resistant hypertension

RESISTANT HYPERTENSION

Dr-Rashna Sharmin JuthiMBBSEastern Medical College and Hospital

“AS WE ENTER THE THIRD MILLENNIUM,WE ARE ON THE VERGE OF THE

BIGGEST EPIDEMIC OF CARDIOVASCULAR DISEASE IN HUMAN HISTORY,

MOST OF IT BLOOD PRESSURE RELATED”

DR. VINOD SHARMA

NATIONAL HEART INSTITUDE

NEW DELHI

DEFINITION2008 AMERICAN HEART ASSOCIATION GUIDELINE BLOOD PRESSURE THAT REMAINS ABOVE GOAL

IN SPITE OF CONCURRENT USE OF THREE ANTIHYPERTENSIVE AGENTS OF DIFFERENT

CLASSES, ONE OF WHICH SHOULD BE A DIURETIC. PATIENTS WHOSE BLOOD PRESSURE IS

CONTROLLED WITH FOUR OR MORE MEDICATIONS ARE CONSIDERED TO HAVE

RESISTANT HYPERTENSION (20-30%).

American Heart Association guideline

PROBLEMS OF RESISTANT HYPERTENSION

Systolic BP difficult control

Diastolic BP in old age

• Module of Prof. Dr. Sarma VSN Rachakonda

• Hon. National Professor of Medicine, IMA – CGP, India• Senior Consultant Physician & Cardio-metabolic Specialist• Adjunct Professor, Tamilnadu Dr. MGR Medical University,

Chennai

PREVALENCE • APPROXIMATELY 25% OF ADULTS WORLDWIDE ARE AFFECTED BY

HYPERTENSION• HYPERTENSION IS RESPONSIBLE FOR 13% OF TOTAL WORLDWIDE DEATHS.• RESISTANT HYPERTENSION IS FOUND IN UP TO 10-20% OF PATIENTS WITH

HYPERTENSION• IT IS ESTIMATED THAT PATIENTS WITH RESISTANT HYPERTENSION ARE

ALMOST 50% MORE LIKELY TO EXPERIENCE AN ADVERSE CARDIOVASCULAR EVENT COMPARED WITH PATIENTS WITH BLOOD PRESSURE CONTROLLED BY THREE OR FEWER ANTIHYPERTENSIVE AGENTS

CIRCULATION 2008, ALLAHT, JOURNAL OF AMERICAN BOARD OF FAMILY MEDICINE 2012

In General Population - Low

In Specialized Clinics -15%

In Clinical Trials* - 30%

*ALLHAT (Anti-lipid lowering heart attack trial), CONVINCE, LIFE, INSIGHT

ETIOLOGY

1. PRIMARY CAUSES2. SECONDARY CAUSES 3. FACTORS CONTRIBUTING TO RESISTANT HYPERTENSION

CIRCULATION 2008, JOURNAL OF AMERICAN BOARD OF FAMILY MEDICINE 2012

CAUSES OF RESISTANT HYPERTENSION

Patient Related

High Sodium Intake

Poor adherence to Rx. plan

Intake of Drugs that raise BP

Lack of Life Style Adherence• Module of Prof. Dr. Sarma VSN Rachakonda• Hon. National Professor of Medicine, IMA – CGP, India• Senior Consultant Physician & Cardio-metabolic Specialist• Adjunct Professor, Tamilnadu Dr. MGR Medical University, Chennai

STRONG ASSOCIATES OF RESISTANT HYPERTENSION

• HbA1c > 9.0 • Creat. >1.5

• AHI >20• BMI >30

T2DM CKD

OSAS(obstructive

sleep apnea)

LVH


• Hon. National Professor of Medicine, IMA – CGP, India

• Senior Consultant Physician & Cardio-metabolic Specialist

• Adjunct Professor, Tamilnadu Dr. MGR Medical University, Chennai

SECONDARY AND RESISTANT HYPERTENSION

Hypertension

Secondar

y

30%

5%


• Hon. National Professor of Medicine, IMA – CGP, India• Senior Consultant Physician & Cardio-metabolic Specialist• Adjunct Professor, Tamilnadu Dr. MGR Medical University,

