DENERVAZIONE RENALE NEL TRATTAMENTO DELL’ IPERTENSIONE ARTERIOSA RESISTENTE: UNA REVIEW SISTEMATICA
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High blood pressure is a major health problem and a risk factor for cardiovascular events. Estimated population with Hypertension is 1 billion adults.
Clinical trial suggest that 10-20 % have resistant or refractory Hypertension.
We have a diagnosis of Resistant Hypertension when blood pressure levels are persistently elevated, in spite of use of three antihypertensive drugs, including a diuretic at higher dosage.
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For the right diagnosis we have to exclude other factors for example white coat effect or inadequate or poor patient compliance to treatment.
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Recently from 2009 a new endovascular method permitted a new approach to hypertension with renal nerve ablation by radiofrequency or ultrasound energy.
This technique has the same physiologic mechanism of surgical symphathectomy exerted in the last century when pharmacological therapy was not available but with a high mortality and morbidity.
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Catheter arrives to renal artery by femoral access and treat nerves from distal to proximal.
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Position of nerves is different in the proximal, in the middle and in distal part
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Results of this approach were different depending from single clinical studies.In early studies results were positive for the magnitude of systolic blood pressure reduction while in later studies, when sham-controlled trials were performed, were negative.
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We conducted a systematic review approved by Hypertension cochrane to assess short and long-term effects of renal denervation on clinical endpoints: Cardiovascular events, Hospitalization, Quality of life, complications related to procedure.
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From literature screening 12 studies were included for qualitative analysis for a total of more than 1000 patients and 6 studies served for quantitative analysis.
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We found non significant effect of Office Systolic and Diastolic Blood Pressure but also for 24 hours pressure monitoring.
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Then we analyzed main outcomes. They were very sparse or often evidence was absent.
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It didn’t increase the risk of Cardiovascular events. Myocardial infarct, angina, stroke.
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The only adverse outcome was Bradycardia, it increased of 7-fold respect to controls.
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No episodes of Hypotension or hypertension crisis appeared renal denervation group
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Number of Related complications were not increased respect to sham-controls
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In conclusion our review demonstrated that renal denervation results, until now, are not sufficient to support its use in clinical. Benefits on Hard Outcomes are inconclusive.
Renal Denervation is a safe procedure.
For the future we need trials with longer follow-up periods and larger populations. The use of catheter with multi-electrodes able to reach and treat nerves without the empiric approach emerged with current technologies could help to improve the use of renal denervation for hypertension.