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1 resistant hypertension 1 resistant hypertension Presentation Transcript

  • SALES TRAINING ONLY.
  • • Introduction to Module Series• Module 1 - Resistant hypertension: Definitions and prevalence• Module 2 - Renal sympathetic activity in metabolic diseases• Module 3 - Differential diagnosis of resistant hypertension• Module 4 - Conventional management of resistant hypertension• Module 5 - Preclinical and early clinical rationale for renal denervation• Module 6 - Renal denervation: The procedure• Module 7 - Renal denervation: Clinical trial data• Module 8 - Patient selection SALES TRAINING ONLY.
  • Resistant Hypertension: The Clinical Issue Globally, <50% of treated hypertensives achieve BP goal Patients With Controlled BP (%) 53.1 49.5 41.0 33.6 29.2 28.8 15.5Kearney PM et al. J Hypertens. 2004;22:11-19. SALES TRAINING ONLY.
  • The Role of the Sympathetic Nervous System (SNS) in Resistant Hypertension Renal sympathetic nerves contribute to development and perpetuation of hypertension • Sympathetic outflow to kidneys is activated in patients with essential hypertension1 • Efferent sympathetic outflow:2 – Stimulates renin release – Increases tubular sodium reabsorption – Reduces renal blood flow • Afferent signals from kidney modulate central sympathetic outflow and directly contribute to neurogenic hypertension3-51. Esler M et al. Hypertension. 1988;11:3–20; 2.DiBona GF, Kopp UC. Physiol Rev. 1997;77:75–197; 3. Kopp UC et al. Am JPhysiol Regul Integr Comp Physiol. 2007;293:R1561–R1572; 4. Hausberg M et al. Circulation. 2002;106:1974–1979; 5.Stella A, Zanchetti A. Physiol Rev. 1991;71: 659–682. SALES TRAINING ONLY.
  • • Introduction to Module Series• Module 1 - Resistant hypertension: Definitions and prevalence• Module 2 - Renal sympathetic activity in metabolic diseases• Module 3 - Differential diagnosis of resistant hypertension• Module 4 - Conventional management of resistant hypertension• Module 5 - Preclinical and early clinical rationale for renal denervation• Module 6 - Renal denervation: The procedure• Module 7 - Renal denervation: Clinical trial data• Module 8 - Patient selection SALES TRAINING ONLY.
  • Learning ObjectivesBy the end of the module, you should beable to:• Recognize the differences between uncontrolled hypertension and resistant hypertension• Define treatment-resistant hypertension and recognize how the definition varies according to the AHA, BHS, ESH and JNC VII Guidelines• Identify the typical patient features of resistant hypertension and how these features relate to patients with white- coat syndrome SALES TRAINING ONLY.
  • Renal Sympathetic Denervation A potential treatment option for selected patients with resistant hypertension • Nonselective surgical sympathectomy was historically used to treat hypertension prior to advent of antihypertensive drugs1 • New endovascular catheter technology enables selective renal denervation • First-in-man trial demonstrated reduction in sympathetic activity and renin release with reductions in central sympathetic outflow2 • Pivotal multicenter trial demonstrates procedure is safe and effective in providing significant BP reductions in treatment-resistant hypertensive patients31. Hoobler SW et al. Circulation. 1951;4:173-183;2. Schlaich MP et al. N Engl J Med. 2009;361:932-934; 3. Symplicity HTN-2 Investigators. Lancet. 2010;376:1903-1909. SALES TRAINING ONLY.
  • Definitions of Resistant Hypertension Vary United States Europe JNC 7 (2003)1 AHA (2008)2 ESH (2007)3 BHS (2011)4 Failure to reach BP BP that remains BP ≥140/90 mm Hg Someone whose goal in patients who above goal despite despite treatment BP is not are adhering to full concurrent use of with at least 3 controlled to doses of an 3 antihypertensive drugs (including a <140/90 mm Hg, appropriate 3-drug agents of different diuretic) in adequate despite optimal or regimen that classes (ideally, doses and after best-tolerated includes a diuretic one of which is a exclusion of doses of third-line diuretic, and all spurious treatment agents are hypertension such optimized) as isolated office hypertension and failure to use large cuffs on large armsAHA=American Heart Association; BHS=British Hypertension Society; ESH=European Society of Hypertension; JNC=Joint National Committee1. Chobanian AV et al. JAMA. 2003;289:2560-2572; 2. Calhoun DA et al. Circulation. 2008;117:e510-526; 3. Mancia G et al. J Hypertens.2007;25:1751-1762; 4. National Clinical Guideline Centre. Available at: http://www.nice.org.uk/nicemedia/live/12167/54727/54727.pdf.Accessed Nov 19 2011. SALES TRAINING ONLY.
