Hypertension treatment has evolved considerably over time. However, managing adverse events driven by medication is still challenging, as is low patient adherence, be it because of polimedication or associated costs.
Approximately 10% of patients do not reach optimal blood pressure targets, despite adherence optimal medical treatment (OMT); this condition is known as resistant hypertension.
Renal denervation (RDN) is a transcatheter technique that reduces sympathetic activity through the ablation of sympathetic renal nerves. It has been shown effective by studies such as the SPYRAL and global registries such as the Global Simplicity Registry. However, approximately one third of patients treated with RDN do not respond adequately, because of patient or procedure characteristics, and do not reach blood pressure targets after treatment.
To assess which patients could benefit from RDN, Hu et al. carried out a systematic revision and meta-analysis, published in the Journal of the American Heart Association, to identify specific factors in the included hypertensive patients.
They looked at 17 observational studies. Several hemodynamic factors suggested (with moderate certainty) that elevated heart rate was associated to higher antihypertensive efficacy with RDN, both 24 hr. (weighted mean difference (WMD) −4.05; CI 95%, −7.33 to −0.77) and daytime systolic BP (WMD, −5.99 [CI 95%, −9.49 to −2.50).
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When looking at baseline BP, patients with higher baseline BP (defined as night-time BP ≥136, 24 hr. BP ≥155 and office BP ≥180) resulted more responsive. Other findings of RDN response were the presence of orthostatic hypertension (higher efficacy in reducing 24 hr. BP) and BP variability (nocturnal variability was associated with higher efficacy).
As regards arterial rigidity parameter (measured by pulse wave velocity), outcomes suggested a link between RDN response and lower pulse wave velocity (24 hr. BP reduction: WMD, −7.20 [CI 95%, −9.79 to −4.62] and day BP: WMD, −9.09 [CI95%, −11.63 to −6.55]).
Data on the renin-angiotensin axis indicated patients with increased activity (defined as ≥10 mmHg reduction at start of aldosterone inhibitors, renin-aldosterone ratio ≥30 or slow flow at renal angiogram) presented higher chance of success with RDN.
As regards clinical characteristics, younger patients, not black, with good kidney function, responded better to treatment, while there were no significant differences in sex, BMI, obstructive apnea or heart disease (low certainly).
Conclusions
Because of RDN non-response rates, it is crucial to select patients with resistant hypertension to establish this intervention. This study highlights the fact that hypertensive patients with elevated baseline heart rate and low pulse wave velocity might see further reduction in daytime and 24 hr. BP with RDN.
Dr. Omar Tupayachi.
Member of the Editorial Board of SOLACI.org.
Original Title: Patient-Specific Factors Predicting Renal Denervation Response in Patients With Hypertension: A Systematic Review and Meta-Analysis.
Reference: Hu XR, Liao GZ, Wang JW, Ye YY, Chen XF, Bai L, Shi FF, Liu K, Peng Y. Patient-Specific Factors Predicting Renal Denervation Response in Patients With Hypertension: A Systematic Review and Meta-Analysis. J Am Heart Assoc. 2024 Jul 16;13(14):e034915. doi: 10.1161/JAHA.124.034915. Epub 2024 Jul 9. PMID: 38979821.
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