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Renal denervation: a new hope for refractory hypertension

Session presentations
Peripheral Arterial Diseases

Dr J. Mann from Munich, Germany, delivered a presentation on the epidemiology of refractory (resistant) hypertension. Patients with refractory hypertension represent around 12% of all hypertensive patients. The definition of resistance is no appropriate blood pressure reduction when on 3 antihypertensive drugs at the optimal doses, including diuretics. He stressed that the use of ambulatory pressure monitoring is necessary to exclude white coat pseudoresistance. Also, exclusion of other secondary causes of hypertension like primary aldosteronism is important. Addressing the use of diuretics, he said that chlortalidon was more effective than hydrochlorotiazide in the reduction of blood pressure. Spironolactone should be used in patients with refractory hypertension (ASCOT Study) and in the case of side-effects eplerenone may be considered.

Professor G. Mancia from Monza, Italy, emphasized the need for optimal medical treatment in the hypertensive population. This can be done by increasing the doses of already-used medications or by adding a new drug, like beta and/or alpha blockers, spironolactone, central acting agents, vasodilators or renin inhibitors. With spironolactone, careful monitoring of potassium is required, but hyperkalemia exceeding 5.5 mEg/l is relatively rare. Furosemide is usually more effective than hydrochlorotiazide in patients with refractory hypertension (PROBE Study). The antihypertensive therapy should be tailored to the individual patient and based on the major cause of hypertension, like volume overload, sympathetic nerve hyperactivity or structural vascular changes. In this latter case, new drugs may be promising.

Dr Felix Mahfoud (Homburg/Saar, Germany) discussed the role of sympathetic nervous system (SNS) hyperactivity in resistant hypertension and the reduction of afferent and efferent nerve hyperactivity using renal denervation. Central sympathetic activity can be measured by microneurography and renal sympathetic activity by norepinephrine spillover. Overactivity of the SNS may lead to activation of the RAA system, inflammation, hypertension, left ventricular hypertrophy and insulin resistance. SNS overactivity was also diagnosed in patients with heart failure and obstructive sleep apnea. Renal denervation is the new treatment modality aimed at the reduction of SNS activity in patients with refractory hypertension, and through this, at the reduction of blood pressure.

Professor M. Boehm (Homburg/Saar, Germany) explained the selection criteria for candidates for renal denervation, emphasizing the need for the exclusion of pseudoresistance and secondary causes of hypertension. He also presented procedural details of percutaneous denervation and then focused on the results of the HTN-1 and HTN-2 Trials. The reduction of blood pressure after renal denervation is a time-dependent phenomenon, observed in a majority of patients after 6-12 months, with “late” reduction even after 3 years. There is no data on possible re-innervation of the renal arteries after denervation and blood pressure reduction is observed up to 3 years after the procedure. There are only minor and rare complications related to the procedure itself. In a longer follow-up, proper patient reactions to physical exercise and tilt test were observed. There are also data on reduction of microalbuminuria and left ventricular mass after successful renal denervation.

The session was an outstanding educational event, with top researchers in the field of renal denervation on board, with extremely interesting discussion on the growing role of renal denervation in the treatment of hypertension and collateral diseases.




Renal denervation: a new hope for refractory hypertension

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.