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Okamura K, Shimada H, Imazato K, Sako H, Udo A, Taniguchi K, Morisaki S, Imamura I, Urata H, Arima H, Miura SI. Impact of renal denervation on quality of life (How does renal denervation contribute to improving hypertension treatment affected by poor medication adherence?). Hypertens Res 2024:10.1038/s41440-024-01679-7. [PMID: 38605140 DOI: 10.1038/s41440-024-01679-7] [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: 02/27/2024] [Revised: 03/20/2024] [Accepted: 03/22/2024] [Indexed: 04/13/2024]
Abstract
The US Food and Drug Administration has approved renal denervation (RDN) as a new treatment option for hypertension (HT) because it not only has antihypertensive effects but also improves the quality of blood pressure (BP) reduction. RDN is expected to be increasingly used in clinical practice in the future. This review summarizes the impact of RDN on quality of life (QOL). Although the treatment of HT aims to improve life prognosis, the use of antihypertensive agents can impair QOL because of adverse effects and lifestyle changes associated with long-term medication use. Consequently, poor adherence to antihypertensive agents is a common problem and may be the most important issue affecting patient QOL. In RDN trials in patients taking antihypertensive agents, approximately 40% of patients had poor adherence to the drugs. Poor adherence is often the cause of resistant hypertension. Therefore, RDN should be well suited to treating HT and improving QOL. Studies have shown that approximately 30% of HT patients prefer RDN to drug treatment. Patients who prefer RDN are typically male and younger and have high BP, poor adherence, and a history of adverse effects of antihypertensive agents. We hope that RDN will improve not only life prognosis but also QOL in HT patients because of its benefits for adherence. Furthermore, we expect that in the future, RDN will be used in other sympathetic nervous system-related diseases, such as heart failure, atrial fibrillation, and sleep apnea syndrome.
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Affiliation(s)
- Keisuke Okamura
- Department of Cardiology and Cardiovascular Center, Imamura Hospital, Tosu, Saga, Japan.
- Department of Cardiology, Fukuoka University School of Medicine, Fukuoka, Fukuoka, Japan.
| | - Hideaki Shimada
- Department of Cardiovascular Diseases, Fukuoka University Chikushi Hospital, Chikushino, Fukuoka, Japan
| | - Keisuke Imazato
- Department of Cardiology and Cardiovascular Center, Imamura Hospital, Tosu, Saga, Japan
| | - Hideto Sako
- Department of Cardiology and Cardiovascular Center, Imamura Hospital, Tosu, Saga, Japan
| | - Akihiro Udo
- Department of Cardiology and Cardiovascular Center, Imamura Hospital, Tosu, Saga, Japan
| | - Kenichiro Taniguchi
- Department of Cardiology and Cardiovascular Center, Imamura Hospital, Tosu, Saga, Japan
| | - Shogo Morisaki
- Department of Cardiology and Cardiovascular Center, Imamura Hospital, Tosu, Saga, Japan
| | - Ichiro Imamura
- Department of Cardiology and Cardiovascular Center, Imamura Hospital, Tosu, Saga, Japan
| | - Hidenori Urata
- Department of Cardiovascular Diseases, Fukuoka University Chikushi Hospital, Chikushino, Fukuoka, Japan
| | - Hisatomi Arima
- Department of Preventive Medicine and Public Health, Faculty of Medicine, Fukuoka University, Fukuoka, Fukuoka, Japan
| | - Shin-Ichiro Miura
- Department of Cardiology, Fukuoka University School of Medicine, Fukuoka, Fukuoka, Japan
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Hamdy A, El-Bassossy HM, Elshazly SM, El-Sayed SS. Rosuvastatin, but not atorvastatin, enhances the antihypertensive effect of cilostazol in an acute model of hypertension. NAUNYN-SCHMIEDEBERG'S ARCHIVES OF PHARMACOLOGY 2024; 397:2321-2334. [PMID: 37819392 PMCID: PMC10933198 DOI: 10.1007/s00210-023-02758-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 09/27/2023] [Indexed: 10/13/2023]
Abstract
PURPOSE Hypertensive emergency, a sudden and severe increase in blood pressure, necessitates immediate intervention to avoid end-organ damage. Cilostazol, a selective phosphodiesterase-III inhibitor, has vasodilator effect. Here, we investigated the effect of two commonly used statins, atorvastatin or rosuvastatin, on cilostazol antihypertensive activity in acute model of hypertension. METHODS Hypertensive emergency was induced via angiotensin II intravenous infusion (120 ng.kg-1.min-1). Rats were subjected to real-time arterial hemodynamics and electrocardiogram recording while investigated drugs were injected slowly at cumulative doses 0.5, 1, and 2 mg.kg-1, individually or in combination, followed by baroreflex sensitivity (BRS) analysis and serum electrolytes (Na+ and K+) and vasomodulators (norepinephrine (NE), and nitric oxide (NO)) assessment. RESULTS Cilostazol reduced systolic blood pressure (SBP), while co-injection with rosuvastatin augmented cilostazol SBP-reduction up to 30 mmHg. Compared to atorvastatin, rosuvastatin boosted the cilostazol-associated reduction in peripheral resistance, as evidenced by further decrease in diastolic, pulse, and dicrotic-notch pressures. Rosuvastatin co-injection prevented cilostazol-induced changes of ejection and non-ejection durations. Additionally, rosuvastatin coadministration produced better restoration of BRS, with an observed augmented increase in BRS indexes from spectral analysis. Greater reduction in sympathetic/parasympathetic ratio and serum NE upon rosuvastatin coadministration indicates further shift in sympathovagal balance towards parasympathetic dominance. Additionally, rosuvastatin coinjection caused a greater decrease in serum sodium, while more increase in NO indicating augmented reduction of extracellular volume and endothelial dysfunction. CONCLUSION Rosuvastatin boosted cilostazol's antihypertensive actions through effects on peripheral resistance, BRS, sympathovagal balance, endothelial dysfunction, and electrolytes balance, while atorvastatin did not demonstrate a comparable impact.
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Affiliation(s)
- Ahmed Hamdy
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Zagazig University, Zagazig, 44519, Egypt
| | - Hany M El-Bassossy
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Zagazig University, Zagazig, 44519, Egypt
| | - Shimaa M Elshazly
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Zagazig University, Zagazig, 44519, Egypt
| | - Shaimaa S El-Sayed
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Zagazig University, Zagazig, 44519, Egypt.
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Salman IM. Key challenges in exploring the rat as a preclinical neurostimulation model for aortic baroreflex modulation in hypertension. Hypertens Res 2024; 47:399-415. [PMID: 37919429 DOI: 10.1038/s41440-023-01486-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 10/02/2023] [Accepted: 10/06/2023] [Indexed: 11/04/2023]
Abstract
Electrode-based electrophysiological interfaces with peripheral nerves have come a long way since the 1960s, with several neurostimulation applications witnessing widespread clinical implementation since then. In resistant hypertension, previous clinical trials have shown that "carotid" baroreflex stimulation using device-based baroreflex activation therapy (BAT) can effectively lower blood pressure (BP). However, device-based "aortic" baroreflex stimulation remains untouched for clinical translation. The rat is a remarkable animal model that facilitates exploration of mechanisms pertaining to the baroreceptor reflex and preclinical development of novel therapeutic strategies for BP modulation and hypertension treatment. Specifically, the aortic depressor nerve (ADN) in rats carries a relatively pure population of barosensitive afferent neurons, which enable selective investigation of the aortic baroreflex function. In a rat model of essential hypertension, the spontaneously hypertensive rat (SHR), we have recently investigated the aortic baroreceptor afferents as an alternate target for BP modulation, and showed that "low intensity" stimulation is able to evoke clinically meaningful reductions in BP. Deriving high quality short-term and long-term data on aortic baroreflex modulation in rats is currently hampered by a number of unresolved experimental challenges, including anatomical variations across rats which complicates identification of the ADN, the use of unrefined neurostimulation tools or paradigms, and issues arising from anesthetized and conscious surgical preparations. With the goal of refining existing experimental protocols designed for preclinical investigation of the baroreflex, this review seeks to outline current challenges hindering further progress in aortic baroreflex modulation studies in rats and present some practical considerations and recently emerging ideas to overcome them. Aortic baroreflex modulation.
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Affiliation(s)
- Ibrahim M Salman
- Department of Pharmaceutical Sciences, College of Pharmacy, Alfaisal University, Riyadh, Saudi Arabia.
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Soares JÍ, da Silva TM, Castania JA, Reis UÁ, Roque LFM, Ribeiro AB, Salgado HC, Ribeiro AB. Electrical carotid sinus nerve stimulation attenuates experimental colitis induced by acetic acid in rats. Life Sci 2023; 335:122281. [PMID: 37984513 DOI: 10.1016/j.lfs.2023.122281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 11/14/2023] [Accepted: 11/17/2023] [Indexed: 11/22/2023]
Abstract
AIMS The carotid bodies are sensors that detect physiological signals and convey them to the central nervous system, where the stimuli are processed inducing reflexes through efferent pathways. Recent studies have demonstrated that electrical stimulation of the carotid sinus nerve (CSN) triggers the anti-inflammatory reflex under different conditions. However, whether this electrical stimulation attenuates colitis was never examined. This study aimed to evaluate if the electrical CSN stimulation attenuates the experimental colitis induced by intrarectal administration of acetic acid in rats. METHODS Electrodes were implanted around the CSN to stimulate the CSN, and a catheter was inserted into the left femoral artery to record the arterial pressure. The observation of hypotensive responses confirmed the effectiveness of the electrical CNS stimulation. This maneuver was followed by a 4 % acetic acid or saline administered intrarectally. After 24 h, colons were segmented into distal and proximal parts for macroscopy, histological and biochemical assessment. KEY FINDINGS As expected, the electrical CSN stimulation was effective in decreasing arterial pressure in saline and colitis rats. Moreover, electrical CSN stimulation effectively reduced colonic tissue lesions, colitis scores, and histopathologic parameters associated with colitis. In addition, the CSN stimulation also reduced the colonic mucosa pro-inflammatory cytokine interleukin-1 beta, and increased the anti-inflammatory interleukin-10, in rats submitted to colitis. SIGNIFICANCE These findings indicated that electrical CSN stimulation breaks the vicious cycle of local colon inflammation in colitis, which might contribute to its better outcome.
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Affiliation(s)
- Jefferson Ícaro Soares
- Department of Physiology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Thaís Marques da Silva
- Department of Physiology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Jaci Airton Castania
- Department of Physiology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | | | | | | | - Helio Cesar Salgado
- Department of Physiology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Aline Barbosa Ribeiro
- Department of Physiology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil; Barão de Mauá University Center, Ribeirão Preto, São Paulo, Brazil.
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Hering D, Narkiewicz K. Novel approaches: targeting sympathetic outflow in the carotid sinus. Blood Press 2023; 32:2232873. [PMID: 37470450 DOI: 10.1080/08037051.2023.2232873] [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: 11/28/2022] [Revised: 05/31/2023] [Accepted: 06/29/2023] [Indexed: 07/21/2023]
Abstract
Uncontrolled hypertension drives the global burden of increased cardiovascular disease (CVD) morbidity and mortality. Although high blood pressure (BP) is treatable and preventable, only half of the patients with hypertension undergoing treatment have their BP controlled. The failure of polypharmacy to attain adequate BP control may be due to a lack of physiological response, however, medication non-adherence and clinician inertia to increase treatment intensity are critical factors associated with poor hypertension management. The long-time medication titration, lifelong drug therapy, and often multi-drug treatment strategy are frustrating when the BP goal is not achieved, leading to increased CVD risk and a substantial burden on the healthcare system. Growing evidence indicates that neurohumoral activation is critical in initiating and maintaining elevated BP and its adverse consequences. Over the past decades, device-based therapies targeting the mechanisms underlying hypertension pathophysiology have been extensively studied. Among these, robust clinical experience for hypertension management exists for renal denervation (RDN) and baroreflex activation therapy (BAT), carotid body denervation (CBD), central arteriovenous anastomosis, and to a lesser extent, deep brain stimulation. Future studies are warranted to define the role of device-based approaches as an alternative or adjunctive treatment option to treat hypertension.
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Affiliation(s)
- Dagmara Hering
- Department of Hypertension and Diabetology, Medical University of Gdansk, Gdansk, Poland
| | - Krzysztof Narkiewicz
- Department of Hypertension and Diabetology, Medical University of Gdansk, Gdansk, Poland
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Kiuchi MG, Carnagarin R, Schultz C, Shetty S, Ward NC, Santos CE, Schlaich MP. Update on advanced interventional neuromodulatory approaches to lower blood pressure. Heart 2023; 109:1734-1740. [PMID: 37353317 DOI: 10.1136/heartjnl-2022-321499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 06/01/2023] [Indexed: 06/25/2023] Open
Abstract
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.
