lifestyle And Hypertension

DR. Mohamed El Ghoubary associate proffessor of internal medicine cairo university MD. MRCP

lifestyle And Hypertension
The effect of dietary patterns on blood pressure control in hypertensive patients: results from the Dietary Approaches to Stop Hypertension (DASH) trial. Conlin PR, Chow D, Miller ER 3rd, Svetkey LP, Lin PH, Harsha DW, Moore TJ, Sacks FM, Appel LJ. Source Endocrinology-Hypertension Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA. pconlin●rics.bwh.harvard.edu Abstract To determine the impact of dietary patterns on the control of hypertension we studied the subgroup of 133 participants with systolic blood pressure (BP) of 140 to 159 mm Hg and/or diastolic BP of 90 to 95 mm Hg enrolled in the Dietary Approaches to Stop Hypertension (DASH) study. Participants were fed a control diet for a 3-week period and were then randomized to receive for 8 weeks either the control diet; a diet rich in fruits and vegetables, but otherwise similar to control;

or a combination diet rich in fruits, vegetables, and low-fat dairy products, including whole grains, fish, poultry, and nuts, and reduced in fats, red meats, sweets, and sugar-containing beverages. Sodium intake and body weight were held constant throughout the study. The combination diet significantly reduced systolic BP (-11.4 mm Hg, P < .001) and diastolic BP (-5.5 mm Hg, P < .001). The fruits-and-vegetables diet also sireduced systolic BP (-7.2 mm Hg, P< .001) and diastolic BP (-2.8 mm Hg, P = .013). The combination diet produced significantly greater BP effects (P < .05) than the fruits-and-vegetables diet. Blood pressure changes were evident within 2 weeks of starting the intervention feeding. After the 8-week intervention period, 70% of participants eating the combination diet had a normal BP (systolic BP < 140 and diastolic BP < 90 mm Hg) compared with 45% on the fruits-and-vegetables diet and 23% on the control diet.

In patients with hypertension, the DASH combination diet effectively lowers BP and may be useful in achieving control of Stage 1 hypertension. The Effect of Gastric Bypass Surgery on Hypertension in Morbidly Obese Patients E. Ruddy, MD; Amy E. Duff, MHS; Nathaniel J. Holmes, MD; Ronald P. Cody, EdD; Robert E. Brolin, MD Arch Intern Med. 1994;154(2):193-200. doi:10.1001/archinte.1994.00420020107012 Background: Hypertension is the most common medical disorder associated with obesity. The relationship between dietary weight loss and the reduction of blood pressure is well established. However, the effect of gastric bypass surgery on blood pressure has not been well studied. Methods:

We evaluated the relationship between weight loss and blood pressure in patients with diastolic hypertension who had gastric bypass surgery for morbid obesity. Patients were defined as hypertensive if taking antihypertensive medication or if both the preoperative office and Jeffrey L. Carson, MD; Michael gnificantly meanshospital diastolic blood pressures were greater than 90 mm Hg. Two of the authors (J.L.C.,M.E.R.), blinded to all postoperative weights, classified the follow-up hypertensive status into one of four categories: resolved, improved, no change, or worse. The relationship between postoperative changes in blood pressure status and mean weight loss, percent excess weight loss, and body mass index were examined using a one-way analysis of variance.

The relationship between postoperative weight loss and blood pressure was assessed in the baseline normotensive population using linear regression analysis. Results: There were 45 patients with diastolic hypertension; 91% were taking an antihypertensive medication. The mean follow-up was 39 months. The mean pre-operative weight was 137 kg and the mean weight loss at 1, 12, and 24 months following surgery was 13, 21, and 45 kg, respectively. Twelve months after surgery, hypertension had resolved in 22 patients (54%) and had improved in six patients (15%).

These findings persisted through 48 months postoperatively. There was a significant relationship between the percentage of excess weight lost and improvement of hypertension at the 6-month and 12-month follow-up visits. There was also a significant relationship between the bodymass index and improvement of hypertension at the 1-month, 12-month, 24-month, and 48-month follow-up visits. In the base-line normotensive patients there was not a significant relationship between our weight loss measures and changes in blood pressure.

