SELECTION OF PATIENTS WITH RESISTANT ARTERIAL HYPERTENSION FOR RENAL DENERVATION

Aim. To develop an optimized scientifically based approach to medical and diagnostic measures before renal denervation.

Methods. 91 patients with a previously diagnosed primary arterial hypertension aged 54.2 (52.0, 69.3) years

history of arterial hypertension was 11.4±4.2 years. 57 (62.6%) patients had asymptomatic lesions of target or-gans. 34 (37.4%) were present with associated clinical conditions. The average number of classes of antihyper-tensive drugs taken by patients was 4±1.2. 18 patients (19.8%) received aldosterone antagonists. All patients were included in the study. The duration of the positive underwent standard clinical, laboratory and instrumental tests. The quality of life was assessed using the SF-36 questionnaire. Patients’ adherence to treatment was eval-uated using the Morisky-Green test. After therapy optimi-zation and a number of additional diagnostic procedures, true resistant arterial hypertension was detected in 19 pa-tients, of whom 9 were excluded from the study. 4 patients were excluded because of specific anatomy, and 5 patients were allergic to the contrast media.

Results. Optimization of the diagnostic and medical algorithm for managing patients with arterial hy-pertension allowed identifying patients with secondary arterial hypertension, accounted to 8.8% of the study sample, as well as achieving significant reduction of blood pressure according to the 24-hour blood pressure monitoring findings: SBP by 34 ± 12 mm Hg, and DBP by 12 ± 4 mm Hg, compared to the initial values (p = 0.046). The obtained results are comparable in the groups with high and low adherence. 54 patients (77.1%) achieved blood pressure targets. The study groups demonstrated significant improvements of the quality of life and adherence to treatment. The proportion of patients with true resistant arterial hypertension has been identified.

Conclusion. The presented algorithm of selecting patients for renal denervation allows to optimize the management strategy inpatients, who are suspected to suffer from resistant arterial hypertension, and to per-form targeted interventions.

1. Mancia G., Fagard R., Narkiewicz K., Redon J., Zanchetti A., Bohm M., Christiaens T., Cifkova R., De Backer G., Dominiczak A. , Galderisi M., Grobbee D.E., Jaarsma T., Kirchhof P., Kjeldsen S.E., Laurent S., Manolis A.J., Nilsson P.M., Ruilope L.M., Schmieder RE., Sirnes P.A., Sleight P., Viigimaa M., Waeber B., Zannad F. 2013 ESH/ ESC Practice Guidelines for the Management of Arterial Hypertension. Blood Press 2014; 23:3-16.

2. Pimenta E., Calhoun D.A. Resistant hypertension: incidence, prevalence and prognosis. Circulati on.2012;125:1594-1596.

3. Конради A.O. Ключевые достижения в комбинированной антитипертензивной терапии последних лет. Артериальная гипертензия. 2012;18 (6):1-5. [KonradiA.O. Kljuchevyedo stizhenijavkombinirovannojantigipertenzivnojterapiiposlednihlet. Arterial’naja gipertenzija. 2012;18 (6):1-5. (In Russ)].

4. Di Pilla M., Bruno R.M., Taddei S. Resistant Hypertension: An Incurable Disease or Just a Challenge For Our Medical Skill? High Blood Press Cardiovasc Prev. 2016;23(4):347-353. doi: 10.1007/s40292-016-0159-y

5. Gewirtz J.R., Bisognano J.D. Catheter-based renal sympathetic denervation: A targeted approach to resistant hypertension. Cardiol J. 2011; 97-102

6. Mahfoud F., Luscher T.F., Andersson B., Baumgartner I., Cifkova R., Dimario C.et al. Expert consensus document fromthe European Society of Cardiology on catheter-based renal denervation. Eur Heart J. 2013;34(28): 2149-57. doi: 10.1093/eurheartj/eht154.

7. Schlaich M.P., Sobotka P.A., Krum H., Whitbourn R., Walton A., Esler M. et al. Renal sympathetic-nerve ablation for uncontrolled hypertension. N Engl J Med. 2009; 361:932-4.

