Download Renal Denervation with the SPYRAL HTN Global Clinical Trial

American Society of Hypertension
Renal Denervation with the SPYRAL
HTN Global Clinical Trial Program
• Understand the impact of variable adherence to
complex drug therapy regimens on clinical trial
outcomes
• Appreciate the relationship between absolute
pressure drop and cardiovascular risk reduction
across the spectrum of co-morbidities within the
uncontrolled hypertensive population
• Uncover new histological insights into the
anatomical distribution of the renal nerves
Improving Cardiovascular Clinical
Outcomes: The Role of Beta Blockers
in Dual RAAS Blockade
• Explain the mechanisms of action of the RAAS, its
interaction with the SNS, specifically with respect to
cardiovascular diseases like hypertension and heart
failure
• Contrast the mechanisms of action and pharmacologic
effects of beta-blockers in treating hypertension and
heart failure, including receptor targets and
vasodilatory properties
• Identify the benefits of beta blockers in the
management of hypertension and heart failure
• Formulate management plans for patients that
incorporate
Applying Technological Innovations in Blood
Pressure Measurement for Improved Outcomes
in Treatment and Management
• Explain the role of central blood pressure in
individual hypertensive patient assessment
• Apply technological evaluations of the
cardiovascular system to improve risk assessment
• Characterize differential effects of antihypertension medications on brachial and central
blood pressure
• Utilize the central blood pressure waveform and
arterial stiffness measurements for improved
outcomes in patients with elevated blood
pressures
Hypertension 2015: Important
Concepts In BP Control
• Evaluate the benefits of initial combination versus
single agent antihypertensive therapy to control
elevated blood pressure
• Delineate pharmacologic and clinical differences within
the thiazide diuretic class
• Define resistant hypertension and its appropriate
workup
• Recognize the importance of lifestyle modification, and
the evidence for the use of chlorthalidone vs. HCTZ,
and mineralocorticoid receptor antagonism
(spironolactone) in those with resistant hypertension
Target organ complications and cardiovascular events
associated with masked hypertension and white coat
hypertension: analysis from the dallas heart study
• Our study demonstrated a first direct evidence
of increased target organ damage and CV
complications associated with white coat
hypertension and Masked hypertension in a
multiethnic population.
• Study provided support for routine use of
home BP monitoring in detecting presence of
MH and WCH
Increased risk of stroke among hypertensive patients with
abnormally short sleep duration: analysis of the national health
interview survey
• Hypertensive patients with either very short
sleep or long sleep duration had an almost
two fold greater likelihood of having a stroke.
• Healthcare providers caring for hypertensive
patients should incorporate a sleep history in
their routine examination in order to optimize
efforts to prevent or manage stroke
White coat hypertension as predictor of
long-lasting blood pressure decline in
stage 1 hypertension
• In a substantial portion of young-to-middleage stage 1 hypertensives antihypertensive
treatment can be deferred because of a
spontaneous long-lasting BP decline.
• WCH at baseline is an important predictor of
this favourable outcome even when the initial
clinic BP drop is taken into account.
Wave intensity patterns in the aorta are associated
with diastolic function in older adults
• A prominent late systolic
suction wave traveling forward
in the arterial tree is associated
with abnormal diastolic
relaxation.
• This novel adverse pattern of
abnormal ventricular-arterial
interactions may be due to a
premature onset of LV relaxation
or excessive blood inertia as a
result of abnormal arterial load.
• Wave intensity analysis is a
useful technique to gain insights
into systolic-diastolic coupling
Effects of aging and blood pressure on timing and
amplitude of central pulse contour landmarks
• Timing of central pressure landmarks is
relatively fixed, while the amplitude of the
late-systolic central BP peak is associated with
aging, hypertension, proximal large artery
stiffness and distal arteriolar resistance
Targeted delivery of endothelial cells by overexpression of
interleukin-8 receptors promotes functional recovery of the
kidney after ischemia-reperfusion injury
• Ischemia-reperfusion acute kidney injury (AKI)
damages the renal microvascular endothelium
compromising renal function.
• We tested the hypothesis that targeted
systemic delivery of rat aortic endothelial cells
(ECs) transduced with IL8 receptors attenuates
the inflammatory response and promotes
structural and functional recovery of the
kidney in rats following AKI.
Prescribing patterns of renin-angiotensin-aldosterone-system inhibitors are
inconsistent with guidelines for treatment of cardio renal comorbiditie
• Despite clear-cut clinical guidelines, relatively few
patients in the U.S. are prescribed maximum
recommended doses of RAASi, even those
patients with serious comorbidities.
