La dénervation rénale un traitement pour l’hypertension artérielle résistante : expérience française

Arterial hypertension is the largest single contributor to global mortality, and is poorly controlled in approximately 50% of patients despite lifestyle and pharmacologic interventions. Randomized clinical trials have demonstrated that catheter-based renal sympathetic denervation reduces blood pressure (BP) in patients with resistant hypertension. We sought to evaluate the efficacy of this novel therapy in “Real World” clinical practice. Consecutive patients with treatment-resistant primary hypertension, as defined as home BP > 160 mmHg despite treatment with ≥ 3 antihypertensive drugs, were selected for denervation following renal artery screening. Ambulatory and home BP monitoring was performed in all patients prior to and following percutaneous renal sympathetic denervation. In total, 35 patients were selected for catheter-based renal sympathetic denervation. The mean age was 63.6 ± 11.7 years, 37.1% were women, 37.1% were diabetic, and 11.4% had renal impairment (GFR < 45 mL/min). The basal BP (home or ambulatory) was 179.1 ± 20.75/99.66 ± 19.76 mmHg, despite an average of 4.91 ± 0.98 medications per patient. Successful bilateral sympathetic denervation was performed in 33/35 patients (1 renal artery stenosis on angiography [not ablated], 1 patient with renal artery spasm [unilateral denervation]), with an average 5.9 ± 1.6 ablations per renal artery. No procedural complications occurred. At 6 months, blood pressure was 15.5 ± 22.37/87.76 ± 13.97 mmHg (P < 0.01). At 2 years follow-up, systolic blood pressure (ABPM or Home BP) was 143.8 ± 15.30 mmHg (P < 0.0001) and diastolic 83.42 ± 12.80 mmHg (P = 0.0004). There were no adverse events during follow-up, and no deterioration in renal function was observed. Catheter-based renal denervation is safe and efficacious treatment, which results in significant reductions in blood pressure in patients with treatment-resistant hypertension, stable at 2 years follow-up. These results are applicable to real-world patient populations.     

Caractéristiques épidémio-cliniques de l’hypertension artérielle résistante du sujet noir africain

Introduction

Few studies in sub-Saharan Africa were interested in resistant hypertension. The objectives of this study were to determine the frequency of resistant hypertension in hypertensive black African population, and to describe its clinical and therapeutic features.

Patients and methods

From May 1, 2010 to May 31, 2012, we included consecutively hypertensive followed in two hospitals in the city of Ouagadougou, under antihypertensive treatment at optimum dose and observant. Patients whose blood pressure was uncontrolled despite a triple antihypertensive therapy at the optimal dose including a diuretic associated with dietary measures have received ambulatory blood pressure monitoring. Following this examination, patients whose blood pressure was ≥ 135/85 mmHg during the day and/or ≥ 120/70 mmHg at night were considered resistant hypertension. We investigated the cardiovascular risk factors as well as target organ damages. We combined spironolactone 50 mg in treatment when absence of contra-indication appreciated the evolution of blood pressure under this treatment. The measurement of plasma renin activity was not performed. Statistical analysis was performed using SPSS Version 17 for Windows.

Results

We included 692 patients with 14.6% of resistant hypertension. The average age of patients was 54.8 ± 11.1 years in the general population, 56.5 ± 11.8 years in the subgroup of non-resistant hypertension and 64.2 ± 5.4 years in the subgroup of resistant hypertension. The symptoms were represented by headache (11.9%), dizziness (9.9%) and chest pain (8.9%). Modifiable cardiovascular risk factors were dominated by dyslipidemia, diabetes and obesity/overweight. These risk factors were significantly more frequent in the subgroup of resistant hypertension. The global cardiovascular risk was high in 24.9% of cases in the general population, 22.5% in the subgroup of non-resistant hypertension and 38.6% in the subgroup of resistant hypertension. The target organ damages were significantly more frequent in the same subgroup of resistant hypertension. After addition of spironolactone, 21.8% of resistant hypertensive patients were controlled.

Conclusion

This study shows that resistant hypertension is common in black Africans. It is mostly subjects of the sixth decade, with limited economic income and living in rural areas. In the absence of contra-indication, spironolactone contributed to decrease the morbidity of this pathology.     

Les réponses sympathiques dans l’hypertension artérielle essentielle

High blood pressure (BP) is a major cause of cardiovascular disease and primary hypertension is a frequent pathological condition. Sympathetic hyperactivity may be involved in primary hypertension. The purpose of this study was mainly to evaluate sympathetic activity when performing cardiovascular autonomic profile examination in patients with primary hypertension in comparison with normotensive subjects.