Chennai

THE PRIMARY CAUSES

• OLDER AGE; ESPECIALLY >75 YEARS• HIGH BASELINE BLOOD PRESSURE AND CHRONICITY OF UNCONTROLLEDHYPERTENSION• TARGET ORGAN DAMAGE (LEFT VENTRICULAR HYPERTROPHY, CHRONICKIDNEY DISEASE)• DIABETES• OBESITY• ATHEROSCLEROTIC VASCULAR DISEASE• AORTIC STIFFENING• SEX (WOMEN)• ETHNICITY (BLACK)• EXCESSIVE DIETARY SODIUM

Circulation2008, journal of American board of family medicine 2012

SECONDARY CAUSES OF RESISTANT HYPERTENSION

• PRIMARY HYPERALDOSTERONISM • RENAL ARTERY STENOSIS • RENAL PARENCHYMAL DISEASE • OBSTRUCTIVE SLEEP APNOEA • PHAEOCHROMOCYTOMA • THYROID DISEASES • CUSHING’S SYNDROME • COARCTATION OF THE AORTA • INTRACRANIAL TUMOURS


RHTN & OBSTRUCTIVE SLEEP APNOEA (OSA)

• PREVALENCE – MEN 24%; WOMEN 9% (WISCONSIN SLEEP COHORT STUDY)

• HIGH PREVALENCE OF RHTN IN OSA (N = 41); 96% MEN, 65% WOMEN (APNEA – HYPERAPNOEA INDEX > 10)

• MECHANISM- INCREASED SYMPATHETIC ACTIVITY- INCREASED ALDOSTERONE LEVELS- INCREASE IN REACTIVE OXYGEN SPECIES WITH CONCOMITANT REDUCTIONS IN NITRIC OXIDE

BIOAVAILABILITY


RHTN & ALDOSTERONE• PREVALENCE OF PRIMARY HYPERALDOSTERONISM IN PATIENTS WITH

RHTN 11 – 20%LANCET 2008: 371

• COMPARED TO CONN’S SYNDROME, PICTURE OF BIOCHEMICALLY CONFIRMED PRIMARY HYPERALDOSTERONISM REMAINS DIVERSE:- SHOWS NEGATIVE IMAGING- REMAINS IDIOPATHIC- HYPOKALEMIA IS USUALLY A LATE MANIFESTATION- NORMOKALEMIA IS QUITE COMMON AMONG THESE PATIENTS

J. CLIN ENDOCRINOL METAB 2009

RHTN & RENAL ARTERY STENOSIS (RAS)• RENOVASCULAR DISEASE ( >70% STENOSIS) FOUND IN MORE

THAN 20% CASES UNDERGOING CAG• ROLE OF SUCH LESION IN CAUSATION OF HYPERTENSION IS

UNKNOWN• > 90% RAS ARE ATHEROSCLEROTIC (ELDERLY MALE), <10% ARE

DUE TO FOOT AND MOUTH DISEASE (FMD) (F<50 YEARS OF AGE)• LARGE EXPERIENCE WITH BOTH SURGICAL AND ENDOVASCULAR

REVASCULARIZATION INDICATES THAT SOME PATIENTS WITH RENOVASCULAR HYPERTENSION EXPERIENCED IMPROVED BP CONTROL ALTHOUGH RANDOMIZED CONTROLLED TRIAL (RCT) IN GENERAL HAVE NOT SHOWN CONVINCING BENEFIT IN REGARD TO IMPROVEMENT IN RENAL FUNCTION OR BP CONTROL


• Hon. National Professor of Medicine, IMA – CGP, India

• Senior Consultant Physician & Cardio-metabolic Specialist

• Adjunct Professor, Tamilnadu Dr. MGR Medical University, Chennai

FACTORS CONTRIBUTING TO RESISTANT HYPERTENSION

LIFESTYLE FACTORS• OBESITY• EXCESS ALCOHOL INTAKE• EXCESS DIETARY SODIUM• COCAINE AND AMPHETAMINES MISUSEDRUG RELATED CAUSES• NON-STEROIDAL ANTI-INFLAMMATORY DRUGS• CONTRACEPTIVE HORMONES—COMBINED ORAL CONTRACEPTIVES ARE MORE OFTEN

ASSOCIATEDWITH ELEVATED BLOOD PRESSURE, WHEREAS MENOPAUSAL HORMONE THERAPY HAS MINIMAL EFFECTS ON BLOODPRESSURE

PPT ON RESISTANT HYPERTENSION PUBLISHED BY HEALTH CARE LINK:HTTP://WWW.SLIDESHARE.NET/DRANJALIVYAS/RESISTANT-HYPERTENSION

FACTORS CONTRIBUTING TO RESISTANT HYPERTENSION (CONT.)