Conclusions: We conclude that postoperative weight loss in patients undergoing gastric bypass surgery was associated with resolution or improvement of diastolic hypertension in approximately 70% of cases. Resolution or improvement of hypertension occurred more often in patients with a lower postoperative body mass index.(Arch Intern Med. 1994;154:193-200) Abstract P023: Resolution of Systemic Hypertension after Bariatric Surgery is Predicted by Sagittal Diameter Decrement and Age Audrey Auclair; Julie Martin; Marjorie Bastien; Nadine Bonneville; Marie-Eve Leblanc; Frederic-Simon Hould; Fady Moustarah; Laurent Biertho; Paul Poirier Institut Universitaire de cardiologie et de pneumologie de Québec, Quebec, Canada Severe obesity is associated with several comorbidities including systemic hypertension. Whilebariatric surgery is the most effective long term treatment for the management of severe obesity, systemic hypertension is the most poorly resolved comorbidity after the surgery. The purpose of this study was to compare, in severely obese subject with and without systemic hypertension, body composition changes after bariatric surgery and to identify determinants of systemic hypertension resolution. Blood samples, anthropometric measurements and abdominal computed tomography scan were performed at baseline and 12 months following a billiopancreatic diversion with duodenal switch (BPD-DS) procedure. Up to now, 40 subjects (25 hypertensive subjects and 15 non-hypertensive subjects) were included in this study.

Before the BPD-DS, in the hypertensive group, there was more subjects with type 2 diabetes (19 vs. 6) and with dyslipidemia (17 vs. 8) compared to the non-hypertensive group; all p < 0.001. At baseline, the hypertensive subjects were significantly (all p < 0.05) different from the non-hypertensive regarding the percentage of women (60 vs. 100 %), age (51.4 ± 8.7 vs. 40.7 ± 9.6 years), fasting blood glucose (7.4 ± 2.5 vs. 5.8 ± 1.9 mmol/L), homeostatic model assessment (8.3 ± 4.2 vs. 5.5 ± 3.4), glycated hemoglobin (6.4 ± 0.1 vs. 5.7 ± 0.1 %) and visceral adipose tissue area (336.6 ± 107.1 vs. 270.5 ± 62.8 cm2).

There was no difference between hypertensive and non- hypertensive subjects regarding, weight, body mass index, sagittal diameter and lipids profile. At 12 months after the BPD-DS, 44 % of hypertensive subjects normalized blood pressure (p < 0.001).

Subjects who remained hypertensive depicted lesser decrease in weight (-32,2 ± 6,9 vs. -39,3 ± 6.9 %), low-density lipoprotein cholesterol (-14.7 ± 38.4 vs. 37.2 ± 30.0 %), fat mass (-50.7 ± 12.7 vs. -64.4 ± 14.2 %), visceral adipose tissue (-51.5 ± 15.8 vs. -68.3 ± 15.4 %) and sagittal diameter (-26.2 ± 6.4 vs. -33.1 ± 8.8 %) compared to subjects who resolved their hypertension; all p < 0.05. There was no difference regarding changes in other parameters between groups. In conclusion, after the BPD-DS surgery, less than half the subjects had resolved their systemic hypertension. At 12 months, subjects who remain hypertensive are those who had lost significantly less weight, fat mass and visceral adipose tissue. The decrement in sagittal diameter and age mostly explained (59 %) the resolution of systemic hypertension 12 months after the BPD-DS surgery. Author Disclosures:

A. Auclair: None. J. Martin: None. M. Bastien: None. N. Bonneville: None. M. Leblanc: None. F. Hould: None. F. Moustarah: None. L. Biertho: None. P. Poirier: None. Pak J Pharm Sci. 2013 Sep;26(5):859-63. Effects of Allium sativum (Garlic) on systolic and diastolic blood pressure in patients with essential hypertension. Source Department of Pharmacology, College of Pharmacy, King Khalid University, Abha, Saudi Arabia. Abstract The present study evaluated the effects of garlic on blood pressure in patients with essential hypertension.