Patients and methods

This prospective study included one group of hypertensive patients (n = 120, mean age 54 years) compared with a control group (n = 120, mean age 52 years) of normotensive subjects. Autonomic tests included deep-breathing (DB), hand-grip (HG) and echostress test (ES). Comparison tests between the two groups, similar in age, were expressed as mean ± SE and made using the t Student test, p < 0.05 was considered significant.

Results

Alpha-adrenergic sympathetic response using ES method produced a BP response of 20,0% ± 9,8 in hypertensive patients group and 15,2% ± 8,6 in the control group (p < 0.001). Alpha-adrenergic sympathetic response using three minutes HG test was of 16,7% ± 7,5 in hypertensive patients group and 13,3% ± 6,5 in the control group (p < 0.001). Vagal stimulation in hypertensive group after DB showed that electrocardiographic: ECG (EKG) waves R (RR) interval variation was of 30,2% ± 8,1 meanwhile in the control group this RR variation was of 46,1% ± 21,1 p < 0.001, and the one of HG of 15 seconds was 17,6% ± 10,2 versus 32,5% ± 12,7 p < 0.001.

Conclusion

Hypertensive patients had a significantly higher sympathetic response to central and peripheral stimulations and a significantly lower parasympathetic response when compared to normotensive controls.     

Hypertension artérielle,atteinte rénale et génétique chez le sujet noir : mise au point

The incidence and prevalence of hypertension is markedly elevated in Afro-American populations vs Caucasians. The development of end-stage renal disease is also more frequent in Afro-American subjects, independently of blood pressure control. As compared to Caucasians, Afro-American subjects have a higher risk of end-stage renal disease when they are infected with HIV or have lupus. For decades, these data remained mysterious. Within the last 3 years, results from studies in the field of genetics and infectious diseases have transformed our view on this problem. The aim of this paper is to explain how these results have changed our understanding of hypertension and its consequences in Afro-American subjects.     

Dénervation rénale pour HTA réfractaire sans anesthésie générale : intérêt d’un protocole MEOPA Morphine. Expérience préliminaire

Renal denervation using the technique of radiofrequency is used only recently for the treatment of resistant hypertension. Normally, it is done under general anesthesia because the ablation point technique is painful. We suggest an alternative to general anesthesia comprising an association of morphin 0.1 mg/kg IV to MEOPA (gas combining oxygen and azot protoxyd) delivered through an oxygen mask. Our series includes 12 consecutive patients treated between October 2011 and June 2013, the first five patients (group 1) have received only an hydroxizin and morphin sedation. Every five have felt the ablation painful, in two cases bearable pain (EVA < 5), in three cases intense (EVA > 5) pain leading to increasing doses of morphin, (total dose of 0.25 mg/kg in two cases, 0.17 mg in one case). For the seven following patients, a protocol including hydroxyzin, morphin and MEOPA given through a mask has been set up. Only one patient has felt a mild pain (EVA 5) leading to an increasing dose of morphin (total dose 0.17 mg/kg). None of the six other patients has felt any pain during the procedure. The average dose of morphin is 0.17 mg/kg in group 1, 0.11 mg/kg in group 2. This is a preliminary study; if confirmed, it will allow a lot of hospitals without on-site possibilities of general anesthesia, to realize such procedures. Conclusion: regarding pain, the procedure of renal ablation was well tolerated for six among seven patients receiving the association MEOPA and IV morphin. In contrast, in the five patients treated only with IV morphin, we observed a less good tolerance to pain and the need to increase the doses of IV morphin.     

Influence de la fonction rénale sur la pertinence diagnostique du BNP chez l’insuffisant cardiaque âgé

Aim of the study

BNP levels are accurate in the diagnosis of heart failure and useful in clinical practice. Relationship between BNP, heart failure (HF) and renal function are little known in the elderly. Renal function influence the optimal cut point of BNP in patients with a Glomerular Filtration Rate (eGFR) lesser than 60 ml/min/1.73 m².

Methodology

A total of 71 patients (mean age = 85 years) were admitted in a Cardiogeriatric Unit. We noted several parameters, age, gender, the presence or the absence of Systolic Heart Failure (clinical history and physical examination), the echographic measure of the left ventricular ejection fraction, the eGFR value calculated by simplified MDRD formula and the BNP value. We divided these patients into six groups according the presence of HF and eGFR value higher than 60ml/min/1.73m²,or between 30 and 60 or between 15 and 30.

Results

Our results show that the BNP value is higher in all the three groups of patients with Heart Failure with or without diminution of the eGFR: for example, 1220 pg/ml in the presence of HF versus 788 pg/ml in the absence of HF in the two groups with the eGFR is calculated between 15 and 30 ml/min/1.73m².

Conclusion

BNP is a helpful tool in clinical practice for the diagnosis of Systolic Heart Failure in the presence of renal impairment in the elderly with a higher biomarker cut point.     