• ADRENAL STEROID HORMONES• SYMPATHOMIMETIC AGENTS (NASAL DECONGESTANTS, DIET PILLS)• ERYTHROPOEITIN, CICLOSPORIN, AND TACROLIMUS• LIQUORICE (SUPPRESSES THE METABOLISM OF CORTISOL)• HERBAL SUPPLEMENTS (EPHEDRA, BITTER ORANGE, ETC)VOLUME OVERLOAD• PROGRESSIVE RENAL INSUFFICIENCY• HIGH SALT INTAKE• INADEQUATE DIURETIC THERAPY

PPT on Resistant hypertension published by health care Link:http://www.slideshare.net/dranjalivyas/resistant-hypertension

DIAGNOSIS

• THE DIAGNOSIS OF RESISTANT HYPERTENSION REQUIRES EXCLUSION OF BOTH PSEUDO-RESISTANCE AND REVERSIBLE OR ORGANIC CAUSES


PSEUDO-RESISTANCE

• BLOOD PRESSURE CAN BE OVERESTIMATED AS A CONSEQUENCE OF INACCURATE MEASUREMENT TECHNIQUE

• THE MOST COMMON CAUSES OF OVERESTIMATED BLOOD PRESSURE ARE USING A CUFF THAT IS TOO SMALLMEASURING BLOOD PRESSURE BEFORE THE PATIENT IS SITTING QUIETLY NO ADHERENCE TO PRESCRIBED ANTIHYPERTENSIVE THERAPY


PSEUDO-RESISTANCE

J Am Coll Cardiol 2008;52:1749–57

Causes of Pseudo-Resistant Hypertension

WHITE COAT EFFECT

• MANY PEOPLE HAVE BLOOD PRESSURE IN THE DOCTOR`S OFFICE THAN THEY HAVE DURING THEIR REGULAR DAY

• IF YOUR DOCTOR SUSPECTS WHITE-COAT EFFECT, YOU MAY NEED TO WEAR A SMALL, PORTABLE, 24-HOUR PRESSURE MONITOR TO SEE WHAT YOUR PRESSURE LOOKS LIKE OVER TIME DURING YOUR DAILY ACTIVITES



HOW TO EVALUATE & MANAGE WITH PATIENTS APPEARING TO HAVE RESISTANT HYPERTENSION?

INVESTIGATIONS • UREA AND ELECTROLYTES• ESTIMATED GLOMERULAR FILTRATION RATE• PLASMA GLUCOSE• PLASMA RENIN OR ALDOSTERONE LEVELS• 24 HOUR URINARY METANEPHRINES OR NOR-METANEPHRINES (FOR

PHAEOCHROMOCYTOMA)• URINE ANALYSIS—MICRO ALBUMINURIA AND MACRO ALBUMINURIA,

HAEMATURIA)• ELECTROCARDIOGRAPHY • ECHOCARDIOGRAPHY SHOULD BE PERFORMED, ALONG WITH

FUNDOSCOPY • RENAL IMAGING


TARGET ORGAN DAMAGE IN RESISTANT HYPERTENSION

• LEFT VENTRICULAR HYPERTROPHY• HYPERTENSIVE RETINOPATHY• RENAL DISEASE (THAT IS, PERSISTENTLY ELEVATED URINARY ALBUMIN

EXCRETION RATE, HAEMATURIA, OR RENAL IMPAIRMENT)


LIFE STYLE PRINCIPLES FOR HYPERTENSION

• SALT RESTRICTION• WEIGHT LOSS• PHYSICAL ACTIVITY• SMOKING CESSATION• ALCOHOL ABSTINENCE• GLYCAEMIA AND LIPID CONTROL • Module of Prof. Dr. Sarma

