Jean Marco's open questions on ESH consensus paper

Questions and comments addressed to the RHC Steering board and open to the whole community, concerning the ESH the consensus paper:

ESH Position Paper: Renal denervation – an interventional therapy of resistant hypertension – Schmieder, et al. - Journal of Hypertension 837-841

 

Page 839:  ELIGIBILITY CRITERIA FOR RENAL DENERVATION

“Based on current evidence from available clinical studies hypertensive patients are eligible for RDN if they have (severe) treatment-resistant hypertension defined by office SBP at least 160 systolic ( 150mmHg in type 2 diabetes) despite treatment with at least three antihypertensive drugs of different types in adequate doses, including one diuretic, which is equivalent to stage 2 or 3 hypertension.”

Patients should have been evaluated by a hypertension specialist in very experienced hospital centres (e.g. ESH Centres of Excellence).

Page 840:  PERSPECTIVE

Renal denervation may have beneficial effects in other conditions characterised by excessive sympathetic activation, and is currently under assessment in several clinical investigations. Until these results are available, we should only use RDN in patients with treatment-resistant hypertension who fulfil the above criteria and after careful selection in hypertension excellence centres. RDN should be performed in experienced hypertension excellence centres by well-trained interventionalists throughout Europe.”

My questions in relation to the above is:

The definition of resistant hypertension in this paper is different to that of the French Consensus Paper: Can you comment on this?

What ‘evidence’ is there to support that “patients should have been evaluated by a hypertension specialist in very experienced hospital centres (e.g. ESH Centres of Excellence) or that RDN should be performed in very experienced hypertension excellence centres”?

My comment is:

In a centre not ‘accredited ‘ as an  “ESH Centre of Excellence” with cardiologists and/or endocrinologists and/or nephrologists, (e.g. Clinique Pasteur, Toulouse, France), adequately educated in the management of hypertension and with a broad experience of interventional procedures as well as an established ‘regional network’ of  general practitioners or general cardiologists and hospitals in the area: what would be your reasons for not selecting patients and performing RDN procedures?

What are the criteria to define a centre as “ a Hypertension Centre of Excellence”?

 

Comments

Tue, 2013-02-12 18:56
Sverre Kjeldsen

Making a ”consensus paper” is always a way of compromising. The definition here of treatment-resistant hypertension

“Based on current evidence from available clinical studies, hypertensive patients are eligible for RDN if they
have (severe) treatment-resistant hypertension defined by office SBP at least 160 systolic (≥150mmHg in type 2
diabetes) despite treatment with at least three antihypertensive drugs of different types in adequate doses,
including one diuretic, which is equivalent to stage 2 or 3 hypertension.”

is insufficient in as much as the ESH/ESC definition also includes "excluding spurious hypertension" which means including qualifying (elevated) ambulatory BP. The use of spironolactone is not required as this is not evidence based medicine (there is no support for spironlactone from RCTs in hypertension).

Tue, 2013-02-12 20:04
abuhusamuser@twitter

we performed 6 cases till now . 3 of them had initial pressures of > 220/135. Now we are in the range of 200-210/ 120-125. all patients are on > 10 medications maximum dosages. all were screened for all possible endocrine and nephrology causes and were negative. We are really stucked with these patients and we really don't know what to do. we wonder if we can re-attempt RDN .please help.

Wed, 2013-02-13 03:15
Anonymous

In our center we have a specialized 50-bed hypertension unit that deals each year with more than 1000 cases of hard-to-control hypertension referred as treatment failures from primary and secondary care clinics. Yet with current criteria only 20-30 patients of this group are eligible for RDN meaning that today RDN eligible hypertension is so rare case that RDN program may only be rational in a few large centers. In my opinion until the indication for RDN is substantially widened, e.g. to all cases of severe hypertension it is not worthy of serious discussion.

Wed, 2013-02-13 12:21
Marco jean

Following the comment raised by abuhusamuser@twitter:
It will be more than positive for all of us that you accept to share all the details of your patients( incduding pre and during procedure information) with the community
if you accpet, please send us this information and we will load in the web
thank you