Dysfonction endothéliale : le rôle des bêtabloquants vasodilatateurs dans l’hypertension artérielle et l’insuffisance cardiaque chronique

The beneficial effects of beta blocking drugs in hypertension and heart failure are well known. However, this class of drugs is pharmacologically heterogeneous. In contrast to the non vasodilator betablockers like propranolol, atenolol or metoprolol which, in hypertension do not decrease intima media thinckness both in arterioles and large arteries, do not decrease arterial rigidity and can induce diabetes mellitus, the betablockers with vasodilating properties are beneficial on these parameters. Moreover, in heart failure, they more markedly decrease left ventricular workload than betablockers without any vascular relaxing effect and the results of SENIOR with nebivolol could suggest the beneficial role of NO on left ventricular dysfunction. Finally, the third generation betablockers, represented by celiprolol, carvedilol and nebivolol, have antioxidant properties which are probably implicated in their endothelial protective effects and in their absence of deleterious metabolic effects, effects which are probably of interest in term of protection of target organs during chronic treatment of hypertensive patients.     

Plasticité cérébrale : de la théorie à la pratique dans le traitement de l’accident vasculaire cérébral

It has long been believed that cerebral lesions were irreversible in the adult human brain. However, the spontaneous improvement in functional outcome observed in the following weeks after cerebral ischemia suggests plasticity phenomenons involving postischemic neuronal network reorganization. Regarding the large prevalence of stroke in industrialized countries, and the few available treatments, the understanding of cerebral plasticity has become an important issue but also a potential source of new therapeutic approaches in stroke. Thus, “constraint induced therapy” and repetitive transcranial magnetic stimulation (rTMS) are based on the concept of local but also remote consequences of the ischemic focal lesion. Cell-therapy is based on the capacity of stem cells to respond to hypoxic signals and adapt their phenotype to the host organ, but above all to release cytokines locally and boost endogeneous repair mechanisms. We could consider to perform in the future a sequential treatment with fibrinolysis, stem cell therapy, repetitive transcranial magnetic stimulation and constraint-induced therapy in the same patient.     

Prise en charge actuelle de l’hypertension artérielle

Hypertension is a common health problem with serious consequences for individuals and a heavy attributable burden for populations. Reducing this burden requires preventive actions at the population level and early diagnosis at the individual level, followed by proactive interventions with proven benefits. Given the variability of blood pressure measurement, diagnosis is established only after repeated measurements under standardized conditions, if possible outside the clinic. Lifestyle changes can modestly reduce blood pressure; their impact is significant if they can be achieved on a large scale. Hypertension treatment requires a rational pharmacological approach, which can reach the target blood pressure within less than 6 months and three pharmacological classes at most in more than 80% of cases. Specialized consultation is required in the remaining 20% to detect secondary hypertensions, to optimize drug therapy and to discuss, in a minority of cases, non-pharmacological treatments. Recommendations are written by experts who select, interpret, and extrapolate the results of clinical research. As a consequence, they are sometimes unsuitable for primary care practice and frequently inconsistent across guidelines. Efforts are currently made to produce less disputable and more usable guidelines.     

Fibrose rétropéritonéale idiopathique : évolution à long terme du pronostic rénal dans une série rétrospective multicentrique de 30 cas

Purpose

Idiopathic retroperitoneal fibrosis (IRF) is an inflammatory disorder, affecting the aorta and the surrounding vessels and tissues. The prognosis is mainly driven by the risks of chronic kidney disease and relapse. Our aim was to assess the prevalence of chronic kidney disease at follow-up.

Methods

We retrospectively reviewed the medical records of patients diagnosed for IRF in Seine-Saint-Denis (France) between 1987 and 2011. We collected informations about presentation, radiologic findings and follow-up. Diagnosis of IRF was confirmed when all the following criteria were met: infiltration of the infrarenal aorta or iliac vessels, absence of aneurysmal dilation, lack of clinical suspicion of malignancy.

Results

Thirty patients were identified, with a male/female ratio of 4.9. Mean age was 55 ± 13 years old. The mean creatinine clearance was 66 mL/min/1.73 m² and the mean CRP was 45 ± 36 mg/L. In 24 (80%) patients, the location of IRF was periaortic and periiliac. Eleven patients (37%) underwent a diagnostic biopsy, and 14 (47%) required an ureteral procedure. A mean follow-up of 63 months was available for 29 patients: 69% relapsed, 7 developed chronic renal disease (24%), and one died of urinary sepsis. Older age (P = 0.023), diabetes (P = 0.007), and initial renal insufficiency (P = 0.05) were associated with a risk of chronic renal insufficiency.

Conclusion

The high frequency of relapses and chronic renal disease emphasizes the need of close follow-up in patients diagnosed with IRF.