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Affiliation(s)
- Marcio Galindo Kiuchi
- Dobney Hypertension Centre, Medical School, The University of Western Australia, Perth, Western Australia, Australia
| | - Revathy Carnagarin
- Dobney Hypertension Centre, Medical School, The University of Western Australia, Perth, Western Australia, Australia
| | - Carl Schultz
- Department of Cardiology, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Sharad Shetty
- Department of Cardiology, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - Natalie C Ward
- Dobney Hypertension Centre, Medical School, The University of Western Australia, Perth, Western Australia, Australia
| | | | - Markus P Schlaich
- Dobney Hypertension Centre, Medical School, The University of Western Australia, Perth, Western Australia, Australia
- Department of Cardiology, Royal Perth Hospital, Perth, Western Australia, Australia
- Department of Nephrology, Royal Perth Hospital, Perth, Western Australia, Australia
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Peeters LE, Hesselink DA, Lafeber M, Severs D, van den Hoogen MW, Sonneveld MA, Ramakers CR, Bahmany S, van Gelder T, Koch BC, Versmissen J. Monitoring antihypertensive drug concentrations to determine nonadherence in hypertensive patients with or without a kidney transplant. J Hypertens 2023; 41:1239-1244. [PMID: 37195099 PMCID: PMC10328507 DOI: 10.1097/hjh.0000000000003459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 04/12/2023] [Indexed: 05/18/2023]
Abstract
BACKGROUND Nonadherence to antihypertensive drugs (AHDs) is a major contributor to pseudo-resistant hypertension. The primary objective of this study was to determine the prevalence of nonadherence to AHDs among patients visiting the nephrology and vascular outpatient clinics. METHODS Patients were eligible to participate in this prospective observational study if they used at least two AHDs that could be measured with a validated UHPLC-MS/MS method and had an office blood pressure at least 140 and/or at least 90 mmHg. For resistant hypertension, included patients had to use at least three AHDs including a diuretic or four AHDs. Adherence was assessed by measuring drug concentrations in blood. The complete absence of drug in blood was defined as nonadherence. A posthoc analysis was performed to determine the influence of a having a kidney transplant on the adherence rates. RESULTS One hundred and forty-two patients were included of whom 66 patients fulfilled the definition of resistant hypertension. The overall adherence rate to AHDs was 78.2% ( n = 111 patients), with the highest adherence rate for irbesartan (100%, n = 9) and lowest adherence rate for bumetanide ( n = 69%, n = 13). In further analysis, only kidney transplantation could be identified as an important factor for adherence (adjusted odds ratio = 3.35; 95% confidence interval 1.23-9.09). A posthoc analysis showed that patients with a kidney transplant were more likely to be adherent to AHDs (non-KT cohort 64.0% vs. KT-cohort 85.7%, χ 2 (2) = 10.34, P = 0.006). CONCLUSION The adherence rate to AHDs in hypertensive patients was high (78.2%) and even higher after a kidney transplant (85.7%). Furthermore, patients after kidney transplant had a lower risk of being nonadherent to AHDs.
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Affiliation(s)
- Laura E.J. Peeters
- Erasmus MC, University Medical Center Rotterdam, Department of Hospital Pharmacy
- Erasmus MC, University Medical Center Rotterdam, Department of Internal Medicine, Division of Vascular Medicine
| | - Dennis A. Hesselink
- Erasmus MC, University Medical Center Rotterdam, Department of Internal Medicine, Division of Nephrology and Transplantation
- Erasmus MC, University Medical Center Rotterdam, Erasmus MC Transplant Institute
| | - Melvin Lafeber
- Erasmus MC, University Medical Center Rotterdam, Department of Internal Medicine, Division of Vascular Medicine
| | - David Severs
- Erasmus MC, University Medical Center Rotterdam, Department of Internal Medicine, Division of Nephrology and Transplantation
- Erasmus MC, University Medical Center Rotterdam, Erasmus MC Transplant Institute
| | - Martijn W.F. van den Hoogen
- Erasmus MC, University Medical Center Rotterdam, Department of Internal Medicine, Division of Nephrology and Transplantation
| | - Michelle A.H. Sonneveld
- Erasmus MC, University Medical Center Rotterdam, Department of Internal Medicine, Division of Vascular Medicine
| | - Christian R.B. Ramakers
- Erasmus MC, University Medical Center Rotterdam, Department of Clinical Chemistry, Rotterdam, the Netherlands
| | - Soma Bahmany
- Erasmus MC, University Medical Center Rotterdam, Department of Hospital Pharmacy
| | - Teun van Gelder
- Erasmus MC, University Medical Center Rotterdam, Department of Hospital Pharmacy
- Erasmus MC, University Medical Center Rotterdam, Department of Internal Medicine, Division of Nephrology and Transplantation
- Erasmus MC, University Medical Center Rotterdam, Erasmus MC Transplant Institute
| | - Birgit C.P. Koch
- Erasmus MC, University Medical Center Rotterdam, Department of Hospital Pharmacy
| | - Jorie Versmissen
- Erasmus MC, University Medical Center Rotterdam, Department of Hospital Pharmacy
- Erasmus MC, University Medical Center Rotterdam, Department of Internal Medicine, Division of Vascular Medicine
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Salman IM, Ameer OZ, McMurray S, Hassan SF, Sridhar A, Lewis SJ, Hsieh YH. Differential central integration of left versus right baroreceptor afferent input in spontaneously hypertensive rats. J Hypertens 2023; 41:1191-1200. [PMID: 37074354 PMCID: PMC10241432 DOI: 10.1097/hjh.0000000000003448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 03/07/2023] [Indexed: 04/20/2023]
Abstract
BACKGROUND The blood pressure (BP) regulatory impact of the arterial baroreflex has been well established in health and disease. Under normotensive conditions, we have previously demonstrated functional differences in the central processing of the left versus right aortic baroreceptor afferent input. However, it is unknown if lateralization in aortic baroreflex function remains evident during hypertension. METHOD We therefore, investigated the effects of laterality on the expression of baroreflex-driven cardiovascular reflexes in a genetic model of essential hypertension, the spontaneously hypertensive rat (SHR). Anesthetized male SHRs (total n = 9) were instrumented for left, right, and bilateral aortic depressor nerve (ADN) stimulation (1-40 Hz, 0.2 ms, and 0.4 mA for 20 s) and measurement of mean arterial pressure (MAP), heart rate (HR), mesenteric vascular resistance (MVR), and femoral vascular resistance (FVR). RESULTS Left right, and bilateral ADN stimulation evoked frequency-dependent decreases in MAP, HR, MVR, and FVR. Left and bilateral ADN stimulation evoked greater reflex reductions in MAP, HR, MVR, and FVR compared with right-sided stimulation. Reflex bradycardia to bilateral stimulation was larger relative to both left-sided and right-sided stimulation. Reflex depressor and vascular resistance responses to bilateral stimulation mimicked those of the left-sided stimulation. These data indicate a left-side dominance in the central integration of aortic baroreceptor afferent input. Furthermore, reflex summation due to bilateral stimulation is only evident on the reflex bradycardic response, and does not drive further reductions in BP, suggesting that reflex depressor responses in the SHRs are primarily driven by changes in vascular resistance. CONCLUSION Together, these results indicate that lateralization in aortic baroreflex function is not only evident under normotensive conditions but also extends to hypertensive conditions.
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Affiliation(s)
- Ibrahim M. Salman
- Department of Pharmaceutical Sciences, College of Pharmacy, Alfaisal University, Riyadh, Saudi Arabia
| | - Omar Z. Ameer
- Department of Pharmaceutical Sciences, College of Pharmacy, Alfaisal University, Riyadh, Saudi Arabia
| | | | | | - Arun Sridhar
- Galvani Bioelectronics, Stevenage, Hertfordshire, UK
| | - Stephen J. Lewis
- Division of Pulmonology, Allergy and Immunology, Department of Pediatrics, School of Medicine
- Electrical Stimulation Center
| | - Yee-Hsee Hsieh
- Division of Pulmonary, Critical Care, and Sleep Medicine, School of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
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Salgado HC, Brognara F, Ribeiro AB, Lataro RM, Castania JA, Ulloa L, Kanashiro A. Autonomic Regulation of Inflammation in Conscious Animals. Neuroimmunomodulation 2023; 30:102-112. [PMID: 37232031 DOI: 10.1159/000530908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 04/20/2023] [Indexed: 05/27/2023] Open
Abstract
Bioelectronic medicine is a novel field in modern medicine based on the specific neuronal stimulation to control organ function, cardiovascular, and immune homeostasis. However, most studies addressing neuromodulation of the immune system have been conducted on anesthetized animals, which can affect the nervous system and neuromodulation. Here, we review recent studies involving conscious experimental rodents (rats and mice) to better understand the functional organization of neural control of immune homeostasis. We highlight typical experimental models of cardiovascular regulation, such as electrical activation of the aortic depressor nerve or the carotid sinus nerve, bilateral carotid occlusion, the Bezold-Jarisch reflex, and intravenous administration of the bacterial endotoxin lipopolysaccharide. These models have been used to investigate the relationship between neuromodulation of the cardiovascular and immune systems in conscious rodents (rats and mice). These studies provide critical information about the neuromodulation of the immune system, particularly the role of the autonomic nervous system, i.e., the sympathetic and parasympathetic branches acting both centrally (hypothalamus, nucleus ambiguus, nucleus tractus solitarius, caudal ventrolateral medulla, and rostral ventrolateral medulla), and peripherally (particularly spleen and adrenal medulla). Overall, the studies in conscious experimental models have certainly highlighted to the reader how the methodological approaches used to investigate cardiovascular reflexes in conscious rodents (rats and mice) can also be valuable for investigating the neural mechanisms involved in inflammatory responses. The reviewed studies have clinical implications for future therapeutic approaches of bioelectronic modulation of the nervous system to control organ function and physiological homeostasis in conscious physiology.
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Affiliation(s)
- Helio Cesar Salgado
- Department of Physiology, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
| | - Fernanda Brognara
- Department of Nursing, General and Specialized, Nursing School of Ribeirão Preto, University of São Paulo, São Paulo, Brazil
| | | | - Renata Maria Lataro
- Department of Physiological Sciences, Center of Biological Sciences, Federal University of Santa Catarina, Florianópolis, Brazil
| | - Jaci Airton Castania
- Department of Physiology, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
| | - Luis Ulloa
- Department of Anesthesiology, Center for Perioperative Organ Protection, Duke University Medical Center, Durham, North Carolina, USA
| | - Alexandre Kanashiro
- Department of Dermatology, School of Medicine and Public Health, University of Wisconsin Medical Sciences Center, Madison, Wisconsin, USA
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Gupta A, Nagaraju SP, Bhojaraja MV, Swaminathan SM, Mohan PB. Hypertension in Chronic Kidney Disease: An Update on Diagnosis and Management. South Med J 2023; 116:237-244. [PMID: 36724542 DOI: 10.14423/smj.0000000000001516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Hypertension (HTN) and chronic kidney disease (CKD) are pathophysiologic states that are intimately related, such that long-term HTN can lead to poor kidney function, and renal function decline can lead to worsening blood pressure (BP) control. HTN in CKD is caused by an interplay of factors, including salt and water retention, with extracellular volume expansion, sympathetic nervous system overactivity, renin-angiotensin-aldosterone system activation, and endothelial dysfunction. BP variability in the CKD population is significant, however, and thus requires close monitoring for appropriate management. With accumulating evidence, the diagnosis as well as management of HTN in CKD has been evolving in the last decade. In this comprehensive review based on current evidence and recommendations, we summarize the basics of pathophysiology, BP variability, diagnosis, and management of HTN in CKD with an emphasis on special populations with CKD.
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Affiliation(s)
- Ankur Gupta
- From the Department of Medicine, Whakatane Hospital, Whakatane, New Zealand
| | - Shankar Prasad Nagaraju
- the Department of Nephrology, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Mohan V Bhojaraja
- the Department of Nephrology, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Shilna Muttickal Swaminathan
- the Department of Nephrology, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Pooja Basthi Mohan
- the Department of Gastroenterology and Hepatology, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
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Renal sympathetic activity: A key modulator of pressure natriuresis in hypertension. Biochem Pharmacol 2023; 208:115386. [PMID: 36535529 DOI: 10.1016/j.bcp.2022.115386] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 12/11/2022] [Accepted: 12/13/2022] [Indexed: 12/23/2022]
Abstract
Hypertension is a complex disorder ensuing necessarily from alterations in the pressure-natriuresis relationship, the main determinant of long-term control of blood pressure. This mechanism sets natriuresis to the level of blood pressure, so that increasing pressure translates into higher osmotically driven diuresis to reduce volemia and control blood pressure. External factors affecting the renal handling of sodium regulate the pressure-natriuresis relationship so that more or less natriuresis is attained for each level of blood pressure. Hypertension can thus only develop following primary alterations in the pressure to natriuresis balance, or by abnormal activity of the regulation network. On the other hand, increased sympathetic tone is a very frequent finding in most forms of hypertension, long regarded as a key element in the pathophysiological scenario. In this article, we critically analyze the interplay of the renal component of the sympathetic nervous system and the pressure-natriuresis mechanism in the development of hypertension. A special focus is placed on discussing recent findings supporting a role of baroreceptors as a component, along with the afference of reno-renal reflex, of the input to the nucleus tractus solitarius, the central structure governing the long-term regulation of renal sympathetic efferent tone.
