Renal denervation lowers BP regardless of antihypertensive regimen, polypharmacy burden
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Key takeaways:
- BP reduction conferred by renal denervation was sustained regardless of the number of prescribed BP-lowering drugs.
- Patients on four or more drug classes at 36 months had an increased rate of heart attack.
Renal denervation lowered blood pressure out to 36 months, regardless of baseline antihypertensive class combinations and polypharmacy burden, according to an analysis of the Global SYMPLICITY Registry DEFINE.
At 36 months, 31% of participants decreased the number of antihypertensive drug classes, according to the study published in Hypertension.
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Additionally, adverse event rates were similar between groups based on the number and type of antihypertensive drug classes patients were taking, apart from patients taking four or more different drug classes, who experienced higher rates of MI at both 24 and 36 months.
“Multiple trials have demonstrated that renal denervation is a safe, effective and durable approach to reduce BP in patients with uncontrolled hypertension in both the absence and presence of antihypertensive medications,” Felix Mahfoud, MD, cardiologist at Saarland University Medical Center in Homberg, Germany, and colleagues wrote. “Recently, we reported that BP reduction after radiofrequency renal denervation was similar for patients with varying high-risk comorbidities. This analysis aimed to determine whether the number or type of prescribed antihypertensive medications was associated with increased long-term BP reductions and cardiovascular outcomes following radiofrequency renal denervation in real-world patients with uncontrolled hypertension.”
The Global SYMPLICITY Registry DEFINE
The ongoing Global SYMPLICITY Registry DEFINE is a real-world all-comers study to evaluate the efficacy and safety of radiofrequency renal denervation, and includes patients prescribed multiple antihypertensive medications for treatment of resistant hypertension.
As Healio previously reported, radiofrequency renal denervation (Symplicity Spyral or Symplicity Flex, Medtronic) contributed to sustained 3-year reductions of BP without increasing polypharmacy.
For the present study, Mahfoud and colleagues evaluated whether the number or type of antihypertensive medications impact long-term BP reductions and CV outcomes after radiofrequency renal denervation.
As of March, 3,332 patients were enrolled into Global SYMPLICITY Registry DEFINE, of whom 2,746 had data on both the number and type of antihypertensive medications as well as sequential BP data available (mean age, 61 years; 42% women).
Mean baseline office systolic BP was 166 mm Hg and 24-hour systolic BP was 154 mm Hg.
Change in BP and polypharmacy after renal denervation
The researchers reported that 18% of participants were prescribed zero to three classes of antihypertensive drugs and 82% were prescribed four or more.
The most common classes were diuretics (78.9%), followed by calcium channel blockers (78.2%), beta-blockers (77.8%), angiotensin receptor blockers (63.9%), centrally acting sympatholytics (37.9%), alpha-adrenergic blockers (36.7%), ACE inhibitors (34.6%), aldosterone antagonists (27.9%), direct-acting vasodilators (13.8%) and direct renin inhibitors (5.3%).
At 36 months, office systolic BP decreased by approximately 19 mm Hg among patients prescribed zero to three classes of antihypertensive drugs and 16.2 mm Hg among those prescribed four or more (P for both < .0001).
Additionally, 24-hour systolic BP decreased by approximately 10.7 mm Hg among patients prescribed zero to three classes of antihypertensive drugs and 8.9 mm Hg among those prescribed four or more (P for both < .0001).
Mahfoud and colleagues observed that 36-month reductions in BP were similar across antihypertension drug class subgroups and combinations.
Of note, 8.7% of participants had been prescribed both an ACE inhibitor and an angiotensin receptor blocker in the same regimen, which is not guideline-recommended, according to the study. Average 24-hour systolic BP did not significantly change in this subgroup of patients.
The number of prescribed antihypertensive drug classes decreased from approximately 4.6 to 4.3 at 36 months (P < .0001).
Overall, 31% of participants decreased the number of antihypertensive drug classes while 47% had no change and 22% increased the number of classes.
The researchers observed an inverse association between number of baseline antihypertensive drug classes and change in prescribed classes at 36 months (P < .001).
The composite rate of adverse CV events at 36 months was 11.1%. The rate of MI at 24 months was higher among patients taking four or more classes of antihypertensive medications compared with those on fewer classes (1.8% vs. 0.3%; P = .023) and the gap continued to widen through 36 months (2.8% vs. 0.3%; P = .009).
There were no significant differences between the groups for any other adverse events, including stroke, new-onset HF hospitalization, CV death and all-cause death.
“This Global SYMPLICITY Registry DEFINE study reflects on the real-world challenge of patients with multiple comorbidities, uncontrolled hypertension despite taking average five different classes of antihypertensive medications,” the researchers wrote. “High burden of antihypertensive medications is associated with nonadherence. Radiofrequency renal denervation may offer an effective, adjunctive hypertension therapy, while reducing the burden of long-term antihypertensive medications.”
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