Clinical Implications

Abstract

HomeHypertensionVol. 74, No. 3Clinical Implications Free AccessIn BriefPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessIn BriefPDF/EPUBClinical Implications Originally published7 Aug 2019https://doi.org/10.1161/HYPERTENSIONAHA.119.13545Hypertension. 2019;74:431is related toProcedural and Anatomical Determinants of Multielectrode Renal Denervation EfficacyAssociation of Blood Pressure Level With Left Ventricular Mass in AdolescentsEdoxaban Versus Warfarin Stratified by Average Blood Pressure in 19 679 Patients With Atrial Fibrillation and a History of Hypertension in the ENGAGE AF-TIMI 48 TrialDeterminants of Biomarker Reduction in Denervation (page 546)Download figureDownload PowerPointCatheter-based radiofrequency renal denervation reduces sympathetic activity and blood pressure with variable success. Among the reasons cited for variability in response was suboptimal procedural performance with incomplete nerve ablation. Further optimization of renal denervation systems and understanding of the dependence of efficacy on the pattern of ablations is necessary. The coupling of quantitative preclinical experiments and computational models provided a comprehensive understanding of the procedural dependence of renal norepinephrine reduction as a biomarker of efficacy. Biomarker effects were shown to track with the percentage of affected nerves in the treated artery segment, such that half-maximal norepinephrine reduction was achieved when >46% of nerves were affected. For 15 W/30 s treatments, threshold effects were only attained when ≥4 electrodes were powered. The total fractions of ablation area and annular coverage were the prime determinants of renal denervation efficacy. Hence, all else being equal, efficacy decreased with increasing vessel diameter owing to an increase in the target area, or when radiofrequency electrodes directed their energy at blood vessels owing to efficient heat clearance and reduced ablation area. Design of new renal denervation therapies should focus on strategies for maximizing total ablation area and arc rather than depth of ablation. In particular, strategies for delivering multiple helically staggered ablations and abrogating the heat clearance effects of periarterial blood vessels seem promising.Association of BP With LV Mass in Adolescents (page 590)Download figureDownload PowerPointHypertension is associated with left ventricular hypertrophy, a risk factor for cardiovascular events. The current guidelines on management of blood pressure (BP) in children recommend evaluation for left ventricular hypertrophy at the time of starting medication to treat hypertension, usually when BP is persistently above the 95th percentile of the normal BP distribution in healthy children. However, the optimal BP percentile associated with left ventricular hypertrophy in youth is unknown. In this multicenter study of 303 adolescents, we found that the 90th percentile for systolic BP resulted in the best balance between sensitivity and specificity for predicting left ventricular hypertrophy. Therefore, our findings indicate that many youths with lower levels of BP than currently recommended for medication treatment may be at risk for BP-related target organ damage. Validation of our findings in other cohorts and examination of other measures of target organ damage are needed to provide additional evidence to inform future BP guidelines on pediatrics.BP and Anticoagulation in Atrial Fibrillation (page 597)Download figureDownload PowerPointHypertension is the most common comorbid condition with atrial fibrillation and is associated with increased risks of stroke and bleeding. Because uncontrolled hypertension is a known risk factor for stroke, cardiovascular mortality, and bleeding in anticoagulated patients, there are concerns that the benefits of direct oral anticoagulants may be modified by blood pressure (BP). Although direct oral anticoagulants compare favorably to warfarin in preventing cardiovascular events and reducing the risk of major bleeding, including intracranial hemorrhage, the relationship between on-treatment BP and the efficacy and safety of direct oral anticoagulants is not fully known. In this post hoc analysis of the ENGAGE AF-TIMI 48 trial (Effective Anticoagulation With Factor Xa Next Generation in Atrial Fibrillation–Thrombolysis in Myocardial Infarction 48), we examined the efficacy and safety of edoxaban relative to warfarin stratified by average BP during the trial among 19 679 patients with atrial fibrillation, a history of hypertension, and elevated stroke risk. The efficacy and safety of high dose edoxaban relative to warfarin were consistent across the full range of average systolic BP. Further, the superior safety of edoxaban was most pronounced among patients with elevated diastolic BP. As direct oral anticoagulants continue to be underused in patients with atrial fibrillation perceived to be at elevated bleeding risk, including those with uncontrolled hypertension, these findings emphasize the importance of this class of medications in the management of this high-risk patient population. Previous Back to top Next FiguresReferencesRelatedDetailsRelated articlesProcedural and Anatomical Determinants of Multielectrode Renal Denervation EfficacyAbraham R. Tzafriri, et al. Hypertension. 2019;74:546-554Association of Blood Pressure Level With Left Ventricular Mass in AdolescentsElaine M. Urbina, et al. Hypertension. 2019;74:590-596Edoxaban Versus Warfarin Stratified by Average Blood Pressure in 19 679 Patients With Atrial Fibrillation and a History of Hypertension in the ENGAGE AF-TIMI 48 TrialSungha Park, et al. Hypertension. 2019;74:597-605 September 2019Vol 74, Issue 3 Advertisement Article InformationMetrics © 2019 American Heart Association, Inc.https://doi.org/10.1161/HYPERTENSIONAHA.119.13545 Originally publishedAugust 7, 2019 PDF download Advertisement