Diagnosis of Hypertension and
Role of Ambulatory Monitoring
Dr Vikas Kapil
SpR and Hon Lecturer
Centre for Clinical Pharmacology
NIHR Cardiovascular Biomedical Research Unit
William Harvey Research Institute
Barts Health NHS Trust & QMUL
CEG Chronic Disease Management Training Day
20th June 2013
Disclosures
• Committee membership:
• British Hypertension Society education sub-committee
• Royal College of Physicians joint specialty committee
• Honoraria:
• nil
• Funding:
• British Heart Foundation
Several slides in this presentation have been gifted by Dr M Lobo
Aims
• Stage 1 hypertension and treatment categories
• we'd hope to have a one sheet flow chart clearly showing the criteria
• Interpretation of common issues arising from 24hr ABPM
reports
• Management of resistant hypertension
• how is ABPM helpful
• what 4th line agents etc
BP MEASUREMENT: KEY TECHNIQUES
 BP (mm Hg) if not done
Rest ≥ 5 min, quiet
Seated, back supported
↑ 12/6
↑ 6/8
Cuff at midsternal level
↑ ↓ 2/inch
Correct cuff size (undercuffing)
↑ 6-18/4-13
Bladder center over artery
Deflate 2 mm Hg/sec
↑ 3-5/2-3
↑ SBP/↓ DBP
If initial BP > goal BP:
1st reading higher
“Alerting response”
3 readings, 1 min apart
Discard 1st, average last 2
Hypertension 2005; 45:142
J Hypertens 2005; 23:697
Can J Card 2007; 23:529
Case 1
• 44-year-old man attended for a new patient check. As part of
this, his BP was measured in his left arm at 143/91 mmHg. His
BP in his right arm was 141/93 mmHg.
•
•
•
•
Sequential BPs in his non-dominant arm were:
145/95 mmHg
147/93 mmHg
145/94 mmHg
• What is his clinic BP?
• You suspect that this man may have hypertension. What
should you do next?
Diagnosis (3)
1.2.2
Record the lower of the last two measurements as the
clinic blood pressure
1.2.3
If the clinic blood pressure is 140/90 mmHg or higher,
offer ambulatory blood pressure monitoring (ABPM)
to confirm the diagnosis of hypertension.
Case 1
• 44-year-old man attended for a new patient check. Clinic BP
was 145/94 mmHg. ABP monitoring was performed.
• 24h mean BP:
• 129/74 mmHg
• Daytime mean BP:
• 137/87 mmHg
• Nighttime mean BP:
• 109/68 mmHg
• Does this man have hypertension?
• What stage of hypertension does this man have?
• 1
• 2
• severe
Definitions
Stage 1 hypertension:
• Clinic blood pressure (BP) is 140/90 mmHg or
higher and
• ABPM or HBPM average is 135/85 mmHg or higher.
Stage 2 hypertension:
• Clinic BP 160/100 mmHg is or higher and
• ABPM or HBPM daytime average is 150/95 mmHg
or higher.
Severe hypertension:
• Clinic systolic BP is 180 mmHg or higher or
• Clinic diastolic BP is 110 mmHg or higher.
Daytime 137/87 mmHg
31
40
13
129
74
92
137
87
114
109
68
82
55
50
41
22
Dipping status
normal/extreme
Validity of measurement
13 daytime readings
22% successful
19
22
Diagnosis (4)
When using the following to confirm diagnosis, ensure:
ABPM:
–at least two measurements per hour during the person’s
usual waking hours, average of at least 14 measurements
to confirm diagnosis
Case 1
• 44-year-old man attended for a new patient check. Clinic BP
was 145/94 mmHg. He was unable to perform adequate ABP
monitoring due to disturbed sleep.
• What would you do next?
• Daytime ABP only
Case 1
• 44-year-old man attended for a new patient check. Clinic BP
was 145/94 mmHg. He was unable to perform adequate ABP
monitoring due to interfering with work
• What would you do next?
• Non-work day ABP only
– (but would this reflect real life?)
Case 1
• 44-year-old man attended for a new patient check. Clinic BP
was 145/94 mmHg. He was unable to perform adequate ABP
monitoring due to discomfort.
• What would you do next?
