NON PHARMACOLOGICAL AND CATHETER BASED THERAPY OF DIFFICULT TO TREAT (D2T) HYPERTENSION


Santhosh K. Koshy, M.D., UT Health Sciences Center, Memphis, TN, USA

Resistant or difficult to treat hypertension is not uncommon and is a nightmare for both primary care physicians and specialists. It is defined as an uncontrolled hypertension with blood pressure consistently above 140/90mmHg despite adequate regimen with four or more antihypertensives, preferably with one that includes a diuretic. The short and long-term outcomes are worse in patients with resistant hypertension compared to those patients whose hypertension is controlled with lifestyle modification and medications. Pseudo resistance has to be ruled out in all cases of resistant hypertension before considering additional treatment strategies for this patient population. Catheter based renal denervation had shown promising results in their pivotal trials in Europe and Asia, and has been approved as a treatment strategy for patients with resistant hypertension in Europe. Modulation of neuro-hormonal control of blood pressure through denervation of sympathetic nerve fibers around the renal arteries has been shown to successfully reduce the blood pressure with minimal side effects in preclinical animal and human trials. However, the recent Simplicity HTN 3 trial, a more rigorously controlled study that enrolled patients in US, failed to show similar beneficial results. Baroreceptor Activation Therapy is another promising strategy that is being studied and has promising preliminary results. This mode of therapy has not gained rapid enthusiasm and acceptance due to more invasive nature of this surgical procedure, especially in the limelight of the promising initial results with renal denervation therapy. This therapy has not been tested in a large randomized trial, hence the external validity of beneficial preliminary results is still questionable. It is important to recognize the importance of lifestyle modification and adequate work up for identifying a secondary cause performed before selecting patients to advanced treatment modalities for treatment of resistant hypertension.