• Future studies should investigate whether the
availability of new therapies to treat
hyperkalemia may facilitate maintaining patients
on recommended therapeutic doses of RAAS
inhibitors and mineralocorticoid receptor
antagonists
Efficacy and tolerability of nebivolol
added to RAAS inhibitors
• In patients treated, but not controlled, with a RAAS
inhibitor (ACEI or ARB), nebivolol 10 and 20 mg/day
lowered DBP significantly more than placebo at 12
weeks.
• Nebivolol 20 mg/day also lowered SBP significantly
more than placebo .
• Additionally, nebivolol did not increase the rate of
adverse events when added to either an ACEI or
ARB.
• Overall, these data suggest that nebivolol, added to
an ongoing therapy with an ACEI or ARB, has
significant, additional antihypertensive efficacy with
good tolerability.
Predictors of changes in cardiac structure and diastolic function
at dipper and non-dipper treated hypertensive patients
• Worsening of LV diastolic dysfunction was
found at dippers and non-dippers groups of
hypertensive patients after 10 years.
• Abnormalities in LV diastolic function in
hypertensive patients were associated with
baseline diastolic night-time BP, concentric
cardiac remodeling, postprandial
hyperinsulinemia and hsCRP
Effects of dipeptidyl peptidase 4 inhbition on urinary
albumin excretion in type 2 diabetic patients
• The UAE tends to progress over time in type 2
diabetic patients with micro- or
macroalbuminuria regardless of blood
pressure.
• Vildagliptin added as an antidiabetic
treatment may help to slow this progression.
Prognostic impact of sleep-time relative blood pressure decline
for predicting the risk of developing chronic kidney disease
• New-onset CKD was significantly greater in
non-dippers and, to a larger extent in risers.
• Results indicate a blunted sleep-time relative
BP decline predicts the development of CKD,
rather than being a consequence of this
condition
Sleep-time blood pressure as a
therapeutic target for reducing the risk of
developing chronic kidney disease
• Sleeptime SBP mean derived from ambulatory
BP monitoring (ABPM) is the most significant
independent prognostic marker of new-onset
CKD
Influence of class and treatment-time regimen of hypertension
medications on the risk of developing chronic kidney disease
• Renin-angiotensin blockade, however, is
significantly superior to any other BP-lowering
strategy for reducing the risk of CKD, apart
from the documented decrease of
cardiovascular risk, when the medications are
dosed at bedtime.
Clinical and hemodynamic effectiveness of telmisartan at
hypertensives with hyperinsulinemia and heart failure
• HI in hypertensives with HF-PEF leads to a more severe course of
disease with increasing of SBP and DBP, formation ofprognostically
unfavorable circadian BP profiles ‘‘non-dipper’’ and severe HF
clinical signs accompanied by decreasing of 6MWT parameters.
• Complex antihypertensive treatment with inclusion of
telmisartan, torasemid and atorvastatin reduces HF-PEF clinical
signs
• Improves tolerance to physical activity, allowing BP stabilization,
provides formation of favorable circadian BP profiles as with
normal plasma EI level and as with reactive and spontaneous HI in
hypertensives with HF-PEF
Does body mass index (BMI) modulate effect of
dietary sodium reduction on blood pressure: a crossover randomized trial
• Low sodium diet decreases blood pressure in
both BMI groups but the effect was more
significant in patients with normal BMI.
• Obesity may confound or attenuate the effect
of dietary sodium reduction
Systolic blood pressure reductions with sotagliflozin (LX4211), a
dual SGLT1 and SGLT2 inhibitor, are associated with reductions
in urinary sodium excretion
• Sotagliflozin 400 mg qd effectively lowered SBP
at Week 12 in patients with SBP 130 mm Hg.
Patiromer increased time to RAAS inhibitor
discontinuation compared with placebo in
advanced CKD patients with hyperkalemia
• Patiromer discontinuations due to AEs occurred in 6% and 5% of patients in
each phase.
• After controlling s-K+ , patiromer reduced HK recurrence and increased
time to RAAS inhibitor discontinuation compared to placebo in CKD Stage 45 patients, with good tolerabilit
Salt-sensitive? It May Not Be Sodium
Intake; It May be in your Genes
• In this study, 334 subjects from 124 families were
put on a low-salt diet for seven days, followed by
a high-salt diet for seven days and then a highsalt, high-potassium diet for seven days.
• The results of this family-based study indicate
that genetic variants in the Renalese gene are
significantly associated with blood pressure
responses to dietary salt intake, showing that
genetics plays a role in determining how sensitive
a person's blood pressure is to sodium intake.