VSN Rachakonda• Hon. National Professor of Medicine, IMA –

CGP, India• Senior Consultant Physician & Cardio-

metabolic Specialist• Adjunct Professor, Tamilnadu Dr. MGR

Medical University, Chennai

TREATMENTS AVAILABLE FOR RESISTANT HYPERTENSION

• NON-PHARMACOLOGIC INTERVENTION• DRUG INTERVENTION• DEVICE THERAPY


NON-PHARMACOLOGIC INTERVENTION

• WEIGHT LOSS• REGULAR EXERCISE• A HIGH FIBER, LOW FAT, LOW SALT DIET • MODERATION OF ALCOHOL AND CAFFEINE• CESSATION OR DOWN-TITRATION OF INTERFERING EXOGENOUS SUBSTANCES


DRUG TREATMENT OF RESISTANT HYPERTENSION

• IF A CORRECTABLE CAUSE IS FOUND, TREAT THAT• AGGRESSIVE DRUG THERAPY – OPTIMIZING THE CURRENT RX.• EFFECTIVE DIURESIS – FUROSEMIDE/TORSEMIDE• MRA ANTAGONISTS, SPIRONOLACTONE, TRIAMTERENE,

AMILORIDE• HYDRALAZINE OR MINOXIDIL + Β-BLOCKER AND A DIURETIC• TRANSDERMAL CLONIDINE

johns Hopkins medicine health library


DRUG INTERVENTION• PATIENTS DEFINED AS HAVING RESISTANT HYPERTENSION WILL ALREADY BE

RECEIVING OR HAVE RECEIVED AT LEAST THREE ANTIHYPERTENSIVE DRUGS THAT IS, AN ACE INHIBITOR OR ANGIOTENSIN RECEPTOR BLOCKER PLUS A CALCIUM CHANNEL BLOCKER PLUS A THIAZIDE-TYPE DIURETIC (A+C+D)

• SPIRONOLACTONE (THAT IS, 25 MG ONCE DAILY, INCREASING TO 50 MG ONCE DAILY) AS THE PREFERRED FOURTH AGENT IF THE BLOOD POTASSIUM CONCENTRATION IS ≤4.5 MMOL/L.

• CENTRALLY ACTING Α AGONISTS (METHYLDOPA AND CLONIDINE) OR DIRECT VASODILATORS (HYDRALAZINE AND MINOXIDIL) ARE FURTHER OPTIONS.

• THE POTENTIAL ROLES OF OTHER AGENTS SUCH AS ENDOTHELIN RECEPTOR ANTAGONISTS HAVE YET TO BE CLEARLY DEFINED.

JOHNS HOPKINS MEDICINE HEALTH LIBRARYCirculation2008, journal of American board of family medicine 2012

TREATMENT (CONT.)DO NOT KEEP ADDING MEDICATIONS

- APPROPRIATE & OPTIMALLY DOSED 3 DRUG REGIMEN SHOULD SUFFICE FOR BP CONTRO

- ADDING MULTIPLE ADDITIONAL DRUG HAS POTENTIAL FOR SERIOUS SIDE EFFECTS

- ATTEMPT TO FIND AN UNDERLYING CAUSE & TAILORING TREATMENT FOR THAT CAUSE IS NECESSARY

circulation 2008 johns Hopkins medicine health library

RESISTANT HYPERTENSIONPERFORM A “DIURETIC REVIEW”.

DIURETICS IS THE MAINSTAY OF THE RESISTANT HYPERTENSION PATIENT MEDICATION REGIMEN & SHOULD BE OPTIMIZED TO SEE FULL THERAPEUTIC BENEFIT.


DIURETICS• STUDIES INDICATE THAT PATIENTS WITH RESISTANT

HYPERTENSION • FREQUENTLY HAVE INAPPROPRIATE VOLUME

EXPANSION CONTRIBUTING TO THEIR TREATMENT RESISTANCE SUCH THAT A DIURETIC IS ESSENTIAL TO MAXIMIZE BP CONTROL

• IN MOST PATIENTS, USE OF A LONG-ACTING THIAZIDE DIURETIC WILL BE MOST EFFECTIVE

Circulation. 2008;117:e510-e526


RESISTANT HYPERTENSION – DIURETIC REVIEW

• THIAZIDE DIURETIC MAY LACK EFFECT AT LOWER GFR (STAGE 3 KIDNEY DISEASE)

• FRUSEMIDE MAY A BETTER OPTION THAN THIAZIDE FOR BP CONTROL

• BECAUSE OF SHORTER HALF LIFE, FRUSEMIDE MAY BE DOSED TWICE



IS PATIENT TAKING BETA-BLOCKERS?