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12
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Zhou TL, Reulen JPH, Van Der Staaij H, Stehouwer CDA, Van Greevenbroek M, Henry RMA, Kroon AA. Cardiovagal baroreflex sensitivity, blood pressure and blood pressure variability - the Maastricht study. J Hypertens 2023; 41:254-261. [PMID: 36385097 DOI: 10.1097/hjh.0000000000003323] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Low baroreflex sensitivity (BRS) has been hypothesized to underlie high blood pressure (BP) and greater BP variability on the longer term, but evidence is scarce. In addition, these associations may differ by sex and (pre)diabetes. Therefore, we investigated whether cardiovagal BRS is associated with short- to mid-term mean BP and BP variability, and differs according to sex and (pre)diabetes. METHODS Cross-sectional data from the population-based Maastricht study (age 60 ± 8 years, 52% men), where office ( n = 2846), 24-h ( n = 2404) and 7-day BP measurements ( n = 2006) were performed. Spontaneous BRS was assessed by cross-correlating systolic BP and instantaneous heart rate. We used linear regression with adjustments for age, sex, BP or BP variability, and cardiovascular risk factors. RESULTS With regard to BP, 1-SD (standard deviation) lower BRS (-5.75 ms/mmHg) was associated with higher office, 24-h and 7-day systolic BP (2.22 mmHg [95% confidence interval [CI]: 1.59; 2.80], 0.95 mmHg [0.54; 1.36], and 1.48 mmHg [0.99; 1.97], respectively) and diastolic BP (1.31 mmHg [0.97; 1.66], 0.57 mmHg [0.30; 0.84], and 0.86 mmHg [0.54; 1.17], respectively). Per 1-SD lower BRS, these associations were stronger in women (0.5-1.5 mmHg higher compared to men), and weaker in those with type 2 diabetes (1-1.5 mmHg lower compared to normal glucose metabolism). With regard to BP variability, BRS was not consistently associated with lower BP variability. CONCLUSIONS Lower cardiovagal BRS is associated with higher mean BP from the short- to mid-term range, and not consistently with BP variability. The associations with mean BP are stronger in women and weaker in those with type 2 diabetes.
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Affiliation(s)
- Tan Lai Zhou
- Department of Internal Medicine, Maastricht University Medical Centre
- CARIM School for Cardiovascular Diseases, Maastricht University
| | | | | | - Coen D A Stehouwer
- Department of Internal Medicine, Maastricht University Medical Centre
- CARIM School for Cardiovascular Diseases, Maastricht University
| | - Marleen Van Greevenbroek
- Department of Internal Medicine, Maastricht University Medical Centre
- CARIM School for Cardiovascular Diseases, Maastricht University
| | - Ronald M A Henry
- Department of Internal Medicine, Maastricht University Medical Centre
- CARIM School for Cardiovascular Diseases, Maastricht University
- Heart and Vascular Centre, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Abraham A Kroon
- Department of Internal Medicine, Maastricht University Medical Centre
- CARIM School for Cardiovascular Diseases, Maastricht University
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13
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Wallbach M, Born E, Schäfer A, Koziolek MJ. Effect of baroreflex activation therapy on dipping pattern in patients with resistant hypertension. J Clin Hypertens (Greenwich) 2022; 25:22-29. [PMID: 36545753 PMCID: PMC9832236 DOI: 10.1111/jch.14620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 11/21/2022] [Accepted: 11/29/2022] [Indexed: 12/24/2022]
Abstract
A relevant number of patients with resistant hypertension do not achieve blood pressure (BP) dipping during nighttime. This inadequate nocturnal BP reduction is associated with elevated cardiovascular risks. The aim of this study was to evaluate whether a nighttime intensification of BAT might improve nocturnal BP dipping. In this prospective observational study, non-dippers treated with BAT for at least 6 months were included. BAT programming was modified in a two-step intensification of nighttime stimulation at baseline and week 6. Twenty-four hours ambulatory BP (ABP) was measured at inclusion and after 3 months. A number of 24 patients with non- or inverted dipping pattern, treated with BAT for a median of 44 months (IQR 25-52) were included. At baseline of the study, patients were 66 ± 9 years old, had a BMI of 33 ± 6 kg/m2 , showed an office BP of 135 ± 22/72 ± 10 mmHg, and took a median number of antihypertensives of 6 (IQR 4-9). Nighttime stimulation of BAT was adapted by an intensification of pulse width from 237 ± 161 to 267 ± 170 μs (p = .003) while frequency (p = .10) and amplitude (p = .95) remained unchanged. Uptitration of BAT programming resulted in an increase of systolic dipping from 2 ± 6 to 6 ± 8% (p = .03) accompanied with a significant improvement of dipping pattern (p = .02). Twenty four hours ABP, day- and nighttime ABP remained unchanged. Programming of an intensified nighttime BAT interval improved dipping profile in patients treated with BAT, while the overall 24 h ABP did not change. Whether the improved dipping response contributes to a reduction of cardiovascular risk beyond the BP-lowering effects of BAT, however, remains to be shown.
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Affiliation(s)
- Manuel Wallbach
- Department of Nephrology and RheumatologyUniversity Medical Center GöttingenGermany,German Center for Cardiovascular Research (DZHK)Partner Site GöttingenGermany
| | - Ellen Born
- Department of Nephrology and RheumatologyUniversity Medical Center GöttingenGermany
| | - Ann‐Kathrin Schäfer
- Department of Nephrology and RheumatologyUniversity Medical Center GöttingenGermany
| | - Michael J. Koziolek
- Department of Nephrology and RheumatologyUniversity Medical Center GöttingenGermany,German Center for Cardiovascular Research (DZHK)Partner Site GöttingenGermany
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14
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Paolisso P, Dagan A, Gallinoro E, De Colle C, Bertolone DT, Moya A, Penicka M, Degrieck I, Vanderheyden M, Bartunek J. Aortic thoracic neuromodulation in heart failure with preserved ejection fraction. ESC Heart Fail 2022; 10:699-704. [PMID: 36151858 PMCID: PMC9871658 DOI: 10.1002/ehf2.14136] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 08/07/2022] [Accepted: 08/24/2022] [Indexed: 01/27/2023] Open
Abstract
The inadequacy of medical therapies for heart failure with preserved ejection fraction (HFpEF) is driving the development of device-based solutions targeting underlying pathophysiologic abnormalities. The maladaptive autonomic imbalance with a reduction in vagal parasympathetic activity and increased sympathetic signalling contributes to the deterioration of cardiac performance, patient fitness, and the increased overall morbidity and mortality. Thoracic aortic vagal afferents mediate parasympathetic signalling, and their stimulation has been postulated to restore autonomic balance. In this first-in-man experience with chronic stimulation of aortic vagal afferents (Harmony™ System, Enopace, Israel), we demonstrate improved left atrial remodelling and function parallel with improved left ventricular performance. The observed favourable structural and functional cardiac changes remained stable throughout the 1 year follow-up and were associated with improved symptoms and physical fitness. The current experience warrants further validation of the endovascular stimulation of aortic thoracic afferents as a new interventional approach for device-based treatment in HFpEF.
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Affiliation(s)
- Pasquale Paolisso
- Cardiovascular Center Aalst, OLV HospitalAalstBelgium,Department of Advanced Biomedical SciencesUniversity of Naples Federico IINaplesItaly
| | | | - Emanuele Gallinoro
- Cardiovascular Center Aalst, OLV HospitalAalstBelgium,Department of Translational Medical SciencesUniversity of Campania' Luigi Vanvitelli'NaplesItaly
| | - Cristina De Colle
- Cardiovascular Center Aalst, OLV HospitalAalstBelgium,Department of Advanced Biomedical SciencesUniversity of Naples Federico IINaplesItaly
| | - Dario Tino Bertolone
- Cardiovascular Center Aalst, OLV HospitalAalstBelgium,Department of Advanced Biomedical SciencesUniversity of Naples Federico IINaplesItaly
| | - Ana Moya
- Cardiovascular Center Aalst, OLV HospitalAalstBelgium
| | | | - Ivan Degrieck
- Cardiovascular and Thoracic Surgery, OLV‐ClinicAalstBelgium
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Abstract
PURPOSE OF REVIEW Hypertension (HTN) remains the most common and strongest contributing factor to the development of heart failure with preserved ejection fraction (HFpEF). In this review, we aim to summarize the pathophysiological processes linking HTN to HFpEF and highlight novel concepts in medical and device-based management of HFpEF and HTN. RECENT FINDINGS Despite the global increase in the prevalence of HFpEF, there has been limited benefit in current medication and device-based therapy for this complex syndrome. The hallmark of HFpEF is an elevated left intra-atrial and ventricular pressure and exertional dyspnea. Traditional medications used for treating HTN in patients with reduced left ventricular ejection fraction have unclear benefits in patients with HFpEF. Careful analysis of emerging medications such as angiotensin receptor-neprilysin inhibitor and sodium-glucose co-transporter-2 inhibitors showed benefit in reducing not only blood pressure but also hospitalizations in patients with HFpEF. Current data on device-based therapy aims to reduce left intra-atrial pressure, ventricular pressure and stimulate baroreceptors to lower blood pressure; however, needs further investigation. SUMMARY The nexus of HTN and HFpEF remains strong and complex. Although traditional medications for treating HFrEF did not affect long-term outcomes, novel therapies with angiotensin receptor neprilysin-inhibitor and sodium-glucose co-transporter-2 inhibitor offer promising results. Many device-based interventions in the HFpEF population are being developed with the aim to reduce left intra-atrial and ventricular pressure; however, their role in HFpEF hypertensive patients needs to be further investigated.
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Affiliation(s)
- Abdulaziz Joury
- John Ochsner Heart and Vascular Institute, Ochsner Medical Center, New Orleans, Louisiana, USA
- King Salman Heart Center, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Tripti Gupta
- John Ochsner Heart and Vascular Institute, Ochsner Medical Center, New Orleans, Louisiana, USA
- The University of Queensland School of Medicine, Ochsner Clinical School
| | - Selim R Krim
- John Ochsner Heart and Vascular Institute, Ochsner Medical Center, New Orleans, Louisiana, USA
- The University of Queensland School of Medicine, Ochsner Clinical School
- Section of Cardiomyopathy & Heart Transplantation, Ochsner Clinic Foundation, New Orleans, Louisiana, USA
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16
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Clemmer JS, Pruett WA. Modeling the physiological roles of the heart and kidney in heart failure with preserved ejection fraction during baroreflex activation therapy. Am J Physiol Heart Circ Physiol 2022; 323:H597-H607. [PMID: 35984764 PMCID: PMC9467477 DOI: 10.1152/ajpheart.00329.2022] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 08/10/2022] [Accepted: 08/10/2022] [Indexed: 11/22/2022]
Abstract
Heart failure (HF) is a leading cause of death and is increasing in prevalence. Unfortunately, therapies that have been efficacious in patients with HF with reduced ejection fraction (HFrEF) have not convincingly shown a reduction in cardiovascular mortality in patients with HF with preserved ejection fraction (HFpEF). It is thought that high sympathetic nerve activity (SNA) in the heart plays a role in HF progression. Clinical trials demonstrate that baroreflex activation therapy reduces left ventricular (LV) mass and blood pressure (BP) in patients with HFpEF and hypertension; however, the mechanisms are unclear. In the present study, we used HumMod, a large physiology model to simulate HFpEF and predict the time-dependent changes in systemic and cardiac hemodynamics, SNA, and cardiac stresses during baroreflex activation. The baseline HFpEF model was associated with elevations in systolic BP, diastolic dysfunction, and LV hypertrophy and stiffness similar to clinical HFpEF. Simulating 12 mo of baroreflex activation resulted in reduced systolic BP (-25 mmHg) and LV mass (-15%) similar to clinical evidence. Baroreflex activation also resulted in sustained decreases in cardiac and renal SNA (-22%) and improvement in LV β1-adrenergic function. However, the baroreflex-induced reductions in BP and improvements in cardiac stresses, mass, and function were mostly attenuated when renal SNA was clamped at baseline levels. These simulations suggest that the suppression of renal SNA could be a primary determinant of the cardioprotective effects from baroreflex activation in HFpEF.NEW & NOTEWORTHY Treatments that are efficacious in patients with HFrEF have not shown a significant impact on cardiovascular mortality in patients with HFpEF. We believe these simulations offer novel insight into the important roles of the cardiac and renal nerves in HFpEF and the potential mechanisms of how baroreflex activation alleviates HFpEF disease progression.
