Hypertension Update

Health Care Comments Off
  1. Failure of renal denervation in resistant hypertension: Although several unblinded studies suggested that renal denervation could substantially lower blood pressure in patients with resistant hypertension, a blinded randomized trial (SYMPLICITY–HTN–3) failed to demonstrate benefit (1).
  2. Due to the lack of benefit, a larger ongoing international trial (SYMPLICITY–HTN–4) was stopped early.
  3. Revascularization in high–risk patients with renal artery stenosis: Randomized trials of renal artery revascularization in patients with renal artery stenosis did not include many patients with high–risk factors such as flash pulmonary edema, resistant hypertension, and progressive kidney disease. In a prospective cohort study, 467 patients with renal artery stenosis, treated according to patient and physician preferences with either revascularization or medical therapy alone, were followed for a median of 3.8 years (2). Revascularization was independently associated with a lower risk of death in patients who presented with flash pulmonary edema (58 versus 76 percent) and in patients who presented with both resistant hypertension and progressive kidney function decline (9 versus 65 percent).
  4. JNC–8 guidelines: JNC–8, the major change compared with the older JNC–7 guidelines is a higher blood pressure goal for older adults (60 years and older) and for patients with diabetes mellitus or chronic kidney disease. (3)
  5. CORAL trial of stenting in renal artery stenosis: In a randomized trial comparing revascularization plus medical therapy with medical therapy alone in 947 patients with atherosclerotic renal artery stenosis and either poorly controlled hypertension or a decreased estimated glomerular filtration rate (eGFR <60mL/min/1.73m2), revascularization had no effect at 3.6 years on the primary outcome (a composite of cardiovascular or renal death, stroke, myocardial infarction, hospitalization for heart failure, a reduction in eGFR by more than 30 percent, or end–stage renal disease) or any individual component of the primary outcome (4).
  6. BP goal and progression of renal disease in patients with proteinuric CKD: One meta–analysis, combined seven goal blood pressure trials including 5308 patients with CKD that were followed for at least 1.6 years (5). Compared with standard blood pressure lowering, more aggressive blood pressure lowering significantly reduced the risk of renal events (defined as end–stage renal disease, a doubling of serum creatinine, or 50 percent reduction in glomerular filtration rate) among those with proteinuric CKD (38.5 versus 40.5 percent). 6. Blood pressure lowering and cardiovascular events in patients with non–proteinuric CKD: A meta-analysis examined the cardiovascular outcomes and mortality of 30,295 patients with an estimated glomerular filtration rate <60 mL/min/1.73m2 from 26 randomized hypertension trials; 93 percent of patients were non–proteinuric (6). Compared with placebo, both ACE inhibitors (3.2 percent absolute decrease) and calcium channel antagonists (2.1 percent absolute decrease) reduced the composite of stroke, myocardial infarction, heart failure, and mortality. In drug versus drug trials, the incidence of these events was similar comparing angiotensin inhibitors with diuretics or beta–blockers (18 versus 19 percent) or with calcium channel antagonists (23 versus 24 percent).

References

  1. Bhatt DL, Kandzari DE, O’Neill WW, et al. A controlled trial of renal denervation for resistant hypertension. N Engl J Med 2014; 370:1393.
  2. Ritchie J, Green D, Chrysochou C, et al. High–risk clinical presentations in atherosclerotic renovascular disease: prognosis and response to renal artery revascularization. Am J Kidney Dis 2014; 63:186.
  3. James PA, Oparil S, Carter BL, et al. 2014 evidence–based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA 2014; 311:507.
  4. Cooper CJ, Murphy TP, Cutlip DE, et al. Stenting and medical therapy for atherosclerotic renal–artery stenosis. N Engl J Med 2014; 370:13.
  5. Lv J, Ehteshami P, Sarnak MJ, et al. Effects of intensive blood pressure lowering on the progression of chronic kidney disease: a systematic review and meta–analysis. CMAJ 2013; 185:949.
  6. Blood Pressure Lowering Treatment Trialists’ Collaboration, Ninomiya T, Perkovic V, et al. Blood pressure lowering and major cardiovascular events in people with and without chronic kidney disease: meta–analysis of randomised controlled trials. BMJ 2013; 347:f5680.
    (Source Uptodate)