• Home BP monitoring
Diagnosis (5)
When using the following to confirm diagnosis, ensure:
HBPM:
–two consecutive seated measurements, at least 1 minute
apart
–blood pressure is recorded twice a day for at least 4 days
and preferably for a week
–measurements on the first day are discarded –
average value of all remaining is used.
Case 1
• 44-year-old man attended for a new patient check. Clinic BP
was 145/94 mmHg. He was unable to perform adequate ABP
monitoring due to discomfort. He was asked to perform home
BP readings over a 1 week period.
• What is his home BP?
Case 1
Home BP = 157/87 mmHg
Case 1
• 44-year-old man attended for a new patient check. Clinic BP
was 145/94 mmHg. He was unable to perform adequate ABP
monitoring due to <14 readings during awake hours.
• Baseline ECG
Case 1
• 44-year-old man attended for a new patient check. Clinic BP
was 145/94 mmHg. He was unable to perform adequate ABP
monitoring due to <14 readings during awake hours.
• What would you do next?
Diagnosis (6)
Because automated devices may not measure blood
pressure accurately if there is pulse irregularity (for
example, due to atrial fibrillation), palpate the radial or
brachial pulse before measuring blood pressure.
If pulse irregularity is present, measure blood pressure
manually using direct auscultation over the brachial
artery.
Case 2
• 54-year-old woman attended for a BP check as she recently
had a first degree relative with an ischaemic stroke (78-yearold). Clinic BP was 181/112 mmHg. There was no significant
inter-arm difference. She was clinically in sinus rhythm.
• What would you do next?
Diagnosis (7)
Refer the person to specialist care the same day if they
have:
• accelerated hypertension, that is, blood pressure
usually higher than 180/110 mmHg with
• signs of papilloedema and/or retinal haemorrhage
Treatment (1)
Some people may have severe hypertension at
screening with CBPM (i.e. systolic BP ≥180mmHg and/or
diastolic BP ≥110mmHg) and in such cases, clinicians
should not delay treatment whilst awaiting the results of
ABPM – in these cases, the subsequent ABPM will serve
to confirm the diagnosis and severity of the hypertension.
From a starting BP of 180/110 mmHg, 3 BP medications
at half-maximal dose would give a mean BP reduction of
27/16 mmHg which would not bring BP to target, hence
immediate treatment.
Case 3
• 50-year-old woman attended for a BP check as she recently
been refused admission at her local gymnasium due to
elevated BP. Clinic BP was 165/94 mmHg. There was no
significant inter-arm difference. She was clinically in sinus
rhythm.
• What would you do next?
Daytime 151/95 mmHg
142
7
23
107
151
95
112
53
53
Validity
58 daytime readings
100% successful
Profile trend view
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Bar trend view
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Raw data view
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Raw data view
D/N change
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© 2011 dabl® Limited
Control view
© 2011 dabl® Limited
Case 3
• 50-year-old woman attended for a BP check as she recently
been refused admission at her local gymnasium due to
elevated BP. Clinic BP was 165/104 mmHg. There was no
significant inter-arm difference. She was clinically in sinus
rhythm.
• ABPM daytime mean = 151/95 mmHg
• What would you do next?
CBPM ≥160/100 mmHg
& ABPM/HBPM
≥ 150/95 mmHg
Stage 2 hypertension
Care pathway
Offer antihypertensive
drug treatment
Offer lifestyle interventions
Offer patient education and interventions to support adherence to treatment
Offer annual review of care to monitor blood pressure, provide support and
discuss lifestyle, symptoms and medication
Case 4
• 50-year-old woman attended for a BP check as she recently
been refused admission at her local gymnasium due to
elevated BP. Clinic BP was 165/104 mmHg. There was no
significant inter-arm difference. She was clinically in sinus
rhythm.
• What would you do next?
Daytime 137/87 mmHg
129
74
92
137
87
114
109
68
82
55
50
41
Dipping status
normal/extreme
Validity of measurement
58 daytime readings
100% successful
19
22
Case 4
• 50-year-old woman attended for a BP check as she recently
been refused admission at her local gymnasium due to
elevated BP. Clinic BP was 165/94 mmHg. There was no
significant inter-arm difference. She was clinically in sinus
rhythm.