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Affiliation(s)
- John S Clemmer
- Department of Physiology and Biophysics, Center for Computational Medicine, University of Mississippi Medical Center, Jackson, Mississippi
| | - W Andrew Pruett
- Department of Physiology and Biophysics, Center for Computational Medicine, University of Mississippi Medical Center, Jackson, Mississippi
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17
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Low intensity stimulation of aortic baroreceptor afferent fibers as a potential therapeutic alternative for hypertension treatment. Sci Rep 2022; 12:12242. [PMID: 35851099 PMCID: PMC9293925 DOI: 10.1038/s41598-022-15761-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 06/29/2022] [Indexed: 11/17/2022] Open
Abstract
Carotid baroreceptor stimulation has been clinically explored for antihypertensive benefits, but neuromodulation of aortic baroreceptor afferents remains unexplored for potential translation into the clinic. Published studies have used supramaximal stimulations, which are unphysiological and energy inefficient. The objective of the present study was to identify optimal low-charge nerve stimulation parameters that would provide a clinically-relevant (20–30 mmHg) decrease in mean arterial pressure (MAP) in anesthetized spontaneously hypertensive rats. Stimulations of 20 s were delivered to the left aortic depressor nerve (ADN) of these rats using low ranges of pulse amplitudes (≤ 0.6 mA), widths (≤ 0.5 ms) and frequencies (≤ 5 Hz). We also assessed the effects of continuous (20 s) versus intermittent (5 s ON/3 s OFF and 5 s ON/3 s OFF for 20 s) stimulation on MAP, heart rate (HR), mesenteric (MVR) and femoral (FVR) vascular resistance using low (5 Hz) and high (15 Hz) frequencies. Lower pulse amplitudes (0.2 mA) produced 9 ± 2 to 18 ± 2 mmHg decreases in MAP. Higher pulse amplitudes (0.4 mA) produced a median MAP reduction of 28 ± 4 mmHg at 0.2 ms and 5 Hz, with no added benefit seen above 0.4 mA. Continuous and intermittent low frequency stimulation at 0.4 mA and 0.2 ms produced similar sustained decreases in MAP, HR, MVR and FVR. Continuous high frequency stimulation at 0.4 mA and 0.2 ms produced larger reductions in MAP, HR, MVR and FVR compared with all low frequency and/or intermittent high frequency stimulations. We conclude from these findings that “low intensity intermittent” electrical stimulation is an effective alternate way for neuromodulation of the aortic baroreceptor afferents and to evoke a required restoration of MAP levels in spontaneously hypertensive rats. This approach enables low energy consumption and markedly lowers the excessive decreases in MAP and hemodynamic disturbances elicited by continuous high-charge injection protocols.
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18
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Abstract
Purpose of Review To update on definition, diagnosis, prevalence, patient characteristics, pathophysiology, and treatment of refractory hypertension (RfHTN). Recent Findings Refractory hypertension (RfHTN) is defined as blood pressure (BP) that is uncontrolled despite using ≥ 5 antihypertensive medications of different classes, including a long-acting thiazide diuretic and a mineralocorticoid receptor antagonist (MRA) at maximal or maximally tolerated doses. This new phenotype is different from resistant hypertension (RHTN), defined as BP that is uncontrolled despite using ≥ 3 medications, commonly a long-acting calcium channel blocker (CCB), a blocker of the renin-angiotensin system (angiotensin-converting enzyme [ACE] inhibitor or angiotensin receptor blocker [ARB]), and a diuretic. The RHTN phenotype includes controlled RHTN, BP that is controlled on 4 or more medications. RfHTN is largely attributable to increased sympathetic activity, unlike RHTN, which is mainly due to increased intravascular fluid volume frequently caused by hyperaldosteronism and chronic excessive sodium ingestion. Compared to those with controlled RHTN, patients with RfHTN have a higher prevalence of target organ damage and do not have elevated aldosterone levels. Ongoing clinical trials are assessing the safety and efficacy of using devices to aid with BP control in patients with RfHTN. Summary RfHTN is a separate entity from RHTN and is generally attributable to increased sympathetic activity.
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19
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van Kleef MEAM, Devireddy CM, van der Heyden J, Bates MC, Bakris GL, Stone GW, Williams B, Spiering W. Treatment of Resistant Hypertension With Endovascular Baroreflex Amplification: 3-Year Results From the CALM-FIM Study. JACC Cardiovasc Interv 2022; 15:321-332. [PMID: 35144789 DOI: 10.1016/j.jcin.2021.12.015] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 11/23/2021] [Accepted: 12/07/2021] [Indexed: 12/29/2022]
Abstract
OBJECTIVES The aim of this study was to evaluate the long-term (3-year) safety and effectiveness of endovascular baroreflex amplification (EVBA) from both the European and American CALM-FIM cohorts. BACKGROUND The CALM-FIM study demonstrated that EVBA in patients with resistant hypertension significantly lowered blood pressure (BP) with an acceptable safety profile during 6-month follow-up. METHODS The CALM-FIM studies were prospective, nonrandomized, first-in-human studies that enrolled patients with resistant hypertension (office systolic BP ≥160 mm Hg and mean 24-hour ambulatory BP ≥130/80 mm Hg despite a stable regimen of ≥3 antihypertensive medications, including a diuretic agent). The incidence of (serious) adverse events and changes in BP, heart rate, and prescribed antihypertensive medication up to 3 years after implantation were determined. RESULTS The Mobius device was implanted in 47 patients (30 in Europe, 17 in the United States; mean age 54 years, 23 women). Five serious adverse events (hypotension, n = 2; hypertension, n = 1; vascular access complications, n = 2) and 2 transient ischemic attacks occurred within 30 days postprocedure. Two strokes and 1 transient ischemic attack occurred more than 2 years postimplantation. Mean office BP at baseline was 181 ± 17/107 ± 16 mm Hg and decreased by 25/12 mm Hg (95% CI: 17-33/8-17 mm Hg) at 6 months and 30/12 mm Hg (95% CI: 21-38/8-17 mm Hg) at 3 years. Mean 24-hour ambulatory BP at baseline was 166 ± 16/98 ± 15 mm Hg and decreased by 20/11 mm Hg (95% CI: 14-25/8-15 mm Hg) at 6 months. CONCLUSIONS EVBA with the MobiusHD was effective in reducing BP at 3-year follow-up and appears to have an acceptable safety profile in patients with uncomplicated implantation, although data from randomized sham-controlled trials are needed to further evaluate the risk-benefit profile. (Controlling and Lowering Blood Pressure With the MobiusHD™ [CALM-FIM_EUR], NCT01911897; Controlling and Lowering Blood Pressure With the MobiusHD™ [CALM-FIM_US], NCT01831895).
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Affiliation(s)
- Monique E A M van Kleef
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Chandan M Devireddy
- Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Jan van der Heyden
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Mark C Bates
- CAMC Institute of Academic Medicine and West Virginia University, Charleston, West Virginia, USA
| | - George L Bakris
- Department of Medicine, American Society of Hypertension Comprehensive Hypertension Center, University of Chicago Medicine, Chicago, Illinois, USA
| | - Gregg W Stone
- The Zena and Michael A. Wiener Cardiovascular Institute, The Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Bryan Williams
- University College London Institute of Cardiovascular Science and National Institute for Health Research UCL Hospitals Biomedical Research Centre, London, United Kingdom
| | - Wilko Spiering
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht University, the Netherlands.
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Heidari B, Avenatti E, Nasir K. Pharmacotherapy for Essential Hypertension: A Brief Review. Methodist Debakey Cardiovasc J 2022; 18:5-16. [PMID: 36561082 PMCID: PMC9733188 DOI: 10.14797/mdcvj.1175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 11/14/2022] [Indexed: 12/12/2022] Open
Abstract
Hypertension is one of the leading causes of disability-adjusted life years and mortality, with approximately 15% prevalence worldwide. Most patients with hypertension from low- to high-income countries do not receive treatment. Among those who receive treatment, the majority remain undertreated and do not achieve their blood pressure goals. Therefore, new hypertension guidelines introduce more conscientious treatment strategies to maximize the probability of achieving the new strict blood pressure goals compared with the previous guidelines. Who should receive treatment for hypertension? Which antihypertensive medications have the strongest supporting data? Are generic and more affordable medications as effective as expensive brand medications? What are the different treatment strategies to maximize success in controlling blood pressure? Here, we briefly review pharmacotherapy for hypertension and provide answers to these questions as well as some other common questions regarding treatment of hypertension.
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Affiliation(s)
- Behnam Heidari
- Houston Methodist DeBakey Heart & Vascular Center, Houston Methodist, Houston, Texas, US
| | - Eleonora Avenatti
- Houston Methodist DeBakey Heart & Vascular Center, Houston Methodist, Houston, Texas, US
| | - Khurram Nasir
- Houston Methodist DeBakey Heart & Vascular Center, Houston Methodist, Houston, Texas, US
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21
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Li L, Hu Z, Xiong Y, Yao Y. Device-Based Sympathetic Nerve Regulation for Cardiovascular Diseases. Front Cardiovasc Med 2021; 8:803984. [PMID: 34957267 PMCID: PMC8695731 DOI: 10.3389/fcvm.2021.803984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 11/22/2021] [Indexed: 12/05/2022] Open
Abstract
Sympathetic overactivation plays an important role in promoting a variety of pathophysiological processes in cardiovascular diseases (CVDs), including ventricular remodeling, vascular endothelial injury and atherosclerotic plaque progression. Device-based sympathetic nerve (SN) regulation offers a new therapeutic option for some CVDs. Renal denervation (RDN) is the most well-documented method of device-based SN regulation in clinical studies, and several large-scale randomized controlled trials have confirmed its value in patients with resistant hypertension, and some studies have also found RDN to be effective in the control of heart failure and arrhythmias. Pulmonary artery denervation (PADN) has been clinically shown to be effective in controlling pulmonary hypertension. Hepatic artery denervation (HADN) and splenic artery denervation (SADN) are relatively novel approaches that hold promise for a role in cardiovascular metabolic and inflammatory-immune related diseases, and their first-in-man studies are ongoing. In addition, baroreflex activation, spinal cord stimulation and other device-based therapies also show favorable outcomes. This review summarizes the pathophysiological rationale and the latest clinical evidence for device-based therapies for some CVDs.
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Affiliation(s)
| | | | | | - Yan Yao
- National Center for Cardiovascular Diseases, Peking Union Medical College, Chinese Academy of Medical Sciences, Fu Wai Hospital, Beijing, China
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22
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Nolde JM, Cheng SF, Richards T, Schlaich MP. No Evidence for Long Term Blood Pressure Differences Between Eversion and Conventional Carotid Endarterectomy in Two Independent Study Cohorts. Eur J Vasc Endovasc Surg 2021; 63:33-42. [PMID: 34742610 DOI: 10.1016/j.ejvs.2021.09.005] [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: 03/03/2021] [Revised: 08/03/2021] [Accepted: 09/05/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Blood pressure (BP) management is a vital aspect of stroke prevention and post-stroke care. Different surgical carotid endarterectomy (CEA) techniques may impact on BP control post-operatively. Specifically, the carotid sinus nerve, which innervates the carotid baroreceptors and carotid body, is commonly left intact during conventional CEA but is routinely transected as part of eversion CEA. The aim of this study was to assess long term BP control after eversion and conventional CEA. METHODS Patients from the International Carotid Stenting Study (ICSS cohort) and a personal series of patients from the Stroke Clinical Trials Unit at University College London (UCL cohort) were separately analysed and divided into eversion and conventional CEA groups. Mixed effect linear models were fitted and adjusted for baseline demographic data and antihypertensive treatment to test for changes in BP from baseline over a three year follow up period after the respective procedures. RESULTS There were no differences in changes in baseline BP readings and follow up readings between eversion and conventional CEA in the ICSS or UCL cohorts. In the ICSS cohort a mild but significant systolic (-8.6 mmHg; 95% confidence interval [CI] -10.6 - -6.6) and diastolic (-4.9 mmHg; 95% CI -6.0 - -3.8) BP lowering effect was evident at discharge in the conventional group but not in the eversion CEA group. BP monitoring during follow up did not reveal any consistent BP changes with either conventional or eversion CEA vs. baseline levels. CONCLUSION Neither conventional nor eversion CEA seem to result in clinically significant long term BP changes. Potential concerns related to either short or long term alterations in BP levels with transection of the carotid sinus nerve during eversion CEA could not be substantiated.
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Affiliation(s)
- Janis M Nolde
- Dobney Hypertension Centre, Medical School - Royal Perth Hospital Unit / Royal Perth Hospital Medical Research Foundation, University of Western Australia, Perth, Australia
| | - Suk F Cheng
- Stroke Research Centre, Institute of Neurology, University College London, London, UK
| | - Toby Richards
- Division of Surgery, Medical School, The University of Western Australia, Perth, Australia
| | - Markus P Schlaich
- Dobney Hypertension Centre, Medical School - Royal Perth Hospital Unit / Royal Perth Hospital Medical Research Foundation, University of Western Australia, Perth, Australia; Departments of Cardiology and Nephrology, Royal Perth Hospital, Perth, Australia; Neurovascular Hypertension and Kidney Disease Laboratory, Baker Heart and Diabetes Institute, Melbourne, Australia.