RESISTANT HYPERTENSION - BETABLOCKERS

• BETA-BLOCKERS ARE NO LONGER ACCEPTABLE FIRST LINE THERAPIES, UNLESS THERE ARE COMPELLING INDICATIONS LIKE CAD, CHF ETC. &

• ONE AGENT SPECIFICALLY ATENOLOL MAY INCREASE CENTRAL AORTIC PRESSURE

CENTRAL STUDY, J CLIN HYPERT 2011• SWITCH TO A OPTIMAL DOSE OF DUAL ACTING BETA BLOCKER

(CARVEDILOL OR LABETALOL)- ADDITIONAL LOWERING OF BP DUE TO ∞ BLOCKADE- BETTER LV / VASCULAR COUPLING - CARVEDILOL DOES NOT INCREASE INSULIN RESISTANCE


ALPHA 1-ADRENERGIC RECEPTOR BLOCKERS

• NOT TO BE USED FOR MONOTHERAPY• MAY BE USED AS AN ADD-ON FOR RESISTANT HYPERTENSION• MAY CAUSE URINARY INCONTINENCE, ESPECIALLY IN FEMALES, DUE TO BLADDER OUTLET RELAXATION


•Non-steroidal anti-inflammatory agents

•Sympathomimetics- Diet pills- Decongestants

•Stimulants

•Oral contraceptives

•Licorice

•Ephedra

Discontinue or Minimize Interfering Substances


RHTN – CONSTRUCTING AN EFFECTIVE ANTIHYPERTENSIVE REGIMEN

THE USE OF LAST LINE AGENTS VIZ. CLONIDINE LACKS OUTCOME DATA AND MAY ADD ADVERSE DRUG REACTION & DECREASED ADHERENCE BECAUSE OF DOSING FREQUENCY. circulation 2008

johns Hopkins medicine health library

RHTN – CONSTRUCTING A POTENT ANTIHYPERTENSIVE REGIMEN

QUESTION THE VALUE OF HYDRALAZINEHYDRALAZINE DOES NOT HAVE MUCH EVIDENCE OF EFFICACY FOR PREVENTION OF CARDIOVASCULAR BENEFIT WHEN USED FOR ESSENTIAL HYPERTENSION.

COCHRANE DATABASE SYST REV 2011

RHTN – CONSTRUCTING A POTENT ANTIHYPERTENSIVE REGIMEN

MINOXIDIL SHOULD BE A LAST RESORT• POTENT VASODILATOR AND SHOULD BE USED WITH

BETABLOCKER & DIURETICS

• DIFFICULT TO USE & FRAUGHT WITH MANY SERIOUS SIDE EFFECTS (EDEMA, ANASARCA, PERICARDIAL EFFUSION & HIRSUTISM)

• CAN BE USED FOR SELECT PATIENTS BY PHYSICIANS WHO ARE COMFORTABLE WITH DOSING & SIDE EFFECTS

J Hyperten 2007

MINERALOCORTICOID RECEPTOR ANTAGONISTS (CONT.)

• CONSISTENT WITH REPORTS OF A HIGH PREVALENCE OF PRIMARY ALDOSTERONISM IN PATIENTS WITH RESISTANT HT HAVE BEEN STUDIES DEMONSTRATING THAT

• MINERALOCORTICOID RECEPTOR ANTAGONISTS PROVIDE SIGNIFICANT ANTIHYPERTENSIVE BENEFIT WHEN ADDED TO EXISTING MULTIDRUG REGIMENS

Circulation. 2008;117:e510-e526

MINERALOCORTICOID RECEPTOR ANTAGONISTS

• SPIRONOLACTONE • USED FOR RESISTANT HT WITH NORMAL ALDOSTERONE LEVELS, 12.5-50MG/DAILY• ADDITIONAL BENEFITS: ANTIPROTEINURIC, IMPROVES HEART FAILURE SURVIVAL