8. Schlaich M.P, Socratous F, Hennebry S, et al. Sympathetic activation in chronic renal failure. J Am Soc Nephrol. 2009; 20:9339

9. Schlaich M.P., Schmieder R.E., Bakris G., Blankestijn P.J., Boehm M., Campese V.M. et al. International expert consensus statement: Percutaneous transluminal renal denervation for the treatment of resistant hypertension. J Am Coll Cardiol. 2013; 62(22): 2031-45. doi:10.1016/j.jacc.2013.08.1616

10. Krum H., Schlaich M., Whitbourn R., Sobotka P.A., Sadowski J., Bartus K.et al. Catheter-based renal sympathetic denervation for resistant hypertension: a multicentre safety and proof-of-principle cohort study. Lancet 2009;373(9671):1275-81. doi: 10.1016/S0140-6736(09)60566-3

11. Oliveras A., Armario P., Clara A. Spironolactone versus sympathetic renal denervation to treat true resistant hypertension: Results from the DENERVHTA study A randomized controlled trial. Journal of Hypertension. 2016;34(9):1863-1871

12. Wright J.T., Williamson J.D., Whelton P.K., Snyder J.K., Sink K.M., Rocco M.V. et al. A Randomized Trial of Intensive versus Standard Blood-Pressure Control. The New England Journal of Medicine.2015; 373(22): 2103-2116

13. Morisky D.E., Ang A., Krousel-Wood M., Ward H.J. Predictive validity of a medication adherence measure in an outpatient setting.J Clin Hypertens (Greenwich). 2008 May;10(5):348-54

14. Roos J.C., Boer P., Koomans H.A., et al. Haemodynamic and hormonal changes during acute and chronic diuretic treatment in essential hypertension. Eur J Clin Pharmacol. 1981; 19:107-12

15. Olsen L.K., Kamper A.L., Svendsen J.H., Bang L.E., Frimodt-M0ller M., Kelbsk H., et al. High incidence of secondary hypertension in patients referred for renal denervation--the Copenhagen experience. Blood Press. 2014 Aug;23(4):233-9. doi:1 0.3109/08037051.2013.867655

16. Lobo M.D., de Belder M.A., Cleveland T., Collier D., Dasgupta I., Deanfield J., et al. British Hypertension Society; British Cardiovascular Society; British Cardiovascular Intervention Society; Renal Association. Joint UK societies’ 2014 consensus statement on renal denervation for resistant hypertension. Heart.2015; 101: 1016

17. Gupta P., Patel P., Horne R., Buchanan H., Williams B. , Tomaszewski M. How to Screen for Non-Adherence to Antihypertensive Therapy.Curr Hypertens Rep. 2016 Dec;18(12):89

18. Judd E., Calhoun D.A. Apparent and true resistant hypertension: definition, prevalence and outcomes. J Hum Hypertens. 2014; 28:463-468. doi: 10.1038/jhh.2013.140

19. Patel P., Gupta K., White M.J., Stanley A.G., Williams B., Tomaszewski M. Screening for non-adherence to antihypertensive treatment as a part of the diagnostic pathway to renal denervation. J Hum Hypertens. 2016 Jun; 30(6): 368-373. doi: 10.1038/jhh.2015.103

20. Tataru A.P., Barry A.R. A Systematic Review of Add-on Pharmacologic Therapy in the Treatment of Resistant Hypertension. Am J Cardiovasc Drugs. 2017 Aug;17(4):311-318. doi: 10.1007/s40256-017-0224-5

21. Elser M. The sympathetic system and hypertension. AM J Hypertens. 2000; 13: 99S-105S

22. Mahfoud F., Bakris G., Bhatt D.L., Esler M., Ewen S., Fahy M., et al. Reduced blood pressure-lowering effect of catheter-based renal denervation in patients with isolated systolic hypertension: data from SYMPLICITY HTN-3 and the Global SYMPLICITY Registry. Eur Heart J. 2017 Jan 7;38(2):93-100. doi: 10.1093/eurheartj/ehw325

23. Krum H., Schlaich M., Whitbourn R., Sobotka P.A., Sadowski J., Bartus K.et al. Catheter-based renal sympathetic denervation for resistant hypertension: a multicentre safety and proof-of-principle cohort study. Lancet. 2009;373(9671):1275-81. doi: 10.1016/S0140-6736(09)60566-3

24. de Jong M.R., Hoogerwaard A.F., Gal P., Adiyaman A., Smit J.J. et al. Persistent Increase in Blood Pressure After Renal Nerve Stimulation in Accessory Renal Arteries After Sympathetic Renal Denervation. Hypertension. 2016;67(6):1211-1217.http:// dx.doi.org/10.1161/HYPERTENSIONAHA.115.06604

25. Vaclavik J., Taborsky M., Richter D. Unilateral catheterbased renal sympathetic denervation in resistant arterial hypertension shows no blood pressure-lowering effect. Clin Exp Hypertens.2013; 35:192-194

26. Hutchinson B.D., Keane D., Dodd J.D. Renal sympathetic denervation: MDCT evaluation of the renal arteries.AJR Am J Roentgenol. 2013;201(2):342-346. doi: 10.2214/AJR.12.8560.