining in follow-up at 6 months). This trial is registered with ClinicalTrials.gov, number NCT01642498. FINDINGS 83 (43%) of 195 patients screened were assigned arteriovenous coupler therapy (n=44) or normal care (n=39). Mean office systolic blood pressure reduced by 26·9 (SD 23·9) mm Hg in the arteriovenous coupler group (p<0·0001) and by 3·7 (21·2) mm Hg in the control group (p=0·31). Mean systolic 24 h ambulatory blood pressure reduced by 13·5 (18·8) mm Hg (p<0·0001) in arteriovenous coupler recipients and by 0·5 (15·8) mm Hg (p=0·86) in controls. Implantation of the arteriovenous coupler was associated with late ipsilateral venous stenosis in 12 (29%) of 42 patients and was treatable with venoplasty or stenting. INTERPRETATION Arteriovenous anastomosis was associated with significantly reduced blood pressure and hypertensive complications. This approach might be a useful adjunctive therapy for patients with uncontrolled hypertension. FUNDING ROX Medical.
Collapse
Affiliation(s)
- Melvin D Lobo
- William Harvey Research Institute, Barts NIHR Cardiovascular Biomedical Research Unit, Queen Mary University of London, London, UK.
| | - Paul A Sobotka
- ROX Medical, San Clemente, CA, USA; Cardiovascular Medicine, Ohio State University, Columbus, OH, USA
| | - Alice Stanton
- Molecular and Cellular Therapeutics, Royal College of Surgeons in Ireland Medical School, Dublin, Ireland
| | - John R Cockcroft
- Cardiology Department, Wales Heart Research Institute, Cardiff, UK
| | - Neil Sulke
- Cardiology Department, Eastbourne District General Hospital, East Sussex, UK
| | - Eamon Dolan
- Department of Medicine for the Elderly, Connolly Hospital, Dublin, Ireland
| | - Markus van der Giet
- Department of Endocinrology and Nephrology, Universitätsmedizin Berlin, Berlin, Germany
| | - Joachim Hoyer
- Department of Internal Medicine and Nephrology, Universitätsklinikum Gießen und Marburg GmbH, Marburg, Germany
| | - Stephen S Furniss
- Department of Cardiology, East Sussex Healthcare NHS Trust, East Sussex, UK
| | - John P Foran
- Cardiac Department, Royal Brompton Hospital, London, UK; Cardiology Department, St Helier Hospital, Surrey, UK
| | - Adam Witkowski
- Department of Interventional Cardiology and Angiology, Institute of Cardiology, Warsaw, Poland
| | | | - Danny Schoors
- Department of Cardiology, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | | | - Benno J Rensing
- Department of Cardiology, St Antonius Ziekenhuis, Nieuwegein, Netherlands
| | - Benjamin Scott
- Department of Cardiology, ZNA-Cardio Middelheim, Antwerp, Belgium
| | - G André Ng
- Department of Cardiovascular Sciences, University of Leicester Glenfield Hospital/NIHR Leicester Cardiovascular Biomedical Research, Leicester, UK
| | - Christian Ott
- Department of Nephrology and Hypertension, Universitätsklinikum Erlangen, Erlangen, Germany
| | - Roland E Schmieder
- Department of Nephrology and Hypertension, Universitätsklinikum Erlangen, Erlangen, Germany
| |
Collapse
|
29
|
Persu A, Jin Y, Fadl Elmula FEM, Renkin J, Høieggen A, Kjeldsen SE, Staessen JA. Renal denervation in treatment-resistant hypertension: a reappraisal. Curr Opin Pharmacol 2015; 21:48-52. [DOI: 10.1016/j.coph.2014.12.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Revised: 12/11/2014] [Accepted: 12/21/2014] [Indexed: 11/30/2022]
|
30
|
Abstract
