Practice Update: Cardiology

ESC 2017 19

Lancet , Michel Azizi, MD, PhD, with the Paris Descartes University, France, noted that “More studies are needed with the Spyral and other catheters and using dif- ferent technologies (e.g., highly focused ultrasound), not only to support these pre- liminary results but also to investigate whether an escape phenomenon might occur in hypertension in the long term (reports exist of renal nerve regrowth after catheter-based renal denervation in animal models) and the unknown risk of de-novo renal artery stenoses associated with the new catheters.” COMMENT By Clyde W Yancy MD, MSc, MACC, FAHA, MACP, FHFSA SPYRAL HTN-OFF MED T his intriguing study revisits renal denervation as a treatment for hypertension. The prior SYMPLIC- ITY HTN-3 trial failed to demonstrate superiority of renal denervation com- pared with an expertly configured multidrug regimen for resistant hyper- tension treated in specialized centers. The bar for superiority in that trial was quite high, but the standard of optimized best medical therapy for hypertension remains appropriately intact. In this study of only 80 patients with documented hypertension but off med- ical therapy (drug naïve or intolerant), renal denervation led to a 5-mmHg difference, which was statistically sig- nificant. Is this a clinically important benefit? Not likely. The anticipated new hypertension guidelines will almost assuredly target lower blood pressure goals in some (at higher risk) but not all patients with hypertension. A 5-mmHg difference is simply not enough. But, within a global approach of lifestyle modification, antihypertensive ther- apy as tolerated, and careful follow-up, there may emerge a role for renal den- ervation in select patients. The more important observation here is that these new data resume the discussion regard- ing adjunctive interventions that may allow better blood pressure control. Given the global burden of hyperten- sion and its important contribution to cardiovascular disease and stroke, it is necessary that every treatment option be fully explored. PracticeUpdate Editorial Team

The effectiveness of renal denervation in this study may have been due to the new procedural approach, which aimed to achieve complete denervation, and the fact that patients were not taking antihypertensive medications, which may have confounded the results of previous studies.“ Michael Boehm, MD, PhD

Dr. Boehm explained that the results – published simultaneously online in The Lancet – provided biological proof of principle of the efficacy of renal denervation and will inform the design of a larger, more definitive trial of the approach. Dr. Boehm concluded, “The effectiveness of renal denervation in this study may have been due to the new procedural approach, which aimed to achieve complete dener- vation, and the fact that patients were not

taking antihypertensive medications, which may have confounded the results of pre- vious studies.” He added, “With consistent and significant drops across ambulatory and office-based blood pressure – including both systolic and diastolic measurements – we are confident to be moving forward with a pivotal trial so that doctors and patients may have an alter- native approach to lowering blood pressure.” In a recent editorial about the study in The

© ESC Congress 2017 – European Society of Cardiology

VOL. 2 • NO. 2 • 2017