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23
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Rosalia L, Ozturk C, Shoar S, Fan Y, Malone G, Cheema FH, Conway C, Byrne RA, Duffy GP, Malone A, Roche ET, Hameed A. Device-Based Solutions to Improve Cardiac Physiology and Hemodynamics in Heart Failure With Preserved Ejection Fraction. JACC Basic Transl Sci 2021; 6:772-795. [PMID: 34754993 PMCID: PMC8559325 DOI: 10.1016/j.jacbts.2021.06.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 06/03/2021] [Indexed: 12/28/2022]
Abstract
Characterized by a rapidly increasing prevalence, elevated mortality and rehospitalization rates, and inadequacy of pharmaceutical therapies, heart failure with preserved ejection fraction (HFpEF) has motivated the widespread development of device-based solutions. HFpEF is a multifactorial disease of various etiologies and phenotypes, distinguished by diminished ventricular compliance, diastolic dysfunction, and symptoms of heart failure despite a normal ejection performance; these symptoms include pulmonary hypertension, limited cardiac reserve, autonomic imbalance, and exercise intolerance. Several types of atrial shunts, left ventricular expanders, stimulation-based therapies, and mechanical circulatory support devices are currently under development aiming to target one or more of these symptoms by addressing the associated mechanical or hemodynamic hallmarks. Although the majority of these solutions have shown promising results in clinical or preclinical studies, no device-based therapy has yet been approved for the treatment of patients with HFpEF. The purpose of this review is to discuss the rationale behind each of these devices and the findings from the initial testing phases, as well as the limitations and challenges associated with their clinical translation.
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Key Words
- BAT, baroreceptor activation therapy
- CCM, cardiac contractility modulation
- CRT, cardiac resynchronization therapy
- HF, heart failure
- HFmEF, heart failure with mid-range ejection fraction
- HFpEF
- HFpEF, heart failure with preserved ejection fraction
- HFrEF, heart failure with reduced ejection fraction
- IASD, Interatrial Shunt Device
- LAAD, left atrial assist device
- LAP, left atrial pressure
- LV, left ventricular
- LVEF, left ventricular ejection fraction
- MCS, mechanical circulatory support
- NYHA, New York Heart Association
- PCWP, pulmonary capillary wedge pressure
- QoL, quality of life
- TAA, transapical approach
- atrial shunt devices
- electrostimulation
- heart failure devices
- heart failure with preserved ejection fraction
- left ventricular expanders
- mechanical circulatory support
- neuromodulation
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Affiliation(s)
- Luca Rosalia
- Health Sciences and Technology Program, Harvard–Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
| | - Caglar Ozturk
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
| | | | - Yiling Fan
- Department of Mechanical Engineering, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
| | - Grainne Malone
- Tissue Engineering Research Group (TERG), Department of Anatomy and Regenerative Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Faisal H. Cheema
- HCA Healthcare, Houston, Texas, USA
- University of Houston, College of Medicine, Houston, Texas, USA
| | - Claire Conway
- Tissue Engineering Research Group (TERG), Department of Anatomy and Regenerative Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Robert A. Byrne
- Department of Cardiology, Mater Private Hospital, Dublin, Ireland
- Cardiovascular Research, School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Garry P. Duffy
- Tissue Engineering Research Group (TERG), Department of Anatomy and Regenerative Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
- Anatomy & Regenerative Medicine Institute, School of Medicine, College of Medicine, Nursing, and Health Sciences, National University of Ireland Galway, Galway, Ireland
- Centre for Research in Medical Devices, National University of Ireland Galway, Galway, Ireland
- Advanced Materials for Biomedical Engineering and Regenerative Medicine, Trinity College Dublin, and National University of Ireland Galway, Galway, Ireland
- Trinity Centre for Biomedical Engineering, Trinity College Dublin, Dublin, Ireland
| | - Andrew Malone
- Tissue Engineering Research Group (TERG), Department of Anatomy and Regenerative Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Ellen T. Roche
- Health Sciences and Technology Program, Harvard–Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
- Department of Mechanical Engineering, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
| | - Aamir Hameed
- Tissue Engineering Research Group (TERG), Department of Anatomy and Regenerative Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
- Trinity Centre for Biomedical Engineering, Trinity College Dublin, Dublin, Ireland
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24
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Kalarus Z, Merkely B, Neužil P, Grabowski M, Mitkowski P, Marinskis G, Erglis A, Kaźmierczak J, Sturmberger T, Sokal A, Pluta S, Gellér L, Osztheimer I, Malek F, Kolodzińska A, Mika Y, Evans SJ, Hastings HM, Burkhoff D, Kuck KH. Pacemaker-Based Cardiac Neuromodulation Therapy in Patients With Hypertension: A Pilot Study. J Am Heart Assoc 2021; 10:e020492. [PMID: 34387126 PMCID: PMC8475046 DOI: 10.1161/jaha.120.020492] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background In prior unblinded studies, cardiac neuromodulation therapy (CNT) employing a sequence of variably timed short and longer atrioventricular intervals yielded sustained reductions of systolic blood pressure (SBP) in patients with hypertension. The effects of CNT on SBP were investigated in this double-blind randomized pilot study. Methods and Results Eligible patients had daytime ambulatory SBP (aSBP) ≥130 mm Hg and office SBP ≥140 mm Hg despite taking ≥1 antihypertensive medication, and an indication for a dual-chamber pacemaker. Patients underwent Moderato device implantation, which was programmed as a standard pacemaker during a 1-month run-in phase. Patients whose daytime aSBP was ≥125 mm Hg at the end of this period were randomized (1:1, double blind) to treatment (CNT) or control (CNT inactive). The primary efficacy end point was the between-group difference of the change in 24-hour aSBP at 6 months. Of 68 patients initially enrolled and who underwent implantation with the Moderato system, 47 met criteria for study continuation and were randomized (26 treatment, 21 control). The mean age was 74.0±8.7 years, 64% were men, left ventricular ejection fraction was 59.2%±5.7%, and aSBP averaged 141.0±10.8 mm Hg despite the use of 3.3±1.5 antihypertensive medications; 81% had isolated systolic hypertension. Six months after randomization, aSBP was 11.1±10.5 mm Hg (95% CI, -15.2 to -8.1 mm Hg) lower than prerandomization in the treatment group compared with 3.1±9.5 mm Hg (-7.4 to 1.2 mm Hg) lower in controls, yielding a net treatment effect of 8.1±10.1 mm Hg (-14.2 to -1.9 mm Hg) (P=0.012). There were no Moderato device- or CNT-related adverse events. Conclusions CNT significantly reduced 24-hour aSBP in patients with hypertension with a clinical indication for a pacemaker. The majority of patients had isolated systolic hypertension, a particularly difficult group of patients to treat. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT02837445.
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Affiliation(s)
- Zbigniew Kalarus
- Department of Cardiology DMS in ZabrzeMedical University of Silesia Katowice Poland
| | - Béla Merkely
- Heart and Vascular Center Semmelweis University Budapest Hungary
| | - Petr Neužil
- Department of Cardiology Na Homolce Hospital Prague Czech Republic
| | - Marcin Grabowski
- 1st Chair and Department of Cardiology Medical University of Warsaw Poland
| | - Przemysław Mitkowski
- 1st Department of Cardiology Karol Marcinkowski University of Medical Sciences Poznań Poland
| | - Germanas Marinskis
- Department of Cardiovascular Diseases Centre for Cardiology and Angiology Vilnius University Vilnius Lithuania
| | - Andrejs Erglis
- Pauls Stradins Clinical University Hospital University of Latvia Riga Latvia
| | | | - Thomas Sturmberger
- Interne 2 - Kardiologie, Angiologie & Interne Intensivmedizin Ordensklinikum Linz GmbH Elisabethinen Linz Austria
| | - Adam Sokal
- Department of Cardiology DMS in ZabrzeMedical University of Silesia Katowice Poland
| | - Slawomir Pluta
- Department of Cardiology DMS in ZabrzeMedical University of Silesia Katowice Poland
| | - László Gellér
- Heart and Vascular Center Semmelweis University Budapest Hungary
| | | | - Filip Malek
- Department of Cardiology Na Homolce Hospital Prague Czech Republic
| | | | | | | | - Harold M Hastings
- Division of Science, Mathematics and Computing Bard College at Simon's Rock Great Barrington MA.,Department of Physics and Astronomy Hofstra University Hempstead NY
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25
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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.
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26
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Dalos D, Khazen C, Schukro C, Gwechenberger M. Twiddler’s syndrome after implantation of baroreflex activation therapy: a case report. Eur Heart J Case Rep 2021; 5:ytab126. [PMID: 34124559 PMCID: PMC8189308 DOI: 10.1093/ehjcr/ytab126] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 11/30/2020] [Accepted: 03/16/2021] [Indexed: 11/14/2022]
Abstract
Abstract
Background
Twiddler’s syndrome is a rare complication after implantation of cardiac pacemakers or cardioverter-defibrillators that usually occurs within the first year after the procedure. However, it has not yet been described following implantation of baroreflex activation therapy (BAT).
Case summary
A 61-year-old female patient was referred to the cardiology outpatient clinic due to uncontrolled arterial hypertension despite maximal doses of several established drugs. Therefore, right-sided BAT implantation was successfully performed in February 2017 with good clinical response. Because of sustained neck pain at the site of stimulator, surgical revision was performed in November 2019 including a switch of the lead to the contralateral position. Approximately 1 month later, Twiddler’s syndrome was identified on the basis of recurrent pain at the generator site necessitating pocket-revision, however, the lead was only untwisted but not replaced. A few weeks afterwards, unfortunately, lead revision was indispensable due to lead fracture.
Discussion
This case presents the uncommon phenomenon of Twiddler’s syndrome after BAT implantation. In addition, the commonly twisted lead should always be replaced as well during surgical pocket-revision in order to ensure proper long-term function.
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Affiliation(s)
| | | | | | - Marianne Gwechenberger
- Division of Cardiology, Department of Internal Medicine II, Vienna General Hospital, Medical University of Vienna , Waehringer Guertel 18-20, 1090 Vienna, Austria
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27
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Horn CC, Forssell M, Sciullo M, Harms JE, Fulton S, Mou C, Sun F, Simpson TW, Xiao G, Fisher LE, Bettinger C, Fedder GK. Hydrogel-based electrodes for selective cervical vagus nerve stimulation. J Neural Eng 2021; 18. [PMID: 33784636 DOI: 10.1088/1741-2552/abf398] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Accepted: 03/30/2021] [Indexed: 11/11/2022]
Abstract
Objective.Electrical vagus nerve stimulation (VNS) has the potential to treat a wide variety of diseases by modulating afferent and efferent communication to the heart, lungs, esophagus, stomach, and intestines. Although distal vagal nerve branches, close to end organs, could provide a selective therapeutic approach, these locations are often surgically inaccessible. In contrast, the cervical vagus nerve has been targeted for decades using surgically implantable helix electrodes to treat epileptic seizures and depression; however, to date, clinical implementation of VNS has relied on an electrode with contacts that fully wrap around the nerve, producing non-selective activation of the entire nerve. Here we demonstrate selective cervical VNS using cuff electrodes with multiple contacts around the nerve circumference to target different functional pathways.Approach.These flexible probes were adjusted to the diameter of the nerve using an adhesive hydrogel wrap to create a robust electrode interface. Our approach was verified in a rat model by demonstrating that cervical VNS produces neural activity in the abdominal vagus nerve while limiting effects on the cardiovascular system (i.e. changes in heart rate or blood pressure).Main results.This study demonstrates the potential for selective cervical VNS as a therapeutic approach for modulating distal nerve branches while reducing off target effects.Significance.This methodology could potentially be refined to treat gastrointestinal, metabolic, inflammatory, cardiovascular, and respiratory diseases amenable to vagal neuromodulatory control.
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Affiliation(s)
- Charles C Horn
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, United States of America.,UPMC Hillman Cancer Center, Pittsburgh, PA, United States of America.,Center for Neuroscience, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Mats Forssell
- Department of Electrical and Computer Engineering, Carnegie Mellon University, Pittsburgh, PA, United States of America
| | - Michael Sciullo
- UPMC Hillman Cancer Center, Pittsburgh, PA, United States of America
| | - Jonathan E Harms
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, United States of America.,UPMC Hillman Cancer Center, Pittsburgh, PA, United States of America
| | - Stephanie Fulton
- UPMC Hillman Cancer Center, Pittsburgh, PA, United States of America
| | - Chenchen Mou
- Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, PA, United States of America
| | - Fan Sun
- UPMC Hillman Cancer Center, Pittsburgh, PA, United States of America.,Department of Microbiology and Molecular Genetics, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Tyler W Simpson
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Gutian Xiao
- UPMC Hillman Cancer Center, Pittsburgh, PA, United States of America.,Department of Microbiology and Molecular Genetics, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Lee E Fisher
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, PA, United States of America.,Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Christopher Bettinger
- Department of Material Science and Engineering, Carnegie Mellon University, Pittsburgh, PA, United States of America
| | - Gary K Fedder
- Department of Electrical and Computer Engineering, Carnegie Mellon University, Pittsburgh, PA, United States of America
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28
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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.