Hypertension is the most common modifiable risk factor for cardiovascular disease and death, and lowering blood pressure with antihypertensive drugs reduces target organ damage and prevents cardiovascular disease outcomes. Despite a plethora of available treatment options, a substantial portion of the hypertensive population has uncontrolled blood pressure. The unmet need of controlling blood pressure in this population may be addressed, in part, by developing new drugs and devices/procedures to treat hypertension and its comorbidities. In this Compendium Review, we discuss new drugs and interventional treatments that are undergoing preclinical or clinical testing for hypertension treatment. New drug classes, eg, inhibitors of vasopeptidases, aldosterone synthase and soluble epoxide hydrolase, agonists of natriuretic peptide A and vasoactive intestinal peptide receptor 2, and a novel mineralocorticoid receptor antagonist are in phase II/III of development, while inhibitors of aminopeptidase A, dopamine β-hydroxylase, and the intestinal Na
+
/H
+
exchanger 3, agonists of components of the angiotensin-converting enzyme 2/angiotensin(1–7)/Mas receptor axis and vaccines directed toward angiotensin II and its type 1 receptor are in phase I or preclinical development. The two main interventional approaches, transcatheter renal denervation and baroreflex activation therapy, are used in clinical practice for severe treatment resistant hypertension in some countries. Renal denervation is also being evaluated for treatment of various comorbidities, eg, chronic heart failure, cardiac arrhythmias and chronic renal failure. Novel interventional approaches in early development include carotid body ablation and arteriovenous fistula placement. Importantly, none of these novel drug or device treatments has been shown to prevent cardiovascular disease outcomes or death in hypertensive patients.
Collapse
Affiliation(s)
- Suzanne Oparil
- From the Vascular Biology and Hypertension Program, Division of Cardiovascular Disease, Department of Medicine, The University of Alabama at Birmingham, Birmingham, Alabama (S.O.); and Department of Nephrology and Hypertension, University Hospital of the University Erlangen-Nürnberg, Germany (R.E.S.)
| | - Roland E. Schmieder
- From the Vascular Biology and Hypertension Program, Division of Cardiovascular Disease, Department of Medicine, The University of Alabama at Birmingham, Birmingham, Alabama (S.O.); and Department of Nephrology and Hypertension, University Hospital of the University Erlangen-Nürnberg, Germany (R.E.S.)
| |
Collapse
|
31
|
Foran JP, Jain AK, Casserly IP, Kandzari DE, Rocha-Singh KJ, Witkowski A, Katzen BT, Deaton D, Balmforth P, Sobotka PA. The ROX coupler: Creation of a fixed iliac arteriovenous anastomosis for the treatment of uncontrolled systemic arterial hypertension, exploiting the physical properties of the arterial vasculature. Catheter Cardiovasc Interv 2014; 85:880-6. [DOI: 10.1002/ccd.25707] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2014] [Revised: 10/09/2014] [Accepted: 10/10/2014] [Indexed: 11/10/2022]
Affiliation(s)
- John P. Foran
- Royal Brompton Hospital; London United Kingdom
- St. Helier University Hospital; Surrey United Kingdom
| | - Ajay K. Jain
- London Chest Hospital; National Institute for Health Research (NIHR) Cardiovascular Biomedical Research Unit, Barts Health NHS Trust; London United Kingdom
| | | | | | | | | | - Barry T. Katzen
- Miami Cardiac & Vascular Institute, Baptist Hospital of Miami; Miami Florida
| | | | | | - Paul A. Sobotka
- The Ohio State University, Columbus, Ohio; and ROX Medical, Inc.; San Clemente California
| |
Collapse
|
32
|
|
33
|
Aronow HD, Li J, Parikh SA. Where and when device therapy may be useful in the management of drug-resistant hypertension. Curr Cardiol Rep 2014; 16:546. [PMID: 25326400 DOI: 10.1007/s11886-014-0546-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Device therapy for the treatment of uncontrolled and resistant hypertension has evolved significantly over the past several decades. Both renal artery disease and sympathetic hyperactivity have been linked to resistant hypertension. This manuscript will review the current evidence base supporting device therapy (e.g., renal artery revascularization, sympathetic nervous system modulation) for resistant hypertension.