(RALES)• 10% GYNECOMASTIA• NOT WHEN CREATININE > 2.5, K > 5.0


DRUG COMBINATIONS• CHLORTHALIDONE 25MG + SPIRONOLACTONE 12.5-50 MG

• EXCELLENT DIURETIC MAXIMIZATION, ALSO AGAINST HYPOKALEMIA• CHLORTHALIDONE, CAN

• ↓ SERUM K+ ENOUGH TO CAUSE CARDIAC ARREST• ALDOSTERONE BLOCKERS SPIRONOLACTONE CAN

• PROTECT VULNERABLE PATIENTS AND • SIGNIFICANTLY REDUCE BP RESISTANT TO ≥ 3 DRUGS,

• A LOGICAL WAY TO PROVIDE MAXIMAL ANTI-HT EFFICACY AND TO PREVENT HYPOKALEMIA MIGHT BE A

• COMBINATION OF CHLORTHALIDONE AND SPIRONOLACTONE 12.5/25.0 MG/D

Hypertension 2009;54;951-953

RHTN – OPTIMAL ANTIHYPERTENSIVE REGIMEN

PREFERRED ANTIHYPERTENSIVE COMBINATIONS• A RAAS INHIBITOR & A CALCIUM CHANNEL BLOCKER

• A RAAS INHIBITOR & A DIURETICS (ESPECIALLY A THIAZIDE)

• A RAAS INHIBITOR & A CALCIUM CHANNEL BLOCKER PLUS A DIURETIC

Eur Heart J: 2011: 32

RHTN – OPTIMAL ANTIHYPERTENSIVE REGIMEN

ACCEPTABLE COMBINATIONS• BETABLOCKERS & DIURETICS• CALCIUM CHANNEL BLOCKERS & DIURETICS• DUAL CALCIUM CHANNEL BLOCKADE (DHP & NDHP AGENT)

Unacceptable Combinations Dual RAAS blocker RAAS inhibitors plus betablocker Betablockers plus anti adrenergic drugs

Eur Heart J 2011

FUTURE OPTIONS FOR RESISTANT HYPERTENSION

• DIRECT RENIN INHIBITORS• NEUTRAL ENDOPEPTIDASE (NEP) INHIBITORS• NEW ALDOSTERONE ANTAGONISTS• ALDOSTERONE SYNTHASE INHIBITORS• CLONIDINE EXTENDED RELEASE• ENDOTHELIN ANTAGONISTS• NOVEL COMBINATIONS ALGORITHMS


DEVICE THERAPY

• TWO TECHNIQUES HAVE RECENTLY BEEN EVALUATED:

1. PERCUTANEOUS TRANSLUMINAL RADIOFREQUENCY SYMPATHETIC DENERVATION OF THE RENAL ARTERIES (RDN)

2. CAROTID BAROREFLEX ACTIVATION


RENAL SYMPATHETIC DENERVATION

• RECENTLY, A CATHETER-BASED APPROACH HAS BEEN DEVELOPED SELECTIVELY TARGETING THE RENAL SYMPATHETIC NERVES.

• FIVE CE (COUNSEL OF EUROPEAN)-MARKED DEVICES FOR RENAL SYMPATHETIC DENERVATION ARE AVAILABLE


PROCEDURE OF RENAL SYMPATHETIC DENERVATION( RDN)

• THE RADIOFREQUENCY CATHETER IS INSERTED PERCUTANEOUSLY VIA THE FEMORAL ARTERY AND ADVANCED INTO THE RENAL ARTERIES UNDER FLUOROSCOPY USING A GUIDING CATHETER

• AFTER PLACEMENT, THE CATHETER IS WITHDRAWN FROM DISTAL TO PROXIMAL SEGMENTS AND FOUR TO EIGHT ABLATIONS ARE ADMINISTERED WITHIN EACH ARTERY

• FOCALLY APPLIED HEAT (MAXIMUM 70°C) DESTROYS THE SYMPATHETIC NERVE FIBERS LOCATED IN THE ADVENTITIA

• SIMULTANEOUSLY, THE HIGH RENAL BLOOD FLOW COOLS THE VESSEL WALL

• DUE TO THE CLOSE PROXIMITY OF SYMPATHETIC NERVE FIBERS WITH C PAIN FIBERS, THE PROCEDURE IS PAINFUL AND REQUIRES ANALGOSEDATION-ANESTHESIA


INDICATIONS FOR RDN• RDN SHOULD BE CONSIDERED IN PATIENTS WITH SEVERE RESISTANT

HYPERTENSION, DEFINED AS OFFICE SYSTOLIC BLOOD PRESSURE (SBP) ≥160 MMHG (≥150 MMHG IN PATIENTS WITH TYPE 2 DIABETES) DESPITE TREATMENT WITH ≥3 ANTIHYPERTENSIVE DRUGS OF DIFFERENT CLASSES, INCLUDING A DIURETIC, AT OPTIMAL DOSES