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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.)
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29
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Cracchiolo M, Ottaviani MM, Panarese A, Strauss I, Vallone F, Mazzoni A, Micera S. Bioelectronic medicine for the autonomic nervous system: clinical applications and perspectives. J Neural Eng 2021; 18. [PMID: 33592597 DOI: 10.1088/1741-2552/abe6b9] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 02/16/2021] [Indexed: 12/11/2022]
Abstract
Bioelectronic medicine (BM) is an emerging new approach for developing novel neuromodulation therapies for pathologies that have been previously treated with pharmacological approaches. In this review, we will focus on the neuromodulation of autonomic nervous system (ANS) activity with implantable devices, a field of BM that has already demonstrated the ability to treat a variety of conditions, from inflammation to metabolic and cognitive disorders. Recent discoveries about immune responses to ANS stimulation are the laying foundation for a new field holding great potential for medical advancement and therapies and involving an increasing number of research groups around the world, with funding from international public agencies and private investors. Here, we summarize the current achievements and future perspectives for clinical applications of neural decoding and stimulation of the ANS. First, we present the main clinical results achieved so far by different BM approaches and discuss the challenges encountered in fully exploiting the potential of neuromodulatory strategies. Then, we present current preclinical studies aimed at overcoming the present limitations by looking for optimal anatomical targets, developing novel neural interface technology, and conceiving more efficient signal processing strategies. Finally, we explore the prospects for translating these advancements into clinical practice.
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Affiliation(s)
- Marina Cracchiolo
- The BioRobotics Institute and Department of Excellence in Robotics & AI, The BioRobotics Institute, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Matteo Maria Ottaviani
- The BioRobotics Institute and Department of Excellence in Robotics & AI, The BioRobotics Institute, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Alessandro Panarese
- The BioRobotics Institute and Department of Excellence in Robotics & AI, The BioRobotics Institute, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Ivo Strauss
- The BioRobotics Institute and Department of Excellence in Robotics & AI, The BioRobotics Institute, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Fabio Vallone
- The BioRobotics Institute and Department of Excellence in Robotics & AI, The BioRobotics Institute, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Alberto Mazzoni
- The BioRobotics Institute and Department of Excellence in Robotics & AI, The BioRobotics Institute, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Silvestro Micera
- The BioRobotics Institute and Department of Excellence in Robotics & AI, The BioRobotics Institute, Scuola Superiore Sant'Anna, Pisa, Italy.,Bertarelli Foundation Chair in Translational NeuroEngineering, Centre for Neuroprosthetics and Institute of Bioengineering, École Polytechnique Fédérale de Lausanne (EPFL), Lausanne, Switzerland
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30
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Fontaine AK, Futia GL, Rajendran PS, Littich SF, Mizoguchi N, Shivkumar K, Ardell JL, Restrepo D, Caldwell JH, Gibson EA, Weir RFF. Optical vagus nerve modulation of heart and respiration via heart-injected retrograde AAV. Sci Rep 2021; 11:3664. [PMID: 33574459 PMCID: PMC7878800 DOI: 10.1038/s41598-021-83280-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 01/18/2021] [Indexed: 12/16/2022] Open
Abstract
Vagus nerve stimulation has shown many benefits for disease therapies but current approaches involve imprecise electrical stimulation that gives rise to off-target effects, while the functionally relevant pathways remain poorly understood. One method to overcome these limitations is the use of optogenetic techniques, which facilitate targeted neural communication with light-sensitive actuators (opsins) and can be targeted to organs of interest based on the location of viral delivery. Here, we tested whether retrograde adeno-associated virus (rAAV2-retro) injected in the heart can be used to selectively express opsins in vagus nerve fibers controlling cardiac function. Furthermore, we investigated whether perturbations in cardiac function could be achieved with photostimulation at the cervical vagus nerve. Viral injection in the heart resulted in robust, primarily afferent, opsin reporter expression in the vagus nerve, nodose ganglion, and brainstem. Photostimulation using both one-photon stimulation and two-photon holography with a GRIN-lens incorporated nerve cuff, was tested on the pilot-cohort of injected mice. Changes in heart rate, surface electrocardiogram, and respiratory responses were observed in response to both one- and two-photon photostimulation. The results demonstrate feasibility of retrograde labeling for organ targeted optical neuromodulation.
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Affiliation(s)
- Arjun K Fontaine
- Departments of Bioengineering, University of Colorado - Anschutz Medical Campus, Aurora, CO, USA.
- Biomechatronics Development Laboratory, University of Colorado - Anschutz Medical Campus, Aurora, CO, USA.
| | - Gregory L Futia
- Departments of Bioengineering, University of Colorado - Anschutz Medical Campus, Aurora, CO, USA
| | - Pradeep S Rajendran
- UCLA Cardiac Arrhythmia Center, University of California Los Angeles, Los Angeles, CA, USA
- UCLA Neurocardiology Research Program of Excellence, University of California Los Angeles, Los Angeles, CA, USA
| | - Samuel F Littich
- Departments of Bioengineering, University of Colorado - Anschutz Medical Campus, Aurora, CO, USA
- Biomechatronics Development Laboratory, University of Colorado - Anschutz Medical Campus, Aurora, CO, USA
| | - Naoko Mizoguchi
- Departments of Cell and Developmental Biology, University of Colorado - Anschutz Medical Campus, Aurora, CO, USA
- Division of Pharmacology, Department of Diagnostic and Therapeutic Sciences, Meikai University School of Dentistry, Saitama, Japan
| | - Kalyanam Shivkumar
- UCLA Cardiac Arrhythmia Center, University of California Los Angeles, Los Angeles, CA, USA
- UCLA Neurocardiology Research Program of Excellence, University of California Los Angeles, Los Angeles, CA, USA
| | - Jeffrey L Ardell
- UCLA Cardiac Arrhythmia Center, University of California Los Angeles, Los Angeles, CA, USA
- UCLA Neurocardiology Research Program of Excellence, University of California Los Angeles, Los Angeles, CA, USA
| | - Diego Restrepo
- Departments of Cell and Developmental Biology, University of Colorado - Anschutz Medical Campus, Aurora, CO, USA
| | - John H Caldwell
- Departments of Cell and Developmental Biology, University of Colorado - Anschutz Medical Campus, Aurora, CO, USA
| | - Emily A Gibson
- Departments of Bioengineering, University of Colorado - Anschutz Medical Campus, Aurora, CO, USA
| | - Richard F Ff Weir
- Departments of Bioengineering, University of Colorado - Anschutz Medical Campus, Aurora, CO, USA
- Biomechatronics Development Laboratory, University of Colorado - Anschutz Medical Campus, Aurora, CO, USA
- Rocky Mountain Veterans Affairs Medical Center (VAMC), Aurora, CO, USA
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31
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Fay KS, Cohen DL. Resistant Hypertension in People With CKD: A Review. Am J Kidney Dis 2021; 77:110-121. [DOI: 10.1053/j.ajkd.2020.04.017] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 04/17/2020] [Indexed: 01/23/2023]
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32
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Clemmer JS, Pruett WA, Hester RL. In silico trial of baroreflex activation therapy for the treatment of obesity-induced hypertension. PLoS One 2021; 16:e0259917. [PMID: 34793497 PMCID: PMC8601446 DOI: 10.1371/journal.pone.0259917] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 10/28/2021] [Indexed: 11/25/2022] Open
Abstract
Clinical trials evaluating the efficacy of chronic electrical stimulation of the carotid baroreflex for the treatment of hypertension (HTN) are ongoing. However, the mechanisms by which this device lowers blood pressure (BP) are unclear, and it is uncertain which patients are most likely to receive clinical benefit. Mathematical modeling provides the ability to analyze complicated interrelated effects across multiple physiological systems. Our current model HumMod is a large physiological simulator that has been used previously to investigate mechanisms responsible for BP lowering during baroreflex activation therapy (BAT). First, we used HumMod to create a virtual population in which model parameters (n = 335) were randomly varied, resulting in unique models (n = 6092) that we define as a virtual population. This population was calibrated using data from hypertensive obese dogs (n = 6) subjected to BAT. The resultant calibrated virtual population (n = 60) was based on tuning model parameters to match the experimental population in 3 key variables: BP, glomerular filtration rate, and plasma renin activity, both before and after BAT. In the calibrated population, responses of these 3 key variables to chronic BAT were statistically similar to experimental findings. Moreover, blocking suppression of renal sympathetic nerve activity (RSNA) and/or increased secretion of atrial natriuretic peptide (ANP) during BAT markedly blunted the antihypertensive response in the virtual population. These data suggest that in obesity-mediated HTN, RSNA and ANP responses are key factors that contribute to BP lowering during BAT. This modeling approach may be of value in predicting BAT responses in future clinical studies.
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Affiliation(s)
- John S. Clemmer
- Department of Physiology and Biophysics, Center for Computational Medicine, University of Mississippi Medical Center, Jackson, MS, United States of America
- * E-mail:
| | - W. Andrew Pruett
- Department of Physiology and Biophysics, Center for Computational Medicine, University of Mississippi Medical Center, Jackson, MS, United States of America
| | - Robert L. Hester
- Department of Physiology and Biophysics, Center for Computational Medicine, University of Mississippi Medical Center, Jackson, MS, United States of America
- Department of Data Sciences, John D. Bower School of Population Health, University of Mississippi Medical Center, Jackson, MS, United States of America
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33
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Ribeiro AB, Brognara F, da Silva JF, Castania JA, Fernandes PG, Tostes RC, Salgado HC. Carotid sinus nerve stimulation attenuates alveolar bone loss and inflammation in experimental periodontitis. Sci Rep 2020; 10:19258. [PMID: 33159128 PMCID: PMC7648828 DOI: 10.1038/s41598-020-76194-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 10/23/2020] [Indexed: 12/12/2022] Open
Abstract
Baroreceptor and chemoreceptor reflexes modulate inflammatory responses. However, whether these reflexes attenuate periodontal diseases has been poorly examined. Thus, the present study determined the effects of electrical activation of the carotid sinus nerve (CSN) in rats with periodontitis. We hypothesized that activation of the baro and chemoreflexes attenuates alveolar bone loss and the associated inflammatory processes. Electrodes were implanted around the CSN, and bilateral ligation of the first mandibular molar was performed to, respectively, stimulate the CNS and induce periodontitis. The CSN was stimulated daily for 10 min, during nine days, in unanesthetized animals. On the eighth day, a catheter was inserted into the left femoral artery and, in the next day, the arterial pressure was recorded. Effectiveness of the CNS electrical stimulation was confirmed by hypotensive responses, which was followed by the collection of a blood sample, gingival tissue, and jaw. Long-term (9 days) electrical stimulation of the CSN attenuated bone loss and the histological damage around the first molar. In addition, the CSN stimulation also reduced the gingival and plasma pro-inflammatory cytokines induced by periodontitis. Thus, CSN stimulation has a protective effect on the development of periodontal disease mitigating alveolar bone loss and inflammatory processes.
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Affiliation(s)
- Aline Barbosa Ribeiro
- Department of Physiology, Ribeirão Preto Medical School, University of São Paulo, Avenida dos Bandeirantes, 3900, Ribeirão Preto, SP, 14049-900, Brazil
| | - Fernanda Brognara
- Department of Physiology, Ribeirão Preto Medical School, University of São Paulo, Avenida dos Bandeirantes, 3900, Ribeirão Preto, SP, 14049-900, Brazil
| | - Josiane Fernandes da Silva
- Department of Pharmacology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, SP, Brazil
| | - Jaci Airton Castania
- Department of Physiology, Ribeirão Preto Medical School, University of São Paulo, Avenida dos Bandeirantes, 3900, Ribeirão Preto, SP, 14049-900, Brazil
| | | | - Rita C Tostes
- Department of Pharmacology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, SP, Brazil
| | - Helio Cesar Salgado
- Department of Physiology, Ribeirão Preto Medical School, University of São Paulo, Avenida dos Bandeirantes, 3900, Ribeirão Preto, SP, 14049-900, Brazil.