• She is confirmed to have stage 1 hypertension
• What would you do next?
CBPM ≥140/90 mmHg
& ABPM/HBPM
≥ 135/85 mmHg
Care pathway
Stage 1 hypertension
If target organ damage present or
10-year cardiovascular risk > 20%
Offer antihypertensive
drug treatment
Offer lifestyle interventions
Offer patient education and interventions to support adherence to treatment
Offer annual review of care to monitor blood pressure, provide support and
discuss lifestyle, symptoms and medication
Assessing cardiovascular risk
and target organ damage:
updated recommendations
Use a formal estimation of cardiovascular risk to discuss
prognosis and healthcare options with people with
hypertension.
Assessing cardiovascular risk
and target organ damage:
updated recommendations
Use a formal estimation of cardiovascular risk to discuss
prognosis and healthcare options with people with
hypertension.
For all people with hypertension offer to:
–test urine for presence of protein
–take blood to measure glucose, electrolytes, creatinine,
estimated glomerular filtration rate and cholesterol
–examine fundi for hypertensive retinopathy
–arrange a 12-lead ECG.
CBPM ≥140/90 mmHg
& ABPM/HBPM
≥ 135/85 mmHg
Care pathway
Stage 1 hypertension
If target organ damage present or
10-year cardiovascular risk > 20%
Offer antihypertensive
drug treatment
Offer lifestyle interventions
Offer patient education and interventions to support adherence to treatment
Offer annual review of care to monitor blood pressure, provide support and
discuss lifestyle, symptoms and medication
Lifestyle management (1)
Lifestyle advice should be offered initially and then periodically to people
undergoing assessment or treatment for hypertension.
Ascertain people’s diet and exercise patterns because a healthy diet and
regular exercise can reduce blood pressure. Offer appropriate guidance and
written or audiovisual materials to promote lifestyle changes.
Relaxation therapies can reduce blood pressure and people may wish to
pursue these as part of their treatment. However, routine provision by
primary care teams is not currently recommended.
Ascertain people’s alcohol consumption and encourage a reduced intake if
they drink excessively, because this can reduce blood pressure and has
broader health benefits.
Discourage excessive consumption of coffee and other caffeine-rich
products.
Lifestyle management (2)
Encourage people to keep their dietary sodium intake low, either by
reducing or substituting sodium salt, as this can reduce blood pressure.
Do not offer calcium, magnesium or potassium supplements as a method for
reducing blood pressure.
The best current evidence does not show that combinations of potassium,
magnesium and calcium supplements reduce blood pressure.
Offer advice and help to smokers to stop smoking.
A common aspect of studies for motivating lifestyle change is the use of
group working. Inform people about local initiatives by, for example,
healthcare teams or patient organisations that provide support and promote
healthy lifestyle change.
Additional recommendations
Lifestyle interventions
Offer guidance and advice about:
– diet (including sodium and caffeine intake) and exercise
– alcohol consumption
– smoking.
Patient education and adherence
Provide:
– information about benefits of drugs and side effects
– details of patient organisations
– an annual review of care.
CBPM ≥140/90 mmHg
& ABPM/HBPM
≥ 135/85 mmHg
CBPM ≥160/100 mmHg
& ABPM/HBPM
≥ 150/95 mmHg
Stage 1 hypertension
Stage 2 hypertension
CBPM ≥180/110 mmHg
Severepathway
hypertension
Care
If target organ damage present or
10-year cardiovascular risk > 20%
If younger than 40 years
Offer antihypertensive
drug treatment
Consider specialist
referral
Offer lifestyle interventions
Offer patient education and interventions to support adherence to treatment
Offer annual review of care to monitor blood pressure, provide support and
discuss lifestyle, symptoms and medication
Case 5
• 60-year-old woman was diagnosed with stage 1 hypertension
by ABP monitoring. She was found to have LVH on ECG and
proteinuria with preserved renal function on further
investigation. She instigated lifestyle measures for 6 months
but her clinic BP was similar to previous. She was started on
losartan and titrated up to a dose of 50mg once-daily.
• On review after 3 months on this dose, her clinic BP (lowest of
2 readings at single visit) was 143/92 mmHg.
