2. Introduction
Approximately one third of adults worldwide have arterial hypertension, defined as clinic blood
pressure (BP) ≥140/90mmHg.
Deaths due to high BP have increased by 56.1% in the past decade, despite advances in
pharmacological treatment.
New international guidelines (ACC/AHA and ESC/ESH) have lowered the threshold for defining
hypertension to 130/80mmHg, potentially increasing the number of individuals requiring
treatment.
Nature Reviews Cardiology. 2021 Apr;18(4):251-75.
4. Introduction
Promoting lifestyle interventions (e.g., exercise, weight reduction, healthy diet) is crucial for
prevention and management of hypertension, even in cases with higher cardiovascular risk.
Effective lifestyle interventions for lowering BP include physical exercise, weight loss, moderation in
alcohol intake, and adopting healthy dietary patterns (low sodium, high potassium).
Other interventions like guided breathing, yoga, meditation, or biofeedback show uncertain long-term
BP-lowering effects according to guidelines.
Nature Reviews Cardiology. 2021 Apr;18(4):251-75.
5. Characteristic lifestyle factors in non-westernized
and westernized populations
Nature Reviews Cardiology. 2021 Apr;18(4):251-75.
6. Lifestyle factors with blood pressure-reducing
effects.
The current evidence on the main lifestyle factors that can reduce BP and/or the
risk of hypertension
Physical exercise
Body weight management
Healthy dietary patterns
Circadian entrainment and sleep
Stress management
Nature Reviews Cardiology. 2021 Apr;18(4):251-75.
8. Are the beneficial effects of exercise on blood
pressure sustainable?
Exercise shows beneficial effects on blood pressure with long-term interventions (≥12 months)
In the short-to-medium term (3–6 months), exercise interventions reduce systolic blood pressure by 4.4
mmHg and diastolic blood pressure by 4.2 mmHg in young adults with pre-hypertension or hypertension
However, the benefits diminish after ≥12 months, with only a -1.0 mmHg reduction in systolic blood pressure
and -0.9 mmHg in diastolic blood pressure
Further research is needed to confirm the long-term effectiveness of exercise interventions.
Nature Reviews Cardiology. 2021 Apr;18(4):251-75.
9. Can exercise without weight loss lower blood
pressure?
Classic study: Exercise reduced blood pressure (6.4 mmHg in SBP, 5.2 mmHg in DBP) in men with/without
hypertension, no change in body weight405.
Greater weight reduction: Without exercise, weight loss lowered blood pressure (8.8 kg loss: 9.2 mmHg SBP, 6.2
mmHg DBP)405.
Exercise in hypertension: Exercise lowered SBP/DBP (4.4 mmHg/4.3 mmHg) despite small weight loss (1.8
kg)406.
Exercise with weight management: Combined exercise, diet, and weight loss led to more significant
reductions (7.4 mmHg SBP, 5.6 mmHg DBP)406.
Meta-analysis: Exercise reduced SBP/DBP (approx. 5 mmHg/3 mmHg) regardless of body weight changes (≥1.5
kg)407.
Exercise benefits blood pressure independently, but more with weight loss.
Nature Reviews Cardiology. 2021 Apr;18(4):251-75.
10. Hypertensive response to acute exercise
Long-term exercise reduces blood pressure, but blood pressure rises during exercise due to increased cardiac output for
muscle oxygen demands.
This rise is usually a normal physiological response without adverse events.
Some individuals have an exaggerated increase in systolic blood pressure during exercise, called hypertensive
response to exercise (HRE).
HRE is defined as ≥60 mmHg increase in men and ≥50 mmHg increase in women, or systolic blood pressure >210
mmHg in men and >190 mmHg in women408.
In those with normal blood pressure, HRE may predict future hypertension and cardiovascular disease408.
Lifestyle interventions, like healthy diet and exercise, can reduce HRE.
Nature Reviews Cardiology. 2021 Apr;18(4):251-75.
11. Sustainability of weight reduction strategies
Less than 20% maintain a 10% weight loss for over 1 year410.