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34
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Michel JB. Phylogenic Determinants of Cardiovascular Frailty, Focus on Hemodynamics and Arterial Smooth Muscle Cells. Physiol Rev 2020; 100:1779-1837. [DOI: 10.1152/physrev.00022.2019] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The evolution of the circulatory system from invertebrates to mammals has involved the passage from an open system to a closed in-parallel system via a closed in-series system, accompanying the increasing complexity and efficiency of life’s biological functions. The archaic heart enables pulsatile motion waves of hemolymph in invertebrates, and the in-series circulation in fish occurs with only an endothelium, whereas mural smooth muscle cells appear later. The present review focuses on evolution of the circulatory system. In particular, we address how and why this evolution took place from a closed, flowing, longitudinal conductance at low pressure to a flowing, highly pressurized and bifurcating arterial compartment. However, although arterial pressure was the latest acquired hemodynamic variable, the general teleonomy of the evolution of species is the differentiation of individual organ function, supported by specific fueling allowing and favoring partial metabolic autonomy. This was achieved via the establishment of an active contractile tone in resistance arteries, which permitted the regulation of blood supply to specific organ activities via its localized function-dependent inhibition (active vasodilation). The global resistance to viscous blood flow is the peripheral increase in frictional forces caused by the tonic change in arterial and arteriolar radius, which backscatter as systemic arterial blood pressure. Consequently, the arterial pressure gradient from circulating blood to the adventitial interstitium generates the unidirectional outward radial advective conductance of plasma solutes across the wall of conductance arteries. This hemodynamic evolution was accompanied by important changes in arterial wall structure, supported by smooth muscle cell functional plasticity, including contractility, matrix synthesis and proliferation, endocytosis and phagocytosis, etc. These adaptive phenotypic shifts are due to epigenetic regulation, mainly related to mechanotransduction. These paradigms actively participate in cardio-arterial pathologies such as atheroma, valve disease, heart failure, aneurysms, hypertension, and physiological aging.
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Schiavon CA, Pio-Abreu A, Drager LF. Bariatric Surgery for Resistant Hypertension: Working in Progress! Curr Hypertens Rep 2020; 22:55. [PMID: 32671558 DOI: 10.1007/s11906-020-01055-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
PURPOSE OF REVIEW To discuss the recent evidence pointing the benefits of the bariatric surgery on blood pressure control in patients with obesity and hypertension. Particular focus is devoted to discuss the potential impact on resistant hypertension. RECENT FINDINGS Growing evidence suggest that bariatric surgery promotes not only a significant reduction in the anti-hypertensive medication while maintained blood pressure control but also a significant proportion of hypertension remission as compared to the usual care. In a sub-analysis of the GATEWAY trial using both office and 24-h ambulatory blood pressure monitoring, the prevalence of resistant hypertension significantly decreased after 12 months in the surgical group whereas the numbers remained stable in the control group. Despite the lack of robust evidence, preliminary findings underscore the strong need to explore the potential role of bariatric surgery on resistant hypertension in patients with obesity. This statement is justified not only for the burden of obesity in this scenario but also for the unmet demands in managing resistant hypertension appropriately by multiple drug-therapy or the lack of real utility of procedures like renal denervation and carotid baroreflex activation.
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Affiliation(s)
- Carlos A Schiavon
- Bariatric Surgery Center, BP Hospital, Sao Paulo, Brazil. .,Research Institute, Heart Hospital (HCor), Abilio Soares St, 250, 12th Floor, Sao Paulo, SP, 04004-050, Brazil.
| | - Andrea Pio-Abreu
- Hypertension Unit, Renal Division, University of São Paulo Medical School, São Paulo, Brazil
| | - Luciano F Drager
- Hypertension Unit, Renal Division, University of São Paulo Medical School, São Paulo, Brazil.,Heart Institute (InCor), Hypertension Unit, University of São Paulo Medical School, São Paulo, Brazil
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Groenland EH, Spiering W. Baroreflex Amplification and Carotid Body Modulation for the Treatment of Resistant Hypertension. Curr Hypertens Rep 2020; 22:27. [PMID: 32166464 PMCID: PMC7067736 DOI: 10.1007/s11906-020-1024-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
PURPOSE OF REVIEW Patients with true resistant hypertension (RH) are characterized by having high sympathetic activity and therefore potentially benefit from treatments such as baroreflex amplification (baroreflex activation therapy (BAT) or endovascular baroreflex amplification therapy (EVBA)) or carotid body (CB) modulation. This review aims at providing an up-to-date overview of the available evidence regarding these two therapies. RECENT FINDINGS In recent years, increasing evidence has confirmed the potential of baroreflex amplification, either electrically (Barostim neo) or mechanically (MobiusHD), to improve blood pressure control on short- and long-term with only few side effects, in patients with RH. Two studies regarding unilateral CB resection did not show a significant change in blood pressure. Only limited studies regarding CB modulation showed promising results for transvenous CB ablation, but not for unilateral CB resection. Despite promising results from mostly uncontrolled studies, more evidence regarding the safety and efficacy from ongoing large randomized sham-controlled trials is needed before baroreflex amplification and CB modulation can be implemented in routine clinical practice.
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Affiliation(s)
- Eline H Groenland
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht University, 3508, GA, Utrecht, The Netherlands
| | - Wilko Spiering
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht University, 3508, GA, Utrecht, The Netherlands.
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Halbach M, Grothaus D, Hoffmann F, Madershahian N, Kuhr K, Reuter H. Baroreflex activation therapy reduces frequency and duration of hypertension-related hospitalizations in patients with resistant hypertension. Clin Auton Res 2020; 30:541-548. [PMID: 32052254 PMCID: PMC8302539 DOI: 10.1007/s10286-020-00670-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Accepted: 01/30/2020] [Indexed: 12/01/2022]
Abstract
Purpose Baroreflex activation therapy (BAT) has been shown to lower blood pressure in patients with resistant hypertension. The purpose of this study was to analyze whether this translates into a reduction of more relevant clinical endpoints. Methods Patients with resistant hypertension were treated with the second-generation BAT system. Records on hospitalization (dates of admission and discharge, main diagnosis) were obtained from medical insurance companies. Results Records on hospitalization were available for a period of 1 year before BAT in two patients and 2 years in 22 patients. The total number of hospitalizations per patient was 3.3 ± 3.5/year before BAT and 2.2 ± 2.7/year after BAT (p = 0.03). Hospitalizations related to hypertension were significantly decreased from 1.5 ± 1.6/year before BAT to 0.5 ± 0.9/year after BAT (p < 0.01). The cumulative duration of hypertension-related hospital stays was significantly reduced from 8.0 ± 8.7 days/year before BAT to 1.8 ± 4.8 days/year after BAT (p < 0.01). Office cuff blood pressure was 183 ± 27 mmHg over 102 ± 17 mmHg under 6.6 ± 2.0 antihypertensive drugs before BAT and 157 ± 32 mmHg over 91 ± 20 mmHg (both p < 0.01) under 5.9 ± 1.9 antihypertensive drugs (p = 0.09 for number of drugs) at latest follow-up. Daytime ambulatory blood pressure was 164 ± 21 mmHg over 91 ± 14 mmHg before BAT and 153 ± 21 mmHg (p = 0.03) over 89 ± 15 mmHg (p = 0.56) at latest follow-up. Heart rate was 75 ± 16 bpm before BAT and 72 ± 12 bpm at latest follow-up (p = 0.35). Conclusions Rate and duration of hypertension-related hospitalizations in patients with severe resistant hypertension were lowered after BAT. Whether the response is mediated through improvements in blood pressure control requires further studies. Electronic supplementary material The online version of this article (10.1007/s10286-020-00670-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Marcel Halbach
- Department of Internal Medicine III, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany.
| | - David Grothaus
- Department of Internal Medicine III, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Fabian Hoffmann
- Department of Internal Medicine III, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | | | - Kathrin Kuhr
- Institute of Medical Statistics and Computational Biology, University of Cologne, Cologne, Germany
| | - Hannes Reuter
- Department of Internal Medicine III, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany.,Evangelisches Klinikum Köln-Weyertal, Weyertal 76, 50931, Cologne, Germany
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Dyrvig Kristensen AM, Pareek M, Olsen MH, Bhatt DL. Baroreflex Activation Therapy for Resistant Hypertension and Heart Failure. US CARDIOLOGY REVIEW 2020. [DOI: 10.15420/usc.2019.13.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Hypertension and heart failure are important contributors to global morbidity and mortality. Despite therapeutic lifestyle and pharmacological measures, a significant proportion of people with hypertension do not reach treatment targets. Patients with resistant or poorly controlled hypertension are at significantly increased risk of cardiovascular events, including heart failure. Since dysfunction of the sympathetic nervous system appears to play a key role in the development and progression of both hypertension and heart failure, these patients may benefit from treatment modalities aimed at reducing sympathetic function. The purpose of this paper is to provide an overview of baroreflex activation therapy as a potential treatment strategy in patients with resistant hypertension or heart failure.
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Affiliation(s)
| | - Manan Pareek
- Department of Cardiology, North Zealand Hospital, Hilleroed, Denmark; Brigham and Women’s Hospital Heart and Vascular Center, Harvard Medical School, Boston, MA
| | - Michael Hecht Olsen
- Cardiology Section, Department of Internal Medicine, Holbaek Hospital, Holbaek, Denmark
| | - Deepak L Bhatt
- Brigham and Women’s Hospital Heart and Vascular Center, Harvard Medical School, Boston, MA
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Abstract
PURPOSE OF REVIEW To give an overview on recent developments in permanent implant-based therapy of resistant hypertension. RECENT FINDINGS The American Heart Association (AHA) recently updated their guidelines to treat high blood pressure (BP). As elevated BP now is defined as a systolic BP above 120 mmHg, the prevalence of hypertension in the USA has increased from 32% (old definition of hypertension) to 46%. In the past years, device- and implant-mediated therapies have evolved and extensively studied in various patient populations. Despite an initial drawback in a randomized controlled trial (RCT) of bilateral carotid sinus stimulation (CSS), new and less invasive and unilateral systems for baroreflex activation therapy (BAT) with the BAROSTIM NEO® have been developed which show promising results in small non-randomized controlled (RCT) studies. Selective vagal nerve stimulation (VNS) has been successfully evaluated in rodents, but has not yet been tested in humans. A new endovascular approach to reshape the carotid sinus to lower BP (MobiusHD™) has been introduced (baroreflex amplification therapy) with favorable results in non-RCT trials. However, long-term results are not yet available for this treatment option. A specific subgroup of patients, those with indication for a 2-chamber cardiac pacemaker, may benefit from a new stimulation paradigm which reduces the AV latency and therefore limits the filling time of the left ventricle. The most invasive approach for resistant hypertension still is the neuromodulation by deep brain stimulation (DBS), which has been shown to significantly lower BP in single cases. Implant-mediated therapy remains a promising approach for the treatment of resistant hypertension. Due to their invasiveness, such treatment options must prove superiority over conventional therapies with regard to safety and efficacy before they can be generally offered to a wider patient population. Overall, BAROSTIM NEO® and MobiusHD™, for which large RCTs will soon be available, are likely to meet those criteria and may represent the first implant-mediated therapeutical options for hypertension, while the use of DBS probably will be reserved for individual cases. The utility of VNS awaits appropriate assessment.
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Peixoto AJ. Is There a Role for Device Therapies in Resistant Hypertension?: The CON Side. KIDNEY360 2020; 1:9-13. [PMID: 35372851 PMCID: PMC8808493 DOI: 10.34067/kid.0000742019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Affiliation(s)
- Aldo J. Peixoto
- Section of Nephrology, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut; and
- Hypertension Program, Yale New Haven Hospital Heart and Vascular Center, New Haven, Connecticut
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Abstract
Despite availability of effective drugs for hypertension therapy, significant numbers of hypertensive patients fail to achieve recommended blood pressure levels on ≥3 antihypertensive drugs of different classes. These individuals have a high prevalence of adverse cardiovascular events and are defined as having resistant hypertension (RHT) although nonadherence to prescribed antihypertensive medications is common in patients with apparent RHT. Furthermore, apparent and true RHT often display increased sympathetic activity. Based on these findings, technology was developed to treat RHT by suppressing sympathetic activity with electrical stimulation of the carotid baroreflex and catheter-based renal denervation (RDN). Over the last 15 years, experimental and clinical studies have provided better understanding of the physiological mechanisms that account for blood pressure lowering with baroreflex activation and RDN and, in so doing, have provided insight into which patients in this heterogeneous hypertensive population are most likely to respond favorably to these device-based therapies. Experimental studies have also played a role in modifying device technology after early clinical trials failed to meet key endpoints for safety and efficacy. At the same time, these studies have exposed potential differences between baroreflex activation and RDN and common challenges that will likely impact antihypertensive treatment and clinical outcomes in patients with RHT. In this review, we emphasize physiological studies that provide mechanistic insights into blood pressure lowering with baroreflex activation and RDN in the context of progression of clinical studies, which are now at a critical point in determining their fate in RHT management.
