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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Article info
Publication history
Published online: December 11, 2014
Accepted:
December 5,
2014
Received:
August 14,
2014
Footnotes
See page 647 for disclosure information.
Identification
Copyright
© 2015 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.