Patients (n=210) with stage 1 essential hypertension were divided into 7 groups named as A, B, C, D, E, F and G. Each group comprised of 30 patients. Each patient in group A, B, C, D and E has received garlic tablets at the dose of 300/mg, 600/mg, 900/mg, 1200/mg and 1500/mg in divided doses per day respectively for 24 weeks while Group F & group G were given tablet atenolol and placebo respectively. Blood pressure readings were recorded at weeks 0, 12 and 24. Present study showed significant decrease in both Systolic and Diastolic blood pressure in both dose and duration dependent manner.

In each garlic treated group, significant reduction in SBP and DBP (p<0.005) were observed when compared with atenolol (P<0.005) and placebo. Effects of the DASH diet on blood pressure in patients with and without metabolic syndrome: results from the DASH trial. Hikmat F, Appel LJ. Source 1] Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, MD, USA [2] Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA. Abstract In the Dietary Approach to Stop Hypertension (DASH) trial, the DASH diet reduced blood pressure (BP) in a diverse sample of US adults.

Subsequent analyses of this trial documented the efficacy of the DASH diet in several subgroups. Although subgroup analyses in individuals with metabolic syndrome (MS) have not been performed, the DASH diet has been recommended in MS patients. This paper is a subgroup analysis of the DASH trial, in which we examined the effect of study diets on BP in participants with and without MS. Participants were stratified according to MS status (99 with MS, 311 without MS (Non-MS)). The trial was a dietary intervention study in which participants were randomized to receive a control diet, a diet rich in fruits and vegetables, or the DASH diet. Outcomes were

(i) the difference in BP between the end and the beginning of intervention and

(ii) control of hypertension. We found no significant interaction between MS status and diet assignment on BP (each P-interaction >0.05). In the MS subgroup, the DASH diet compared with the control diet reduced systolic BP by 4.9 mm Hg (P=0.006) and diastolic BP by 1.9 mm Hg (P=0.15). In the Non-MS subgroup, corresponding net BP reductions were 5.2 mm Hg (P<0.001) and 2.9 mm Hg (P<0.001), respectively.

The DASH diet controlled hypertension in 75% of hypertensive participants with MS (adjusted odds ratio=9.5 vs the control diet, P=0.05). In conclusion, the DASH diet similarly reduces BP in those with and without MS. How does renal denervation lower blood pressure and when should this technique be considered for the treatment of hypertension? Leong KT, Krum H. Source Department of Cardiology, Changi General Hospital, 2 Simei Street 3, Singapore, 529889, Singapore, Gerard_leong@cgh.com.sg. Abstract Resistant hypertension poses significant health concerns. There are strong demands for new safe therapeutics to control resistant hypertension, while addressing its common causes, specifically poor compliance to lifelong polypharmacy, lifestyle modification and physician inertia. The sympathetic nervous system plays a significant pathophysiological role in hypertension. Surgical sympathectomy for blood pressure reduction is an old but extremely efficacious therapeutic concept, since abandoned, with the dawn of safer contemporary pharmacology era. Recently, clinical studies have revealed promising results for safe and sustained blood pressure reduction with percutaneous renal sympathetic denervation. This is a novel, minimally-invasive, device-based therapy, specifically targeting and ablating the renal artery nerves with radiofrequency waves, without permanent implantation. There are also reported additional benefits in related comorbidities, such as impaired glucose metabolism, renal impairment, left ventricular hypertrophy, heart failure, and others. This is review will focus on how selective renal sympathetic denervation works, as well as its present and potential therapeutic indications. Some supplements have been evaluated as blood pressure-lowering options, including:

● Coenzyme Q10 (CoQ10): People with mild high blood pressure who were taking CoQ10 experienced a significant drop in their blood pressure without appreciable side effects. In addition, CoQ10 appears to reduce blood pressure by a different mechanism than major antihypertensive drugs.

