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Translesional pressure gradients predictive of arterial hypertension improvement after renal stenting
Mangiacapra F. Circ Cardiovasc Interv. 2010;doi:10.1161/CIRCINTERVENTIONS.110.957704.
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A dopamine-induced mean pressure gradient of at least 20 mm Hg was significantly associated with arterial hypertension improvement after renal stenting, leading researchers to conclude that the measurement may be useful for the appropriate selection of patients with arterial hypertension.
“The clinical usefulness of renal artery stenting in improving BP control in patients with hypertension and a renal artery stenosis has been questioned by recent studies,” the researchers wrote. “We evaluated whether translesional pressure gradients using a 0.014-inch pressure guide wire, both at rest and during hyperemia, could help in selecting patients who will benefit from renal artery stenting.”
The study featured 53 consecutive hypertensive patients with unilateral renal artery stenosis who were scheduled for intervention.
At the 3-month follow-up, mean reductions in systolic BP were –20 ± 30 mm Hg and diastolic BP were –2 ± 12 mm Hg. Multivariate analysis revealed dopamine-induced mean gradient as the only independent predictor of the variations of systolic (P<.001) and diastolic (P=.009) BP.
According to researchers, the optimal cutoff for identification of “responders” was a dopamine-induced mean gradient of more than 20 mm Hg.
“In our study, more than half of the patients selected for renal stenting on the basis of a subjective angiographic evaluation had a hyperemic translesional gradient below the threshold we found to be predictive of hypertension improvement,” they said. “Thus, a dopamine-induced mean pressure gradient of 20 mm Hg is highly predictive of arterial hypertension improvement after renal stenting, and therefore this measurement is useful for appropriate selection of patients with arterial hypertension.”
In an accompanying editorial, Ryan D. Madder, MD, and Robert D. Safian, MD, of the department of cardiovascular medicine at William Beaumont Hospital in Royal Oak, Mich., said the unreliability of invasive angiography to identify hemodynamically significant renal artery stenosis was the most important observation of the study because stenosis severity correlated poorly with baseline and dopamine-induced mean pressure gradients. Madder and Safian further propose other readily available methods to assess the physiological effect of renal artery stenosis.
“Nuclear scintigraphy and direct glomerular filtration rate measurements are reliable for measuring single-kidney blood flow and total renal blood flow and may obviate the need for invasive assessment,” they said, adding that renal ischemia can be evaluated invasively with fractional flow reserve or translesional pressure gradients.
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