Maria Angela Magalhães de Queiroz Carreira

Effects of renal denervation with a standard irrigated cardiac ablation catheter on blood pressure and renal function in patients with chronic kidney disease and resistant hypertension

AIMS Evaluation of the safety and efficacy of renal denervation with a standard irrigated cardiac ablation catheter (SICAC) in chronic kidney disease (CKD) patients with refractory hypertension. METHODS AND RESULTS Twenty-four patients were included and treated with a SICAC. Denervation was performed by a single operator following the standard technique. Patients included with CKD were on stages 2 (n = 16), 3 (n = 4), and 4 (n = 4). Data were obtained at baseline and monthly until 180th day of follow-up. Baseline values of blood pressure (mean ± SD) were 186 ± 19 mmHg/108 ± 13 mmHg in the office, and 151 ± 18 mmHg/92 ± 11 mmHg by 24 h ambulatory blood pressure monitoring (ABPM). Office blood pressure values at 180th day after the procedure were 135 ± 13 mmHg/88 ± 7 mmHg (P < 0.0001, for both comparisons). The mean ABPM decreased to 132 ± 15 mmHg/85 ± 11 mmHg at the 180th day after the procedure (P < 0.0001 for systolic and P = 0.0015 for diastolic). Estimated glomerular filtration (mean ± SD) increased from baseline (64.4 ± 23.9 mL/min/1.73 m(2)) to the 180th day (85.4 ± 34.9 mL/min/1.73 m(2), P < 0.0001) of follow-up. The median urine albumin:creatinine ratio decreased from baseline (48.5, IQR: 35.8-157.2 mg/g) to the 180th day after ablation (ACR = 15.7, IQR: 10.3-34.2 mg/g, P = 0.0017). No major complications were seen. CONCLUSION The procedure using SICAC seemed to be feasible, effective, and safe resulting in a better control of BP, a short-term increase in estimated glomerular filtration rate, and reduced albuminuria. Although encouraging, our data are preliminary and need to be validated in the long term.

Long‐Term Effects of Renal Sympathetic Denervation on Hypertensive Patients With Mild to Moderate Chronic Kidney Disease

Thirty patients who underwent percutaneous renal denervation, which was performed by a single operator following the standard technique, were enrolled in this study. Patients with chronic kidney disease (CKD) stage 2 (n=19), 3 (n=6), and 4 (n=5) were included. Data were obtained at baseline and at monthly intervals for the first 6 months. At 7 months, follow‐up data were collected bimonthly until month 12, after which data were collected on a quarterly basis. Baseline blood pressure values (mean±standard deviation) were 185±18/107±13 mm Hg in the office and 152±17/93±11 mm Hg through 24‐hour ambulatory blood pressure monitoring (ABPM). Three patients with stage 4 CKD required chronic renal replacement therapy (one at the 13‐month follow‐up and two at the 14‐month follow‐up) after episodes of acute renal injury; their follow‐up was subsequently discontinued. The office blood pressure values at the 24‐month follow‐up were 131±15/87±9 mm Hg (P<.0001, for both comparisons); the corresponding ABPM values were 132±14/84±12 mm Hg (P<.0001, for both comparisons). The mean estimated glomerular filtration rate increased from 61.9±23.9 mL/min/1.73 m2 to 88.0±39.8 mL/min/1.73 m2 (P<.0001). The urine albumin:creatinine ratio decreased from 99.8 mg/g (interquartile range, 38.0–192.1) to 11.0 mg/g (interquartile range, 4.1–28.1; P<.0001 mg/g). At the end of the follow‐up period, 21 patients (70% of the initial sample) were no longer classified as having CKD.

Renal Sympathetic Denervation in Patients With Hypertension and Chronic Kidney Disease: Does Improvement in Renal Function Follow Blood Pressure Control?

Twenty‐seven patients with resistant hypertension and chronic kidney disease were treated by renal sympathetic denervation (RSD) and followed for 12 months. Patients were retrospectively divided into controlled and uncontrolled blood pressure (BP) groups. Increases in mean estimated glomerular filtration rate (eGFR) were found at months 1, 3, 6, and 12 in the controlled group (P<.0001, for every time point). The mean change in eGFR after 12 months was 18.54±8.15 mL/min/1.73m2 higher in the controlled group (P=.0318). In patients in the controlled group with baseline eGFR <45 mL/min/1.73 m2, responders (with an increase in eGFR >6.2%) corresponded to 50% at 6 months and 83% at 12 months. In the patients with baseline eGFR ≥45 mL/min/1.73 m2, all patients were labeled as responders at months 6 and 12. Median albumin:creatinine ratio after 12 months was lower than baseline only in the controlled group (P=.0003). Our results suggest that patients with this profile who reached BP control by RSD also experienced a significant improvement in renal function.

Proof of concept study: Improvement of echocardiographic parameters after renal sympathetic denervation in CKD refractory hypertensive patients.