• What would you do next?
Monitoring drug treatment (1)
Use clinic blood pressure measurements to monitor
response to treatment. Aim for target blood pressure
below:
• 140/90 mmHg in people aged under 80
• 150/90 mmHg in people aged 80 and over
Physician inertia
• Failure to increase drugs despite established
hypertension falling within remit of guidelines
– responsible ~30% patients not achieving target BP
Egan BM et al., Circ 2011; 124:1046-1058
Monitoring drug treatment (2)
For people identified as having a ‘white-coat effect’
consider ABPM or HBPM as an adjunct to clinic
blood pressure measurements to monitor response
to treatment.
Aim for ABPM/HBPM target average of:
• below 135/85 mmHg in people aged under 80
• below 145/85 mmHg in people aged 80 and over.
(Offer people aged 80 and over the same antihypertensive drug
treatment as people aged over 55, taking into account any
comorbidities).
White-coat effect: a discrepancy of more than
20/10 mmHg between clinic and average
daytime ABPM or average HBPM blood
pressure measurements at the time of
diagnosis.
White coat
hypertension
Initial ABPM reading 175/95 mm Hg
Daytime Mean 133/71 mm Hg
Nocturnal Mean 119/59 mm Hg
********************
White coat effect
Initial ABPM reading 187/104 mm Hg
Daytime Mean 149/87 mm Hg
Nocturnal Mean 121/67 mm Hg
www.dabl.ie
Aged under
55 years
Aged over 55 years
or black person of
African or Caribbean
family origin of any
age
C
A
Summary of
antihypertensive
drug treatment
Step 1
A+C
Step 2
A+C+D
Step 3
Resistant hypertension
Step 4
A + C + D + consider further
diuretic, or alpha- or
beta-blocker
Consider seeking expert advice
Key
A – ACE inhibitor or low-cost
angiotensin II receptor
blocker (ARB)1
C – Calcium-channel
blocker (CCB)
D – Thiazide-like diuretic
Step 4 treatment:
Resistant hypertension
Regard clinic blood pressure that remains higher
than 140/90 mmHg with the optimal or best
tolerated doses of an ACE inhibitor or
angiotensin-II receptor blocker plus a calcium
channel blocker plus a diuretic as resistant
hypertension and consider adding a fourth
antihypertensive drug and/or seeking expert
advice. [new 2011].
Step 4 treatment:
Resistant hypertension
For treatment of resistant hypertension at
step 4, consider further diuretic therapy with
low-dose spironolactone (25 mg once daily) if
blood potassium levels are lower than 4.5
mmol/l. Caution is required in patients with
impaired renal function who are at higher risk
of developing hyperkalaemia. If blood
potassium levels are higher than 4.5 mmol/l,
consider therapy with a higher-dose thiazidelike diuretic treatment. [new 2011]
Spironolactone as 4th line drug
Chapman N et al., Hypertension 2007;49:839-845
Predictors of resistant hypertension
Calhoun DA et al., Hypertension 2008;51:1403-1419
Case 1: RW
• Medical History
– Hypertension 1999
• Initially treated with little
difficulty
• Extreme elevation of
BP since 2005
– Secondary causes
ruled out by another
tertiary centre
• Medications:
–
–
–
–
–
–
Atenolol 50mg od
Candesartan 16mg bd
Ramipril 10mg od
Indapamide MR 1.5mg od
Amlodipine 10mg od
Atorvastatin 10mg od
Case 1: 24h ambulatory BP monitoring
Daytime mean = 178/114 mmHg, Nighttime mean = 178/114
Case 1: observed tablet taking
Amlodipine 10mg
Candesartan 16mg od
Furosemide 80mg
Presented to ED with dizziness
Drugs that affect BP control
Faselis C et al., Int J Hypertens 2011;2011:236239
Inappropriate medication/combinations
• Failure to prescribe within remit of estabished
guidelines
Hanselin MR et al., Hypertension 2011;58:1008-1013
Case 2: 24h ambulatory BP monitoring
Daytime mean = 174/94 mmHg, Nighttime mean = 179/83 mmHg
Case 2: PW
• Investigations
– CT abdomen
• NAD
– MRI brainstem
• Medications:
– Amlodipine 10mg od
– Furosemide 80mg bd
– Perindopril 8mg od
• NAD
– Catecholamines
• NAD
– Urinary sodium
• 298mmol/24h
– Strict salt diet
• Aim <50mmol/24h
• Repeated in 4 weeks
• Achieved 68mmol/24h
Home blood pressure
Monitoring shows mean
149/89 mmHg on 3 meds
Planned to uptitrate
diuretics as eGFR allows ±
alpha-blocker
Secondary causes
• All causes of secondary hypertension are
major risk factors for resistant hypertension
•
•
•
•
•
Obstructive sleep apnoea
Primary hyperaldosteronism
Renal vascular disease
Renal parenchymal disease
Other endocrine disorders
NICE CG127. guidance.nice.org.uk/cg127
Obstructive sleep apnoea
"Sleep!" said the old gentleman, 'he's always
asleep. Goes on errands fast asleep, and snores
as he waits at table."