Body weight management programs with exercise and diet are more effective than exercise alone in the
short-to-medium term (3–6 months, mean difference −5.3 kg) and long term (12–18 months, mean
difference −6.3 kg)411.
• Different diets led to significant weight reductions at 6 months (4.6 kg low-carb, 4.4 kg low-fat, 3.1 kg
moderate intake) and decreased blood pressure (systolic: 5.1 mmHg, 5.1 mmHg, 3.5 mmHg; diastolic:
3.2 mmHg, 2.9 mmHg, 1.9 mmHg)166.
Network meta-analysis:
• Weight loss (−3.2 kg, −3.3 kg, −1.9 kg) and blood pressure reductions (systolic: −1.3 mmHg, 0.3
mmHg, −0.5 mmHg; diastolic: −0.8 mmHg, −0.2 mmHg, −0.1 mmHg) diminished with all diets.
Effects at 12 months:
Nature Reviews Cardiology. 2021 Apr;18(4):251-75.
12. Sustainability of weight reduction strategies
Combined interventions similar to diet alone in short-to-medium term (3–6 months, mean difference
−0.6 kg), but diet-only interventions more effective in the long term (mean difference −1.7 kg)411.
Lifestyle interventions focusing on both exercise and diet showed small beneficial effects on body
weight after 12 months (−1.6 kg) in individuals with obesity who lost >5% of body weight412.
No evidence of efficacy for diet-only or physical activity-only interventions412.
Long-term sustainability of lifestyle interventions for weight reduction remains unclear, but combining
energy-restrictive diets and exercise interventions maximizes the likelihood of maintaining weight loss.
Nature Reviews Cardiology. 2021 Apr;18(4):251-75.
13. Salt intake effects on blood pressure depend on
concomitant water intake
Salt intake linked to blood pressure for a century, low-salt diets prevent hypertension.
Acute blood pressure response to salt depends on changes in plasma osmolality, not just salt amount.
• Activation of osmosensitive neurons T cell pathways
• Increased vasopressin release
• Stimulation of endogenous cardiotonic steroids417-418.
Mechanisms for salt-induced blood pressure elevation include
Nature Reviews Cardiology. 2021 Apr;18(4):251-75.
14. Need of the hour
Many antihypertensive drugs effectively lower blood pressure (BP) in hypertensive patients.
Clinical trials show that calcium channel blockers can reduce blood pressure variability (BPV)
Currently, no specific drugs directly target BPV modulation.
Circadian BPV is influenced by various factors, including posture, exercise, emotional stress, ventilation,
humoral influences, and local vasomotor phenomena.
J Hypertens. 2018 Apr; 36(4): 720–733.
17. Baroreceptor Activation Therapy (BAT)
Conventional BAT (cBAT): Uses fixed stimulation parameters to lower BP promptly, lacks pressure feedback mechanism,
and doesn't address BPV.
Smart BAT (sBAT): Developed to restore baroreceptor reflex function and stabilize BP using pressure feedback
Acute experiments: sBAT replicates baroreceptor reflex, stabilizes BP, prevents postural hypotension in animal
models of baroreceptor impairment16,18.
Clinical application: Need to assess sBAT impact on various pathological states under freely moving settings.
Novel therapeutic option for refractory hypertension, recently gaining interest
Hypertension. 2020;75:885–892
18. • Used with modified sino-aortic denervation (unilateral
baroreceptor denervation and partial restriction of
common carotid blood flow) to mimic BP trend in
hypertensive patients with increased BPV due to impaired
baroreceptor reflex.
Spontaneous Hypertensive Rats (SHRs):
• A promising technique for treating patients with resistant
hypertension. While short-term studies have shown its
efficacy in reducing blood pressure (BP), there is a lack of
long-term data. This study aims to assess the long-term
efficacy and safety of BAT.
Baroreflex Activation Therapy (BAT)
Baroreceptor Activation Therapy (BAT)
Hypertension. 2020;75:885–892
20. Long terms follow up data on BAT
• The study analyzed long-term follow-up data from three trials focusing on treatment-resistant
hypertensive patients.