AIM Evaluation of the effectiveness of the renal sympathetic denervation (RSD) in reducing lesions of target organs such as the heart and kidneys, in resistant hypertensive CKD patients. METHODS AND RESULTS Forty-five patients were included and treated with an ablation catheter with open irrigated tip. RSD was performed by a single operator following the standard technique. Patients included with CKD were on stages 2 (n=22), 3 (n=16), and 4 (n=7). Data were obtained at baseline and monthly until the 6th month of follow-up. Twenty-six out of the 45 patients had LVH and nineteen did not present LVH. The LV mass index decreased from 123.70±38.44g/m(2) at baseline to 106.50±31.88g/m(2) at the 6th month after RSD, P<0.0001. The end-diastolic left ventricular internal dimension (LVIDd) reduced from 53.02±6.59mm at baseline to 51.11±5.85mm 6months post procedure, P<0.0001. The left ventricular end-diastolic posterior wall thickness (PWTd) showed a reduction from 10.58±1.39mm at baseline to 9.82±1.15mm at the 6th month of follow-up, P<0.0001. The end-diastolic interventricular septum thickness (IVSTd) also decreased from 10.58±1.39mm at baseline to 9.82±1.15mm 6months post procedure, P<0.0001. The left ventricular ejection fraction (LVEF) improved from 58.90±10.48% at baseline to 62.24±10.50% at the 6th month of follow-up, P<0.0001. When the ∆ between baseline and the 6th month post RSD in LVH patients and non LVH patients were compared to the same parameters no significant difference was found. CONCLUSIONS The RSD seemed to be feasible, effective, and safe resulting in an improvement of echocardiographic parameters in LVH and non LVH CKD refractory hypertensive patients.

Acute effect of renal sympathetic denervation on blood pressure in refractory hypertensive patients with chronic kidney disease

a Renal Division, Department of Medicine, Universidade Federal Fluminense, Niteroi, RJ, Brazil b Hospital Regional Darcy Vargas, Rio Bonito, RJ, Brazil c Department of Cardiology, Shanghai First Peoples Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China d Fellowship of European Heart Rhythm Association/European Society of Cardiology, Department of Cardiology, Elisabethinen University Teaching Hospital Linz, Linz, Austria e Abteilung Elektrophysiologie, Herzzentrum, Universitat Leipzig, Leipzig, Sachsen, Germany

Effects of renal sympathetic denervation in left ventricular hypertrophy in CKD refractory hypertensive patients

Article history: Received 26 July 2015 Received in revised form 22 August 2015 Accepted 26 August 2015 Available online 29 August 2015 formed consent was obtained from every patient. In the period from June 2011 to December 2012, thirty consecutive patients underwent RSD. All of them had resistant hypertension and CKD (stages 2, 3 and 4), as shown in Table 1. They underwent laboratory tests and assessment of renal function at baseline and 24 h post-procedure, before discharge. The procedures were performed in the catheterization laboratory with direct visualization using fluoroscopy and radiopaque contrast. In

Ativação adrenérgica alterada se associa à recuperação anormal da Frequência Cardíaca

BACKGROUND Heart Rate Recovery (HRR) reflects the capacity of the cardiovascular system to reverse the vagal withdrawal caused by exercise. Scintigraphy with metaiodobenzylguanidine (I(123) MIBG) evaluates innervation and cardiac adrenergic activation. The association of these two methods is not well established. OBJECTIVE To evaluate the association between HRR and washout rate (WO) of I(123) MIBG in patients with heart failure (HF). METHODS Twenty-five patients with ejection fraction < 45% underwent exercise testing, and analysis of the variation of HRR from the 1st to the 8th minute after exertion. Submitted to I(123) MIBG, they were separated into groups by WO: G1) <27% and G2) ≥ 27%. For the statistical analysis Mann-Whitneys U test and Spearmans correlation coefficient were used. RESULTS G2 showed a slower variation of HRR: 1st minute: G1: 21.5 (16.12 to 26.87) vs. G2: 11.00 (8.5 to 13.5) bpm, p = 0.001; 2nd minute: G1: 34 (29-39) vs. G2: 20 (14 - 26) bpm, p = 0.001; 3rd minute: G1: 46 (37.8 - 54.1) vs. G2: 30 (22 - 38) bpm, p = 0.005; 5th minute: G1: 51.5 (42 - 61) vs. G2: 39 (31.5 to 46.5) bpm, p = 0.013, and in the 8th minute: G1: 54.5 (46.5 - 62.5) vs. G2: 43 (34 - 52) bpm, p = 0.037. HRR in the 1st (r = -0.555, p = 0.004), and in the 2nd minute (r = -0.550, p = 0.004) were negatively correlated with WO. CONCLUSION Patients with high HF and WO showed an abnormal HRR compared with patients with normal WO. These findings suggest that adrenergic activation may influence the HRR.