"How very odd!" said Mr.
Pickwick.
"Ah! odd indeed," returned the old
gentleman; "I'm proud of that boy--wouldn't part
with him on any account--he's a natural curiosity!"
The Posthumous Papers of the Pickwick Club. Charles Dickens.
The ABPM shows severe 24-hour systolic & diastolic hypertension
(210/134 mmHg daytime and 205/130 mmHg night-time).
© 2011 dabl® Limited
www.dabl.ie
Arterial stiffness
• In the middle-aged and elderly, vascular
stiffening in the brachial artery can mean that
higher cuff inflation pressures are needed to
occlude the brachial artery
– overestimates brachial artery BP.
• Clues to suspect arterial stiffness
–
–
–
–
Marked hypertension without target organ damage
Symptomatic hypotension + hypertensive range BP
Severe, isolated systolic hypertension
Osler’s manoeuvre.
Daytime Mean 181/117 mm Hg
Nocturnal Mean 111/68 mm Hg
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Increased variability
Baroreflex failure
Neurovascular compression
© 2011 dabl® Limited
ABPM
Mean BP = 191/109 mmHg
Vascular loop
CN X /XI
Arachnoid
Dissection of loop from IX and X
Teflon™ interposition
Intra-operative blood pressure
Removal of vascular loop from brainstem
Mrs JJ, 53-yr-old Caucasian
typist
2006
2007
• headaches, dizziness, • admitted for
nausea & vomiting
observation to local
ski-ing twice
DGH for headaches
– SBP≈190mmHg
• SBP≈150-160mmHg
– px Lisinopril 10mg od
– px diazepam
• diagnosed with
cluster migraine
headaches by
neurologist
Mrs JJ, 53-yr-old Caucasian
typist
2008
2009
• referred to private
• local chest physician
cardiologist for ‘unstable – Ñ CT Thorax
BP and cough’
– 6/52 PPI for GORD cough
– Ñ TTE (no LVH, PFO, • NHS cardiologist
ASD)
– 2x postural collapses
– Ñ ETT
– no antecedent warnings or
– Ñ Holter (SR 58-123bpm)
epileptiform features
– ACE-I changed to β-B
– home SBP: 87-195mmHg
– SBP≈160mmHg
– referred to Barts HTN
– referral to respiratory
service
Mrs JJ, 53-yr-old Caucasian
typist
June 2009
• no symptoms of
phaeochromocytoma
or OSA
• adequate dietary
restrictions
• 100% concordance
• minimal alcohol, nonsmoker
• mother: hypertensive,
IHD in 80’s
o/e
• poor peripheral
pulses
• no vascular delays or
bruits
• no proteinuria
• no hypertensive
retinopathy
• BP≈200/90mmHg
(anxious)
24-hr ambulatory blood pressure monitoring
Daytime mean = 149/91mmHg,
atenolol 50mg od
Nighttime
; indapamde
mean1.5mg
= 148/87mmHg
od; telmisartan 20mg bd
Mrs JJ, 53-yr-old Caucasian
typist
July 2009
• home BP:
Ix
• eGFR (MDRD) 73ml/min
– 80/40-220/120mmHg• K+ 3.9mmol/L
• coughing / stress
• TC / HDL ratio 4.6
– raise BP
• TSH 1.04mU/L
• eating / hot baths
• PRA (upright) 3.0pmol/ml/h
– lower BP
• Aldost (upright) 324pmol/L
Mrs JJ, 53-yr-old Caucasian
typist
July 2009
• home BP:
– 80/40-220/120mmHg
• coughing / stress