• A total of 383 patients were included, with 143 completing 5 years of follow-up and 48 completing 6
years of follow-up.
Methodology
• Long-Term Efficacy: BAT significantly reduced office systolic blood pressure (from 179±24 mm Hg to
144±28 mm Hg) and diastolic pressure (from 103±16 mm Hg to 85±18 mm Hg), with heart rate
decreasing from 74±15 bpm to 71±13 bpm.
• Patient-Specific Outcomes: BAT's effectiveness varied among patients, with greater efficacy in those
with heart failure and lesser efficacy in those with isolated systolic hypertension. About 25% of patients
reduced medications from 6 to 3.
• Safety: Temporary side effects related to surgery or cardiovascular instability were observed but
resolved over time without requiring specific measures.
Observation:
Hypertension. 2017;69:836–843
21. Long terms follow up data on BAT
Conclusion:
After a follow-up of 6 years, BAT demonstrated sustained efficacy in persistently reducing office blood
pressure in patients with resistant hypertension. Moreover, the therapy exhibited no major safety issues.
These findings indicate the potential of BAT as a long-term treatment option for patients with resistant
hypertension.
Hypertension. 2017;69:836–843
22.
23. Recent advance BAT in Resistant Hypertension
Evaluate if intensifying nighttime Baroreflex Activation Therapy (BAT) improves nocturnal BP dipping
• Prospective observational study with non-dippers treated with BAT for at least 6 months.
• Modified BAT programming in a two-step intensification of nighttime stimulation at baseline and week 6.
• Included 24 patients with non- or inverted dipping pattern, treated with BAT for a median of 44 months (IQR
25–52).
Study Methodology
• Patients: Mean age 66 ± 9 years, BMI 33 ± 6 kg/m2, office BP 135 ± 22/72 ± 10 mmHg.
• Median number of antihypertensives: 6 (IQR 4–9).
Baseline Patient Characteristics
• Nighttime stimulation adapted with increased pulse width from 237 ± 161 to 267 ± 170 μs (p = .003), while
frequency (p = .10) and amplitude (p = .95) remained unchanged.
Intensification of Nighttime BAT
24. Recent advance BAT in Resistant Hypertension
• BAT intensification led to an increase in systolic dipping from 2 ± 6 to 6 ± 8% (p = .03).
• Significant improvement in dipping pattern (p = .02).
Improved Nocturnal BP Dipping
• Overall 24-hour ABP, day- and nighttime ABP remained unchanged.
Overall 24-Hour ABP
• Intensified nighttime BAT programming improved dipping profile in patients, without significant
changes in overall 24-hour ABP.
• Potential cardiovascular risk reduction beyond BP-lowering effects of BAT needs further
investigation.
Conclusion
26. Introduction
Initial studies showed significant blood pressure (BP) reduction following Renal Denervation (RDN).
Doubts arose after the SYMPLICITY HTN-3 trial in 2014, which was the first randomized sham-controlled trial
but didn't demonstrate significantly lower office or 24-h ambulatory systolic BP (SBP) compared to sham
treatment.
Factors contributing to the trial's failure to show benefit include variable medication adherence, operator
inexperience with the device, procedure variability, and limitations of the first-generation device.
Interventional Cardiology 2023;18:e06
27. Second-generation studies implemented measures to address these limitations:
Using primary endpoints measuring changes in ambulatory BP rather than office BP.
Rigorous screening procedures to select suitable patients for RDN.
Utilizing newer multisite denervation systems.
Improving procedural techniques.
Implementing objective adherence testing.
Introduction
Interventional Cardiology 2023;18:e06
28. Considerations in Patient Selection to Predict a Better
Response to Renal Denervation
Interventional Cardiology 2023;18:e06
31. Does Renal Denervation Improve Long-term
Outcomes?
Intensive BP lowering improves long-term cardiovascular (CV) outcomes based on meta-analyses and prospective
trial data.
