Physicians' Academy for Cardiovascular Education

Night-time SBP predicts renal denervation response

Twenty-Four-Hour Blood Pressure Monitoring to Predict and Assess Impact of Renal Denervation. The DENERHTN Study (Renal Denervation for Hypertension)

Gosse P, Cremer A, Pereira H, et al. - Hypertension. 2017;69: published online ahead of print

Background

Renal denervation on top of a standardized stepped-care antihypertensive treatment (SSAHT), significantly reduced daytime, night-time, and 24-hour ambulatory systolic blood pressure (SBP), compared with SSAHT alone, in patients with well-defined resistant hypertension (RH). This finding of the DENERHTN trial (Renal Denervation for Hypertension trial) was confirmed by ambulatory blood pressure monitoring (ABPM) [1]. The use of ABPM for the evaluation of the blood pressure effect by renal denervation contributes to the elimination of observer bias and placebo effect, and allows investigating the effects of renal denervationon a 24-hours basis, and on indices of blood pressure variability [2].

In this predefined analysis, the ABPM results were evaluated in detail, especially those of blood pressure and heart rate (HR) variability, and it was assessed whether ABPM can help predicting blood pressure response to renal denervation.

Main results

Conclusion

Renal denervation in addition to standard antihypertensive treatment results in lower blood pressure in patients with resistant hypertension, with a homogenous effect over 24 hours. Night-time SBP and its variability were the best ABPM-derived predictors for renal denervation responders. These findings confirm the guidelines recommendation, according to which, 24-hour ABPM should systematically precede any decision of renal denervation.

Editorial comment

In the editorial article [3], Hering discusses the treatment of resistant hypertension with renal denervation and comments on the DENERHTN trial as follows: ‘..., the investigators of the DENERHTN trial should be commended on their efforts in performing a rigorously designed multicenter randomized clinical trial and for considering limitations encountered in previous renal denervation studies, including standardized medication therapy, comprehensive independent and blinded assessment of ambulatory blood pressure monitoring, medication adherence assessment and ensuring renal denervationwas supervised by an experienced interventionalist across the Hypertension Excellence Centres.’ The author also highlights the importance of being able to predict good response to this procedure that shows a high variability between patients and concludes: ‘While the improvement of patient adherence to medication can considerably decrease the prevalence of renal denervation, there is still a portion of patients who remain drug-resistant despite all available antihypertensive drug classes as indicated in the DENERHTN study. Renal denervation has the potential to substantially improve blood pressure control on top of medication and should be indicated for difficult to treat hypertension provided that it is performed in properly selected patients and experienced centers. Baseline night-time blood pressure may serve as a marker in predicting response to renal denervation and should be further explored in appropriately designed clinical trials with particular consideration given to validated ambulatory blood pressure devices with defined and adjusted diurnal and nocturnal times.’

References

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Find this article online at Hypertension