Exercise testing in hypertensive patients taking different angiotensin-converting enzyme inhibitors

OBJECTIVE To compare blood pressure response to dynamic exercise in hypertensive patients taking trandolapril or captopril. METHODS We carried out a prospective, randomized, blinded study with 40 patients with primary hypertension and no other associated disease. The patients were divided into 2 groups (n=20), paired by age, sex, race, and body mass index, and underwent 2 symptom-limited exercise tests on a treadmill before and after 30 days of treatment with captopril (75 to 150 mg/day) or trandolapril (2 to 4 mg/day). RESULTS The groups were similar prior to treatment (p<0.05), and both drugs reduced blood pressure at rest (p<0.001). During treatment, trandolapril caused a greater increase in functional capacity (+31%) than captopril (+17%; p=0.01) did, and provided better blood pressure control during exercise, observed as a reduction in the variation of systolic blood pressure/MET (trandolapril: 10.7 1.9 mmHg/U vs 7.4 1.2 mmHg/U, p=0.02; captopril: 9.1 1.4 mmHg/U vs 11.4 2.5 mmHg/U, p=0.35), a reduction in peak diastolic blood pressure (trandolapril: 116.8 3.1 mmHg vs 108.1 2.5 mmHg, p=0.003; captopril: 118.2 3.1 mmHg vs 115.8 3.3 mmHg, p=0.35), and a reduction in the interruption of the tests due to excessive elevation in blood pressure (trandolapril: 50% vs 15%, p=0.009; captopril: 50% vs 45%, p=0.32). CONCLUSION Monotherapy with trandolapril is more effective than that with captopril to control blood pressure during exercise in hypertensive patients.

Detection of Autonomic Dysfunction in Hemodialysis Patients Using the Exercise Treadmill Test: The Role of the Chronotropic Index, Heart Rate Recovery, and R-R Variability

Autonomic dysfunction is highly prevalent in hemodialysis patients and has been implicated in their increased risk of cardiovascular mortality. Objective To evaluate the ability of different parameters of exercise treadmill test to detect autonomic dysfunction in hemodialysis patients. Methods Cross-sectional study involving hemodialysis patients and a control group. Clinical examination, blood sampling, echocardiogram, 24-hour Holter, and exercise treadmill test were performed. A ramp treadmill protocol symptom-limited with active recovery was employed. Results Forty-one hemodialysis patients and 41 controls concluded the study. There was significant difference between hemodialysis patients and controls in autonomic function parameters in 24h-Holter and exercise treadmill test. Probability of having autonomic dysfunction in hemodialysis patients compared to controls was 29.7 at the exercise treadmill test and 13.0 in the 24-hour Holter. Chronotropic index, heart rate recovery at the 1st min, and SDNN at exercise were used to develop an autonomic dysfunction score to grade autonomic dysfunction, in which, 83% of hemodialysis patients reached a scoring ≥2 in contrast to 20% of controls. Hemodialysis was independently associated with either altered chronotropic index or autonomic dysfunction scoring ≥2 in every tested model (OR=50.1, P=0.003; and OR=270.9, P=0.002, respectively, model 5). Conclusion The exercise treadmill test was feasible and useful to diagnose of the autonomic dysfunction in hemodialysis patients. Chronotropic index and autonomic dysfunction scoring ≥2 were the most effective parameters to differentiate between hemodialysis patients and controls suggesting that these variables portrays the best ability to detect autonomic dysfunction in this setting.

Interleucina 1β correlaciona-se com MIBG e parâmetros do exercício, na insuficiência cardíaca?

BACKGROUND Interleukin 1β (IL 1β) levels are associated with prognosis in heart failure. The cardiac adrenergic activity as assessed by metaiodobenzylguanidine (I123 MIBG) scintigraphy along with exercise parameters are important predictors of prognosis. The relationship between these variables is not fully established. OBJECTIVE To evaluate the association of IL 1β levels with exercise and I123 MIBG parameters. METHODS Cross-sectional observational study evaluating 25 consecutive patients with heart failure and ejection fraction lower than 45% by means of: determination of IL 1β levels; I123 MIBG parameters [early and late heart/mediastinum ratio, washout rate (WO)]; and treadmill exercise test using the ramp protocol. RESULTS The patients were divided into two groups according to their IL 1β levels (normal vs. increased). The group with increased levels showed lower double-product reserve (DPR); lower functional capacity (FC); slower heart rate recovery at the first (HRR 1º) and second minute (HRR 2º); and higher WO. In the univariate analysis, all variables correlated with IL 1β; DPR: r = 0.203, p = 0.024; FC: r = 0.181, p = 0.034; HRR 1º: r = 0.182, p = 0.034; HRR 2º: r = 0.204, p = 0.023; WO: r = 0.263, p = 0.009. In the multivariate analysis, only WO maintained a significant correlation (r² = 0.263, p = 0.009). CONCLUSION Adrenergic overactivity was the main determinant of IL 1β levels, thus demonstrating that an excessive sympathetic activity influences the systemic inflammatory response. Exercise test variables were not able to identify patients with high IL 1β levels.