• ELEVATED OFFICE SBP SHOULD BE CONFIRMED BY AMBULATORY BLOOD PRESSURE MONITORING

• REVERSIBLE LIFESTYLE FACTORS HAVE TO BE IDENTIFIED AND INTERFERING MEDICATIONS SHOULD BE DISCONTINUED

• EXCLUDE, PSEUDO-RESISTANCE AND SECONDARY CAUSES FOR ELEVATED BLOOD PRESSURE MUST BE SYSTEMATICALLY EXCLUDED

• NONINVASIVE IMAGING OF RENAL ARTERY (DUPLEX ULTRASOUND OR MAGNETIC RESONANCE IMAGING) SHOULD BE PERFORMED TO CHECK WHETHER THE PROCEDURE IS ANATOMICALLY FEASIBLE


CONTRAINDICATIONS TO RDN

RDN SHOULD NOT BE PERFORMED IN PATIENTS WITH:• ANATOMICALLY UNSUITABLE RENAL ARTERIES (DIAMETER <4 MM; LENGTH

<20 MM; FIBROMUSCULAR DYSPLASIA• SIGNIFICANT RENAL ARTERY STENOSIS• IN PATIENTS WITH AN EGFR <45 ML/MIN/1.73 M2


BENEFITS OF RDN• CLINICAL TRIALS HAVE DEMONSTRATED THAT RDN SIGNIFICANTLY

REDUCES BLOOD PRESSURE IN PATIENTS WITH RESISTANT HYPERTENSION

• EXPERIMENTAL STUDIES AND SMALL CLINICAL STUDIES INDICATE THAT RDN MIGHT ALSO HAVE BENEFICIAL EFFECTS IN OTHER DISEASES AND COMORBIDITIES, CHARACTERIZED BY INCREASED SYMPATHETIC ACTIVITY, SUCH AS LEFT VENTRICULAR HYPERTROPHY, HEART FAILURE, METABOLIC SYNDROME AND HYPERINSULINEMIA, ATRIAL FIBRILLATION, OBSTRUCTIVE SLEEP APNEA, AND CHRONIC KIDNEY DISEASE

• FURTHER CONTROLLED STUDIES ARE REQUIRED TO INVESTIGATE THE ROLE OF RDN BEYOND BLOOD PRESSURE CONTROL


ONGOING RESEARCH• THE RESISTANT ARTERIAL HYPERTENSION COHORT STUDY (RAHYCO) IS

INVESTIGATING THE EPIDEMIOLOGY OF RESISTANT HYPERTENSION AND EVALUATING THE EFFICACY AND FEASIBILITY OF A STANDARDISED TREATMENT REGIMEN (INCLUDING RANDOMISATION OF TWO DOSES OF CHLORTALIDONE)

• IT IS ALSO STUDYING TWO INTERVENTIONS IN A GROUP OF NON-COMPLIANT PATIENTS, AND WILL STUDY ENVIRONMENTAL AND GENETIC VARIABLES OF INDIVIDUALS WITH RESISTANT HYPERTENSION WITHIN A FAMILY DESIGN. IT PLANS TO ENROLL 200 PATIENTS AND IS DUE TO COMPLETE IN APRIL 2018


ONGOING RESEARCH• ST JUDE MEDICAL, INC ANNOUNCED THE START OF THE ENLIGHTNMENT • IT IS PROSPECTIVE, RANDOMIZED, CONTROLLED STUDY OF

APPROXIMATELY 4,000 PATIENTS WITH A SBP ≥160 MMHG ENROLLED AROUND THE WORLD AT UP TO 150 SITES

• PATIENTS WILL BE RANDOMIZED TO MEDICAL THERAPY PLUS RDN OR MEDICAL THERAPY ALONE AND WILL BE FOLLOWED FOR 5 YEARS

• PRIMARY ENDPOINTS INCLUDE MAJOR CARDIOVASCULAR EVENTS SUCH AS HEART ATTACK, STROKE, HEART FAILURE WITH HOSPITALIZATION AND CARDIOVASCULAR DEATH


THANK YOU

resistant hypertension

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