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Canadian Journal of Cardiology

Renal Denervation After SYMPLICITY HTN-3: Where Do We Go?

Published:December 11, 2014DOI:https://doi.org/10.1016/j.cjca.2014.12.004

      Abstract

      Previous preclinical and clinical studies provide insight into the mechanisms that account for the chronic lowering of blood pressure (BP) during suppression of central and peripheral sympathetic outflow. From these mechanisms, novel and alternative approaches to BP control in patients with hypertension resistant to medical therapy have been proposed. Over the past 5 years, data from prospective cohorts and randomized studies showed that renal denervation therapy is a safe procedure associated with a significant reduction of office BP but only a modest reduction in ambulatory BP despite intensive ongoing medical therapy. Recently, the failure of the most rigourously designed randomized study, SYMPLICITY HTN-3, to meet its primary efficacy end point has raised several questions and unresolved methodological issues. Further prospective randomized controlled trials are required to further assess the efficacy, durability, and cost-effectiveness of renal denervation therapy and its effects on cardiovascular and renal outcomes in carefully selected patients with true treatment-resistant hypertension.

      Résumé

      Les études précliniques et cliniques précédentes donnent un aperçu des mécanismes qui expliquent la diminution à long terme de la pression artérielle (PA) durant la suppression de la décharge sympathique centrale et périphérique. À partir de ces mécanismes, des approches nouvelles et diverses liées à la maîtrise de la PA des patients souffrant d’hypertension résistante au traitement médical ont été proposées. Au cours des 5 dernières années, les données provenant des cohortes prospectives et des études aléatoires ont montré que le traitement par dénervation rénale est une intervention sécuritaire associée à une importante diminution de la PA en cabinet, mais seulement à une diminution modeste de la PA ambulatoire en dépit du traitement médical intensif en cours. Récemment, l’échec de l’étude aléatoire la plus rigoureusement conçue, la SYMPLICITY HTN-3, pour atteindre son principal critère d’efficacité a soulevé plusieurs questions et problèmes méthodologiques non résolus. D’autres essais cliniques prospectifs à répartition aléatoire sont nécessaires pour évaluer davantage l’efficacité, la durabilité et le rapport coût-efficacité du traitement par dénervation rénale et ses effets sur les résultats cardiovasculaires et rénaux des patients soigneusement sélectionnés ayant une véritable hypertension résistante au traitement.
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