A 5-mmHg decrease in office systolic BP (SBP) reduced
Major CV events by 10%
Stroke by 13%
Ischaemic heart disease by 8%
Heart failure by 13%
CV mortality by 5%,
All-cause mortality by 2% after a median 4.2 years follow-up across various age, sex, and baseline SBP
categories.
Interventional Cardiology 2023;18:e06
32. Does Renal Denervation Improve Long-term
Outcomes?
For Renal Denervation (RDN), the absence of CV outcome-based trials prevents a direct comparison. However, RDN is
assumed to follow the same principle as pharmacological-based BP lowering regarding long-term CV benefits.
Based on Global Symplicity Registry data, major CV events and stroke occurred in 9.9% and 4.5% of patients with 3
years of follow-up, respectively.
The absolute risk reduction of major CV events and stroke was estimated at 5.2% in resistant hypertension,
suggesting RDN might be an option to improve CV outcomes and BP over time according to some consensus
statements.
Interventional Cardiology 2023;18:e06
34. Introduction
Renovascular hypertension accounts for 5% of all hypertension cases, with atherosclerotic renal arterial
disease and fibromuscular dysplasia being significant groups.
A recent review highlights limited applicability of randomized trial results to patients for whom renal artery
stenting is recommended.
Danish centers offering percutaneous transluminal renal angioplasty (PTRA) agreed on limiting PTRA to high-
risk patients in a proof-of-concept study after the publication of the CORAL trial (2014).
US guidelines (2017) consider renal artery stenting appropriate for specific cases of atherosclerotic renal
artery stenosis with cardiac destabilization, resistant hypertension, or progressive ischemic nephropathy.
The European guideline (2017) suggests angioplasty consideration for selected patients with significant
atherosclerotic renal artery stenosis and recurrent heart failure.
J Am Heart Assoc. 2022;11:e024421.
36. Renal artery Stenting in high risk patient with
Atherosclerotic Renovascular Disease
• Mean 24-hour ambulatory systolic blood pressure: 166.2 mm Hg (95% CI, 162.0–170.4).
• Defined daily dose of antihypertensive medication: 6.5 (95% CI, 5.8–7.3).
• Estimated glomerular filtration rate: 41.1 mL/min per 1.73m2 (95% CI, 36.6–45.6).
Baseline Data:
J Am Heart Assoc. 2022;11:e024421
• 102 patients referred for revascularization based on high-risk criteria: severe renal artery stenosis (≥70%)
with true resistant hypertension, rapidly declining kidney function, or recurrent heart failure/sudden
pulmonary edema.
37. Renal artery Stenting in high risk patient with
Atherosclerotic Renovascular Disease
J Am Heart Assoc. 2022;11:e024421
• Mean 24-hour ambulatory systolic blood pressure decreased by 19.6 mm Hg (95% CI, 15.4–23.8; P<0.001).
• Defined daily dose of antihypertensive medication reduced by 52% (95% CI, 41%–62%; P<0.001).
• Estimated glomerular filtration rate increased by 7.8 mL/min per 1.73m2 (95% CI, 4.5–11.1; P<0.001).
3-Month Follow-up Results (96 patients):
• Changes persisted after 24 months follow-up.
Long-Term Follow-up:
• Among 17 patients with a history of hospitalization for acute decompensated heart failure, 14 had no new
episodes after successful revascularization.
Impact on Heart Failure:
• Conclusions:
• Renal artery stenting resulted in significant reductions in blood pressure and antihypertensive medication.
• It led to an increase in estimated glomerular filtration rate and decreased new hospital admissions related to
heart failure/sudden pulmonary edema.
• These positive outcomes were sustained over the long term, suggesting the potential benefits of renal artery
stenting in high-risk patients.
38. Transradial access for renal artery interventions
Percutaneous transluminal renal angioplasty and stenting have shown evidence of improving blood pressure,
reducing flash pulmonary edema, and preventing renal dysfunction worsening.
Randomized controlled trials supporting these interventions are limited, but they are recognized as appropriate
therapies for unilateral or bilateral renal artery stenosis in the setting of accelerated/resistant hypertension.