● Omega-3 fatty acids: Some studies report that EPA and DHA may reduce blood pressure in people with mild hypertension. However, other studies have bad conflicting results. Current evidence suggests that modest reductions of blood pressure may occur with significantly higher doses of omega-3 fatty acids.

● Amino acids: It has been suggested that the diet supplement L-arginine may lower blood pressure; however, the few studies conducted to date were small and not well-controlled, and suggest that L-arginine may lower blood pressure for only a short period of time. Another amino acid, L-taurine, may also have blood pressure-lowering qualities. Herbal Therapies for High Blood Pressure The efficacy and safety of herbal therapies, such as Rauwolfia serpentina (snakeroot), Stephania tetrandra (tetrandrine), Panax notoginseng (ginseng), and Crataegus species (hawthorn) for treating high blood pressure have not been extensively studied. Because of potential health risks associated with these herbs, it is imperative that you inform your doctor if you plan to use or are already using them. This is even more important if these herbs are used in combination with high blood pressure drugs. Agents that can interfere with blood pressure control Non-narcotic analgesics (non- steroidal anti-inflammatory agents,selective COX-2 inhibitors, aspirin)

● Sympathomimetic agents(decongestants, diet pills, cocaine)

● Stimulants (methylphenidate, dexmethylphenidate, dextroamphetamine, amphetamine,methamphetamine)

● Alcohol

● Oral contraceptives

● Cyclosporine

● Erythropoietin

● Natural licorice

● Herbal compounds (ephedra orma huang) Some herbs, such as licorice, ephedra (Ma Huang), and yohimbine (from the bark of a West African tree) , royal jelly should not be used by people with hypertension, because they can increase blood pressure. Acupuncture for High Blood Pressure Extensive research on the effectiveness of acupuncture for lowering blood pressure has been reported, but many studies have considerable weaknesses. More rigorously controlled research is needed to determine the value of acupuncture as a treatment for hypertension. At this time, there is no evidence that acupuncture reliably lowers high blood pressure. Yoga Could Lower Blood Pressure Among People With Hypertension A study presented at the annual meeting of the American Society of Hypertension shows that practicing yoga could help decrease blood pressure in people with mild to moderate hypertension. «So far it looks very promising that yoga might be a useful therapy for patients with mild-to-moderate hypertension who want to avoid using medication,» study researcher Dr. Debbie Cohen, M.D., of the niversity of Pennsylvania, told MedPage Today. «This could also be used as an adjunct to other lifestyle modifications.» The study included 120 people with an average age of 50, 58 of whom completed the study. All the study participants were organized into one of three groups: One was assigned to do yoga two or three times a week in a studio for 24 weeks, while another group was assigned to do a walking/nutrition/weight counseling program. The third group was assigned to do both yoga and dietary counseling. Researchers analyzed their blood pressure at the beginning of the study, 12 weeks into the study, and 24 weeks into the study They found that the people who did yoga had decreases in their systolic blood pressure at the 12-week mark, and decreases in both systolic and diastolic blood pressure at the 24-week mark. However, the researchers noted that the other two groups also experienced positive effects on their blood pressure. Past research has also shown that yoga has an impact on the gene expression of immune cells, which suggests the practice can affect health on a genetic level. Non Parmaclogical Treatments for High Blood Pressure There are many different types of complementary and alternative treatments believed to be effective for treating high blood pressure (hypertension). Scientific evidence indicates that a diet that is low in saturated fat and salt and rich in complex carbohydrates (vegetables, whole grains, legumes, and fruits), increased physical activity, and regular practice of relaxation techniques such as yoga, Tai Chi, or Qigong, can help to lower high blood pressure. Diet to Lower High Blood Pressure One of the simplest and most effective ways to lower your blood pressure is to eat a healthy diet, such as the DASH diet. Doctors recommend:

● Eating more fruits, vegetables, and low-fat dairy foods

● Cutting back on foods that are high in saturated fat, cholesterol, and total fat Eating more whole grain products, fish, poultry, and nuts