– raise BP
• eating / hot baths
– lower BP
Ix
• urinary metanephrines
– negative
• plasma catecholamines
– negative
• CTA aorta / renal
– Ñ arterial tree
• MRA/I brain
– no abnormalities noted
Intra-arterial BP monitoring over 24h
Ward round
Cough
Husband on
ward
Cough
Eating
↓
←Sleeping→
Daytime mean = 115/65mmHg, Nighttime mean = 80/48mmHg
Mrs JJ, 53-yr-old Caucasian
typist
Aug 2009
• px clonidine TTS
patch (0.1mg/daily) +
diazepam 5mg bd
• referral to Prof
Mathias (NHNN) for
evaluation of afferent
baroreflex failure
• intense headaches
during orgasm
• intermittent diarrhoea
& hot flushes for 1
year
• myotonic right pupil
• no deep tendon
reflexes
• hypermobile joints
Mrs JJ, 53-yr-old Caucasian
typist
Dec 2009
• impaired themoregulation
• admitted to NHNN for and sweating
autonomic Ix
• prolonged postural
response to tilt testing, with
no tachycardia
• post-prandial hypotension
• exaggerated pressor &
exercise BP response
Mrs JJ, 53-yr-old Caucasian
typist
• ΔΔ:
– Non-ocular
manifestations of
Holmes-Adie
syndrome with afferent
baroreflex failure and
elements of Ross
syndrome (impaired
sudomotor activity)
– Joint hypermobility
syndrome (ED III)
– advice to use centrally
acting agents such as
clonidine and postural
/ lifestyle manoeuvres
to counteract the
drops / surges
Mrs JJ, 53-yr-old Caucasian
typist
Feb 2013
• complaining of
squeezing central CP
– CMR: unable to
perform adenosine
stress component due
to resting HR>120 and
BP>220 systolic
– LVH 14mm
Mrs JJ, 53-yr-old Caucasian
typist
Feb 2013
• complaining of
squeezing central CP
– CMR: unable to
perform adenosine
stress component due
to resting HR>120 and
BP>220 systolic
– LVH 14mm
• intolerant of:
– benzodiazepines
– higher doses of clonidine /
moxondine
– GTN tablets/patches
– metoprolol 12.5mg PRN
– α-blockade
– standard ABCD drugs at
fractional/liquid doses
– CBT
True resistant hypertension
What happens in secondary care?
Specialist clinics improve BP control
Clinical studies have shown patients with resistant hypertension benefit from referral
to hypertension specialists
18/9 mm Hg drop in BP and control rates increased from 18% to 52% at 1-year
53% of patients with resistant hypertension were controlled to BP target
(<140/90 mm Hg) at 1-yr
Resistant or drug-intolerant patients (mean 3.2 medications), BP reduced by
20/11 mmHg in 1-yr with no increase in medication use
Bansai N et al.,Am J Hyp 2003;16:878-880
Garg JP et al., Am J Hyp 2005;18:619-626
Specialist clinics improve BP control
Focus on lifestyle advice, with specific targets
Confirm adherence
Confirm true office and out-of-office hypertension
Establish on guideline and evidence based
treatment
Look for secondary causes
Newer drugs, combinations, treatments…
True resistant hypertension
What is coming next?