Transradial access for renal artery interventions is a less common but recognized approach that can reduce access
site complications, post-procedure bedrest, and improve patient satisfaction while maintaining successful
intervention.
Hebert et al. Cureus 2023 15(2): e34781. DOI 10.7759/cureus.34781
39. Transradial access for renal artery interventions
A cranio-caudal approach may be advantageous due to the angulation of renal arteries, potentially improving
cannulation and equipment delivery support.
Some considerations include the need for longer equipment lengths with radial access and potential difficulties in
reaching renal arteries in taller patients.
In certain cases, removal of intervening equipment or utilizing the left-radial approach may be necessary to ensure
successful interventions.
Hebert et al. Cureus 2023 15(2): e34781. DOI 10.7759/cureus.34781
Be specific and direct in the title. Use the subtitle to give the specific context of the speech.
-The goal should be to capture the audience’s attention which can be done with a quote, a startling statistic, or fact. It is not necessary to include this attention getter on the slide.
Physical exercise
Body weight management
Healthy dietary patterns
Circadian entrainment and sleep
Stress management
x
Classic study: Exercise reduced blood pressure (6.4 mmHg in SBP, 5.2 mmHg in DBP) in men with/without hypertension, no change in body weight405.
Greater weight reduction: Without exercise, weight loss lowered blood pressure (8.8 kg loss: 9.2 mmHg SBP, 6.2 mmHg DBP)405.
Exercise in hypertension: Exercise lowered SBP/DBP (4.4 mmHg/4.3 mmHg) despite small weight loss (1.8 kg)406.
Exercise with weight management: Combined exercise, diet, and weight loss led to more significant reductions (7.4 mmHg SBP, 5.6 mmHg DBP)406.
Meta-analysis: Exercise reduced SBP/DBP (approx. 5 mmHg/3 mmHg) regardless of body weight changes (≥1.5 kg)407.
Exercise benefits blood pressure independently, but more with weight loss.
Long-term exercise reduces blood pressure, but blood pressure rises during exercise due to increased cardiac output for muscle oxygen demands.
This rise is usually a normal physiological response without adverse events.
Some individuals have an exaggerated increase in systolic blood pressure during exercise, called hypertensive response to exercise (HRE).
HRE is defined as ≥60 mmHg increase in men and ≥50 mmHg increase in women, or systolic blood pressure >210 mmHg in men and >190 mmHg in women408.
In those with normal blood pressure, HRE may predict future hypertension and cardiovascular disease408.
Lifestyle interventions, like healthy diet and exercise, can reduce HRE.
Less than 20% maintain a 10% weight loss for over 1 year410.
Network meta-analysis: Different diets led to significant weight reductions at 6 months (4.6 kg low-carb, 4.4 kg low-fat, 3.1 kg moderate intake) and decreased blood pressure (systolic: 5.1 mmHg, 5.1 mmHg, 3.5 mmHg; diastolic: 3.2 mmHg, 2.9 mmHg, 1.9 mmHg)166.
Effects at 12 months: Weight loss (−3.2 kg, −3.3 kg, −1.9 kg) and blood pressure reductions (systolic: −1.3 mmHg, 0.3 mmHg, −0.5 mmHg; diastolic: −0.8 mmHg, −0.2 mmHg, −0.1 mmHg) diminished with all diets.
Body weight management programs with exercise and diet are more effective than exercise alone in the short-to-medium term (3–6 months, mean difference −5.3 kg) and long term (12–18 months, mean difference −6.3 kg)411.
Combined interventions similar to diet alone in short-to-medium term (3–6 months, mean difference −0.6 kg), but diet-only interventions more effective in the long term (mean difference −1.7 kg)411.
Lifestyle interventions focusing on both exercise and diet showed small beneficial effects on body weight after 12 months (−1.6 kg) in individuals with obesity who lost >5% of body weight412.
No evidence of efficacy for diet-only or physical activity-only interventions412.
Long-term sustainability of lifestyle interventions for weight reduction remains unclear, but combining energy-restrictive diets and exercise interventions maximizes the likelihood of maintaining weight loss.