  • Not All Refractory Hypertension is True Treatment-Resistant Hypertension  Not all patients who fail to respond to antihypertensive therapy have true treatment-resistant hypertension  Long-term outcomes vary substantially among the various subtypes of refractory hypertension  Optimal treatment modalities and approach to management vary among subtypesSecondary Pseudoresistance1,2 Masked White coat True treatment-Hypertension1 Hypertension2 hypertension2 resistant hypertension*3Hypertension Apparent Clinic BP <140/90 Clinic BP ≥140 or BP ≥140/90 mm Hgelicited or hypertension due to mm Hg; daytime ≥90 mm Hg; despite adequateexacerbated by lack of adherence, BP >135 or >85 daytime BP doses of ≥3 drugsother drugs or poor BP mm Hg <135/85 mm Hg (including diuretic)diseases measurement after exclusion of technique spurious hypertension*European Society of Hypertension definitionBP=blood pressure.1. Calhoun DA et al. Circulation. 2008;117:e510-526; 2. Pierdomenico SD et al. Am JHypertens. 2005;18:1422-1428; 3. Mancia G et al. J Hypertens. 2007;25:1751-1762. SALES TRAINING ONLY.
  • Typical Features of Patients With Resistant Hypertension vs White-Coat Hypertension • Compared with patients with white-coat hypertension, true resistant hypertension is associated with: – Male gender – Longer duration of hypertension – Smoking – Diabetes – Target-organ damage (as measured by presence of LVH, impaired renal function, microalbuminuria) – Documented CVD • All of these associations are weak – Demographics have a low discriminating value for the diagnosis of resistant hypertension – ABPM is desirable for correct diagnosis and managementABPM=ambulatory blood pressure measurement; CVD=cardiovascular disease; LVH=left ventricular hypertrophy.de la Sierra A et al. Hypertension. 2011;57:898-902. SALES TRAINING ONLY.
  • When Stringent Definitions are Used, 7.6% to 18% of Patients Have True Treatment-Resistant Hypertension • Spanish ABPM Monitoring Registry definition:1 – Use of 3 antihypertensive drugs 18% (with 1 diuretic) – Clinic BP ≥140 and/or ≥90 mm Hg – Daytime BP ≥130 and/or ≥80 mm Hg • Pierdomenico et al definition:2 – Use of triple therapy Patients (%) – Clinic BP ≥140 or ≥90 mm Hg at ≥2 visits – Daytime BP ≥135 or ≥85 mm Hg • Both studies excluded patients at BP 7.6% target being treated with ≥4 drugs1,2 – True prevalence of treatment-resistant hypertension may therefore be somewhat higher Spanish ABPM Italy: Pierdomenico Monitoring Registry1 et al2 (N=8295) (N=742)ABPM=ambulatory blood pressure monitoring; BP=blood pressure.1. de la Sierra A et al. Hypertension. 2011;57:898-902;2. Pierdomenico SD et al. Am J Hypertens. 2005;18:1422-1428. SALES TRAINING ONLY.
  • Summary • Uncontrolled hypertension is not synonymous with resistant hypertension – Resistant hypertension may be broadly defined as BP that remains above goal despite full doses of ≥3 antihypertensive medications – Resistant hypertension includes patients who achieve BP control but require ≥4 antihypertensive agents • In epidemiologic studies, rates of treatment-resistant hypertension vary from 7.6% (Spain) to 28.0% (US) • A number of “typical features” have been identified for patients with resistant hypertension, but associations are weak – ABPM is desirable for correct diagnosis and managementABPM=ambulatory blood pressure monitoring SALES TRAINING ONLY.