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Affiliation(s)
- Thomas E Lohmeier
- From the Department of Physiology and Biophysics (T.E.L., J.E.H.), University of Mississippi Medical Center, Jackson
| | - John E Hall
- From the Department of Physiology and Biophysics (T.E.L., J.E.H.), University of Mississippi Medical Center, Jackson.,Mississippi Center for Obesity Research (J.E.H.), University of Mississippi Medical Center, Jackson
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Kunz M, Lauder L, Ewen S, Böhm M, Mahfoud F. The Current Status of Devices for the Treatment of Resistant Hypertension. Am J Hypertens 2020; 33:10-18. [PMID: 31570933 DOI: 10.1093/ajh/hpz161] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 09/23/2019] [Accepted: 09/29/2019] [Indexed: 12/22/2022] Open
Abstract
Arterial hypertension is associated with increased cardiovascular morbidity and mortality. Although blood pressure-lowering therapies significantly reduce the risk of major cardiovascular events, blood pressure control remains unsatisfactorily low. Several device-based antihypertensive therapies have been investigated in patients with treatment-resistant hypertension and in patients unable or unwilling to adhere to antihypertensive medication. As the field of device-based therapies is subject to constant change, this review aims at providing an up-to-date overview of different device-based approaches for the treatment of hypertension. These approaches target the sympathetic nervous system (renal denervation, baroreflex amplification therapy, baroreflex activation therapy, and carotid body ablation) or alter mechanical arterial properties by creating an iliac arteriovenous fistula. Notably, the use of all of these treatment options is not recommended for the routine treatment of hypertension by current guidelines but should be investigated in the context of controlled clinical studies.
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Affiliation(s)
- Michael Kunz
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University, Homburg/Saar, Germany
| | - Lucas Lauder
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University, Homburg/Saar, Germany
| | - Sebastian Ewen
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University, Homburg/Saar, Germany
| | - Michael Böhm
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University, Homburg/Saar, Germany
| | - Felix Mahfoud
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University, Homburg/Saar, Germany
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
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Ntiloudi D, Qanud K, Tomaio JN, Giannakoulas G, Al-Abed Y, Zanos S. Pulmonary arterial hypertension: the case for a bioelectronic treatment. Bioelectron Med 2019; 5:20. [PMID: 32232109 PMCID: PMC7098229 DOI: 10.1186/s42234-019-0036-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 11/08/2019] [Indexed: 12/16/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) is a rare disease of unknown etiology that progresses to right ventricular failure. It has a complex pathophysiology, which involves an imbalance between vasoconstrictive and vasodilative processes in the pulmonary circulation, pulmonary vasoconstriction, vascular and right ventricular remodeling, systemic inflammation, and autonomic imbalance, with a reduced parasympathetic and increased sympathetic tone. Current pharmacological treatments for PAH include several classes of drugs that target signaling pathways in vascular biology and cardiovascular physiology, but they can have severe unwanted effects and they do not typically stop the progression of the disease. Pulmonary artery denervation has been tested clinically as a method to suppress sympathetic overactivation, however it is a nonspecific and irreversible intervention. Bioelectronic medicine, in particular vagus nerve stimulation (VNS), has been used in cardiovascular disorders like arrhythmias, heart failure and arterial hypertension and could, in principle, be tested as a treatment in PAH. VNS can produce pulmonary vasodilation and renormalize right ventricular function, via activation of pulmonary and cardiac vagal fibers. It can suppress systemic inflammation, via activation of fibers that innervate the spleen. Finally, VNS can gradually restore the balance between parasympathetic and sympathetic tone by regulating autonomic reflexes. Preclinical studies support the feasibility of using VNS in PAH. However, there are challenges with such an approach, arising from the need to affect a relatively small number of relevant vagal fibers, and the potential for unwanted cardiac and noncardiac effects of VNS in this sensitive patient population.
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Affiliation(s)
- Despοina Ntiloudi
- Institute of Bioelectronic Medicine, Feinstein Institutes for Medical Research, Manhasset, NY 11030 USA.,2Department of Cardiology, AHEPA University Hospital, Thessaloniki, Greece
| | - Khaled Qanud
- Institute of Bioelectronic Medicine, Feinstein Institutes for Medical Research, Manhasset, NY 11030 USA
| | - Jacquelyn-Nicole Tomaio
- Institute of Bioelectronic Medicine, Feinstein Institutes for Medical Research, Manhasset, NY 11030 USA
| | | | - Yousef Al-Abed
- Institute of Bioelectronic Medicine, Feinstein Institutes for Medical Research, Manhasset, NY 11030 USA
| | - Stavros Zanos
- Institute of Bioelectronic Medicine, Feinstein Institutes for Medical Research, Manhasset, NY 11030 USA
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Abstract
ZusammenfassungErhöhter Blutdruck bleibt eine Hauptursache von kardiovaskulären Erkrankungen, Behinderung und frühzeitiger Sterblichkeit in Österreich, wobei die Raten an Diagnose, Behandlung und Kontrolle auch in rezenten Studien suboptimal sind. Das Management von Bluthochdruck ist eine häufige Herausforderung für Ärztinnen und Ärzte vieler Fachrichtungen. In einem Versuch, diagnostische und therapeutische Strategien zu standardisieren und letztendlich die Rate an gut kontrollierten Hypertoniker/innen zu erhöhen und dadurch kardiovaskuläre Erkrankungen zu verhindern, haben 13 österreichische medizinische Fachgesellschaften die vorhandene Evidenz zur Prävention, Diagnose, Abklärung, Therapie und Konsequenzen erhöhten Blutdrucks gesichtet. Das hier vorgestellte Ergebnis ist der erste Österreichische Blutdruckkonsens. Die Autoren und die beteiligten Fachgesellschaften sind davon überzeugt, daß es einer gemeinsamen nationalen Anstrengung bedarf, die Blutdruck-assoziierte Morbidität und Mortalität in unserem Land zu verringern.
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Wang J, Dai M, Cao Q, Yu Q, Luo Q, Shu L, Zhang Y, Bao M. Carotid baroreceptor stimulation suppresses ventricular fibrillation in canines with chronic heart failure. Basic Res Cardiol 2019; 114:41. [PMID: 31502080 DOI: 10.1007/s00395-019-0750-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Accepted: 09/06/2019] [Indexed: 12/16/2022]
Abstract
Carotid baroreceptor stimulation (CBS) has been shown to improve cardiac dysfunction and pathological structure remodelling. This study aimed to investigate the effects of CBS on the ventricular electrophysiological properties in canines with chronic heart failure (CHF). Thirty-eight beagles were randomized into control (CON), CHF, low-level CBS (LL-CBS), and moderate-level CBS (ML-CBS) groups. The CHF model was established with 6 weeks of rapid right ventricular pacing (RVP), and concomitant LL-CBS and ML-CBS were applied in the LL-CBS and ML-CBS groups, respectively. After 6 weeks of RVP, ventricular electrophysiological parameters and left stellate ganglion (LSG) neural activity and function were measured. Autonomic neural remodelling in the LSG and left ventricle (LV) and ionic remodelling in the LV were detected. Compared with the CHF group, both LL-CBS and ML-CBS decreased spatial dispersion of action potential duration (APD), suppressed APD alternans, reduced ventricular fibrillation (VF) inducibility, and inhibited enhanced LSG neural discharge and function. Only ML-CBS significantly inhibited ventricular repolarization prolongation and increased the VF threshold. Moreover, ML-CBS inhibited the increase in growth-associated protein-43 and tyrosine hydroxylase-positive nerve fibre densities in LV, increased acetylcholinesterase protein expression in LSG, and decreased nerve growth factor protein expression in LSG and LV. Chronic RVP resulted in a remarkable reduction in protein expression encoding both potassium and L-type calcium currents; these changes were partly amended by ML-CBS and LL-CBS. In conclusion, CBS suppresses VF in CHF canines, potentially by modulating autonomic nerve and ion channels. In addition, the effects of ML-CBS on ventricular electrophysiological properties, autonomic remodelling, and ionic remodelling were superior to those of LL-CBS.
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Affiliation(s)
- Jing Wang
- Department of Cardiology, Renmin Hospital of Wuhan University, 238 Jiefang Road, Wuhan, 430060, Hubei, People's Republic of China
- Cardiovascular Research Institute, Wuhan University, Wuhan, 430060, People's Republic of China
- Hubei Key Laboratory of Cardiology, Wuhan, 430060, People's Republic of China
| | - Mingyan Dai
- Department of Cardiology, Renmin Hospital of Wuhan University, 238 Jiefang Road, Wuhan, 430060, Hubei, People's Republic of China
- Cardiovascular Research Institute, Wuhan University, Wuhan, 430060, People's Republic of China
- Hubei Key Laboratory of Cardiology, Wuhan, 430060, People's Republic of China
| | - Quan Cao
- Department of Cardiology, Renmin Hospital of Wuhan University, 238 Jiefang Road, Wuhan, 430060, Hubei, People's Republic of China
- Cardiovascular Research Institute, Wuhan University, Wuhan, 430060, People's Republic of China
- Hubei Key Laboratory of Cardiology, Wuhan, 430060, People's Republic of China
| | - Qiao Yu
- Department of Cardiology, Renmin Hospital of Wuhan University, 238 Jiefang Road, Wuhan, 430060, Hubei, People's Republic of China
- Cardiovascular Research Institute, Wuhan University, Wuhan, 430060, People's Republic of China
- Hubei Key Laboratory of Cardiology, Wuhan, 430060, People's Republic of China
| | - Qiang Luo
- Department of Cardiology, Renmin Hospital of Wuhan University, 238 Jiefang Road, Wuhan, 430060, Hubei, People's Republic of China
- Cardiovascular Research Institute, Wuhan University, Wuhan, 430060, People's Republic of China
- Hubei Key Laboratory of Cardiology, Wuhan, 430060, People's Republic of China
| | - Ling Shu
- Department of Cardiology, Renmin Hospital of Wuhan University, 238 Jiefang Road, Wuhan, 430060, Hubei, People's Republic of China
- Cardiovascular Research Institute, Wuhan University, Wuhan, 430060, People's Republic of China
- Hubei Key Laboratory of Cardiology, Wuhan, 430060, People's Republic of China
| | - Yijie Zhang
- Department of Cardiology, Renmin Hospital of Wuhan University, 238 Jiefang Road, Wuhan, 430060, Hubei, People's Republic of China
- Cardiovascular Research Institute, Wuhan University, Wuhan, 430060, People's Republic of China
- Hubei Key Laboratory of Cardiology, Wuhan, 430060, People's Republic of China
| | - Mingwei Bao
- Department of Cardiology, Renmin Hospital of Wuhan University, 238 Jiefang Road, Wuhan, 430060, Hubei, People's Republic of China.
- Cardiovascular Research Institute, Wuhan University, Wuhan, 430060, People's Republic of China.
- Hubei Key Laboratory of Cardiology, Wuhan, 430060, People's Republic of China.
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Long-term effects of baroreflex activation therapy: 2-year follow-up data of the BAT Neo system. Clin Res Cardiol 2019; 109:513-522. [DOI: 10.1007/s00392-019-01536-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 08/01/2019] [Indexed: 12/24/2022]
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Horn CC, Ardell JL, Fisher LE. Electroceutical Targeting of the Autonomic Nervous System. Physiology (Bethesda) 2019; 34:150-162. [PMID: 30724129 DOI: 10.1152/physiol.00030.2018] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Autonomic nerves are attractive targets for medical therapies using electroceutical devices because of the potential for selective control and few side effects. These devices use novel materials, electrode configurations, stimulation patterns, and closed-loop control to treat heart failure, hypertension, gastrointestinal and bladder diseases, obesity/diabetes, and inflammatory disorders. Critical to progress is a mechanistic understanding of multi-level controls of target organs, disease adaptation, and impact of neuromodulation to restore organ function.
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Affiliation(s)
- Charles C Horn
- Biobehavioral Oncology Program, UPMC Hillman Cancer Center , Pittsburgh, Pennsylvania.,Department of Medicine, University of Pittsburgh School of Medicine , Pittsburgh, Pennsylvania.,Center for Neuroscience, University of Pittsburgh , Pittsburgh, Pennsylvania
| | - Jeffrey L Ardell
- University of California- Los Angeles (UCLA) Cardiac Arrhythmia Center, Los Angeles, California.,UCLA Neurocardiology Research Program of Excellence, David Geffen School of Medicine , Los Angeles, California
| | - Lee E Fisher
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh School of Medicine , Pittsburgh, Pennsylvania.,Department of Bioengineering, University of Pittsburgh , Pittsburgh, Pennsylvania
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Lipphardt M, Koziolek MJ, Lehnig LY, Schäfer AK, Müller GA, Lüders S, Wallbach M. Effect of baroreflex activation therapy on renal sodium excretion in patients with resistant hypertension. Clin Res Cardiol 2019; 108:1287-1296. [DOI: 10.1007/s00392-019-01464-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2019] [Accepted: 03/19/2019] [Indexed: 12/29/2022]
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