Sympathetic nervous system and high BP
• Fight and flight system
• Cervical sympathectomy 1930’s
• Blockade of this system reduces BP e.g. with
ganglion blockers, betablockers or doxazosin (alpha1-blocker)
• Renal denervation
Renal Nerves and the SNS
Afferent Renal Sympathetics
Efferent Sympathetic Activation
 Vasoconstriction
HR
Contractility
RBF/GFR
Renin
 Na+/Volume
The kidney is a source of central sympathetic
drive in hypertension, heart failure, chronic
kidney disease, and ESRD
Patients cannot develop and/or
maintain elevated BP without
renal involvement
Renal Nerves as a Therapeutic Target
Vessel
Lumen
• Arise from T10-L1
• Follow the renal artery
• Primarily lie within the
adventitia
Media
Adventitia
Renal
Nerves
Staged Clinical Evaluation
First-in-Man 
Symplicity HTN-1
Series of Pilot studies 
Symplicity HTN-2 
EU/AU Randomized Clinical Trial
USA
EU/AU
Symplicity HTN-3
US Randomized Clinical Trial
(upcoming)
Other Areas of Research:
Insulin Resistance, HF/ Sleep Apnea,
126
Symplicity HTN-2
Lancet. 2010. published electronically on November 17, 2010
•
•
•
Purpose: To demonstrate the effectiveness of catheter-based renal denervation for
reducing blood pressure in patients with uncontrolled hypertension in a prospective,
randomized, controlled, clinical trial
Patients: 106 patients randomized 1:1 to treatment with renal denervation vs. control
Clinical Sites: 24 centers in Europe, Australia, & New Zealand (67% were
designated hypertension centers of excellence)
Symplicity HTN-2 investigators. Lancet 2010;376:1903-1909
127
Baseline Characteristics
Baseline Systolic BP (mmHg)
Baseline Diastolic BP (mmHg)
Age
Gender (% female)
Race (% Caucasian)
BMI (kg/m2)
Type 2 diabetes
Coronary Artery Disease
Hypercholesterolemia
eGFR (MDRD, ml/min/1.73m2)
eGFR 45-60 (% patients)
Serum Creatinine (mg/dL)
Urine Alb/Creat Ratio (mg/g)†
Cystatin C (mg/L)††
Heart rate (bpm)
† n=42
RDN
(n=52)
178 ± 18
97 ± 16
58 ± 12
35%
98%
31 ± 5
40%
19%
52%
77 ± 19
21%
1.0 ± 0.3
128 ± 363
0.9 ± 0.2
75 ± 15
Control
(n=54)
178 ± 16
98 ± 17
58 ± 12
50%
96%
31 ± 5
28%
7%
52%
86 ± 20
11%
0.9 ± 0.2
109 ± 254
0.8 ± 0.2
71 ± 15
p-value
0.97
0.80
0.97
0.12
>0.99
0.77
0.22
0.09
>0.99
0.013
0.19
0.003
0.64
0.16
0.23
for RDN and n=43 for Control, Wilcoxon rank-sum test for two independent samples used for between-group comparisons of UACR
for RDN and n=42 for Control
†† n=39
Symplicity HTN-2 investigators. Lancet 2010;376:1903-1909
128
Primary Endpoint: 6-Month Office BP
∆ from
Baseline
to
6 Months
(mmHg)
Systolic Diastolic
Diastolic
Systolic
•
•
33/11 mmHg
difference between RDN and Control
(p<0.0001)
84% of RDN patients had ≥ 10 mmHg reduction in SBP
10% of RDN patients had no reduction in SBP
Symplicity HTN-2 investigators. Lancet 2010;376:1903-1909
129
Interventional BP treatments
• Renal denervation
• Radiofrequency catheter based (multiple devices)
• Other forms of RDN
•
•
•
•
•
Baroceptor stimulation
Arterio-venous fistula formation
Vaccines and anti-inflammatory drugs
Deep brain stimulation
?...
Discussion
• How do our diagnosis and treatment pathways for
people with hypertension need to change in order to
bring them in line with this guidance?
• What innovative ways can we think of to enhance our
capacity to deliver ABPM to people who need it?
• What action do we need to take to ensure our blood
pressure monitoring devices are properly validated,
maintained and regularly calibrated?
• Who within our team needs briefing or training to
ensure consistent implementation?
Aged under
55 years
Aged over 55 years
or black person of
African or Caribbean
family origin of any
age
C2
A
A+
C2
Summary of
antihypertensive
drug treatment
Step 1
Step 2
A+C+D
Step 3
Resistant hypertension
Step 4
A + C + D + consider further
diuretic3, 4 or alpha- or
beta-blocker5
Consider seeking expert advice
Key
A – ACE inhibitor or low-cost
angiotensin II receptor
blocker (ARB)1
C – Calcium-channel
blocker (CCB)
D – Thiazide-like diuretic