Collapse
Affiliation(s)
- Herbert D Aronow
- Michigan Heart, 5325 Elliott Dr., Ste. #202, Ypsilanti, MI, 48197, USA,
| | | | | |
Collapse
|
34
|
Diogo LN, Monteiro EC. The efficacy of antihypertensive drugs in chronic intermittent hypoxia conditions. Front Physiol 2014; 5:361. [PMID: 25295010 PMCID: PMC4170135 DOI: 10.3389/fphys.2014.00361] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Accepted: 09/03/2014] [Indexed: 12/22/2022] Open
Abstract
Sleep apnea/hypopnea disorders include centrally originated diseases and obstructive sleep apnea (OSA). This last condition is renowned as a frequent secondary cause of hypertension (HT). The mechanisms involved in the pathogenesis of HT can be summarized in relation to two main pathways: sympathetic nervous system stimulation mediated mainly by activation of carotid body (CB) chemoreflexes and/or asphyxia, and, by no means the least important, the systemic effects of chronic intermittent hypoxia (CIH). The use of animal models has revealed that CIH is the critical stimulus underlying sympathetic activity and hypertension, and that this effect requires the presence of functional arterial chemoreceptors, which are hyperactive in CIH. These models of CIH mimic the HT observed in humans and allow the study of CIH independently without the mechanical obstruction component. The effect of continuous positive airway pressure (CPAP), the gold standard treatment for OSA patients, to reduce blood pressure seems to be modest and concomitant antihypertensive therapy is still required. We focus this review on the efficacy of pharmacological interventions to revert HT associated with CIH conditions in both animal models and humans. First, we explore the experimental animal models, developed to mimic HT related to CIH, which have been used to investigate the effect of antihypertensive drugs (AHDs). Second, we review what is known about drug efficacy to reverse HT induced by CIH in animals. Moreover, findings in humans with OSA are cited to demonstrate the lack of strong evidence for the establishment of a first-line antihypertensive regimen for these patients. Indeed, specific therapeutic guidelines for the pharmacological treatment of HT in these patients are still lacking. Finally, we discuss the future perspectives concerning the non-pharmacological and pharmacological management of this particular type of HT.
Collapse
Affiliation(s)
- Lucilia N Diogo
- Centro de Estudos de Doenças Crónicas, CEDOC, NOVA Medical School/Faculdade de Ciências Médicas, Universidade Nova de Lisboa Lisboa, Portugal
| | - Emília C Monteiro
- Centro de Estudos de Doenças Crónicas, CEDOC, NOVA Medical School/Faculdade de Ciências Médicas, Universidade Nova de Lisboa Lisboa, Portugal
| |
Collapse
|
35
|
|
36
|
Ivy JR, Bailey MA. Pressure natriuresis and the renal control of arterial blood pressure. J Physiol 2014; 592:3955-67. [PMID: 25107929 DOI: 10.1113/jphysiol.2014.271676] [Citation(s) in RCA: 98] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
The regulation of extracellular fluid volume by renal sodium excretion lies at the centre of blood pressure homeostasis. Renal perfusion pressure can directly regulate sodium reabsorption in the proximal tubule. This acute pressure natriuresis response is a uniquely powerful means of stabilizing long-term blood pressure around a set point. By logical extension, deviation from the set point can only be sustained if the pressure natriuresis mechanism is impaired, suggesting that hypertension is caused or sustained by a defect in the relationship between renal perfusion pressure and sodium excretion. Here we describe the role of pressure natriuresis in blood pressure control and outline the cascade of biophysical and paracrine events in the renal medulla that integrate the vascular and tubular response to altered perfusion pressure. Pressure natriuresis is impaired in hypertension and mechanistic insight into dysfunction comes from genetic analysis of blood pressure disorders. Transplantation studies in rats show that blood pressure is determined by the genotype of the kidney and Mendelian hypertension indicates that the distal nephron influences the overall natriuretic efficiency. These approaches and the outcomes of genome-wide-association studies broaden our view of blood pressure control, suggesting that renal sympathetic nerve activity and local inflammation can impair pressure natriuresis to cause hypertension. Understanding how these systems interact is necessary to tackle the global burden of hypertension.
Collapse
Affiliation(s)
- Jessica R Ivy
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Matthew A Bailey
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| |
Collapse
|