● Eating less red meat and sweets

● Eating foods that are rich in magnesium, potassium, and calcium Effect of garlic A recent study evaluated the effects of garlic on blood pressure in patients with essential hypertension. Patients (n=210) with stage 1 essential hypertension were divided into 7 groups named as A, B, C, D, E, F and G. Each group comprised of 30 patients. Each patient in group A, B, C, D and E has received garlic tablets at the dose of 300/mg. 600/mg, 900/mg, 1200/mg and 1500/mg in divided doses per day respectively for 24 weeks while Group F & group G were given tablet atenolol and placebo respectively. Blood pressure readings were recorded at weeks 0, 12 and 24. Present study showed significant decrease in both Systolic and Diastolic blood pressure in both dose and duration dependent manner. In each garlic treated group, significant reduction in SBP and DBP (p<0.005) were observed when compared with atenolol (P<0.005) and placebo. Ashraf R, Khan RA, Ashraf I, Qureshi AA.Effects of Allium sativum (Garlic) on systolic and diastolic blood pressure in patients with essential hypertension. Pak J Pharm Sci. 2013 Sep; 26(5):859-63. Resistant hypertensio Resistant hypertension occurs when 1) use of at least three antihypertensive drugs at full daily dosage - of which a diuretic- are unsuccessful in controlling blood pressure, and, having excluded pseudoresistance (white coat phenomenon), 2) contributing factors such as certain exogenous substances, or secondary causes of hypertension including hyperaldosteronism, obstructive sleep apnea, parenchymal and vascular kidney disease, hromocytoma, are possibly at work. Hypertension is resistant in 15-30% of study subjects and is often uncontrolled because of persistently elevated and isolated systolic hypertension. It is characterised by an excess in aldosterone and an increased intravascular volume. Implantation of a Carotid Baroreceptor Stimulator Recently an implantable device to electrically stimulate the carotid baroreceptors, to decrease sympathetic outflow , was used, and may have benefits in BP reduction in conditions with sympathetic nervous system predominance such as obesity , obstructive sleep apnoea, and isolated systolic hypertension . The electrical stimulation of carotid baroreceptors is a noninvasive procedure achieved by: ● An implantable bilateral carotid stimulator (electrodes) permanently placed in the perivascular space around the sinus of the carotid arteries;

● A pulse generator (battery-operated) subcutaneously implanted in the infraclavicular space;

● A computer system connected to the generator which controls the radiofrequency stimulation. Despite advances in pharmacologic therapy, a substantial portion of patients have resistant hypertension (defined as taking the maximal approved or tolerated doses of at least three antihypertensive medications, including a diuretic, and are not at goal blood pressure . For these patients a clinical trial is currently underway to determine the safety and efficacy of Rheos_ System (CVRx, Minneapolis, MN, USA), an implantable device designed to reduce blood pressure by electrically activating the carotid baroreflex. Nervous System Carotid Baroreceptor Stimulation, Sympathetic Activity, Baroreflex Function, and Blood Pressure in Hypertensive Patients. Karsten Heusser, Jens Tank, Stefan Engeli, Nervous System Accepted December 29, 2009 In a recent study involving 7 men and 5 women (ages 43 to 69 years) with treatment-resistant arterial hypertension. A bilateral electric baroreflex stimulator at the level of the carotid sinus (Rheos) was implanted. Intra-arterial blood pressure was 193±9/94±5 mm Hg on medications. Acute electric baroreflex stimulation decreased systolic blood pressure by 32±10 mm Hg (range: +7 to −108 mm Hg; P=0.01).

The depressor response was correlated with a muscle sympathetic nerve activity reduction (r2=0.42; P<0.05).

In responders, muscle sympathetic nerve activity decreased sharply when electric stimulation started. Then, muscle sympathetic nerve activity increased but remained below the baseline level throughout the stimulation period. Heart rate decreased 4.5±1.5 bpm with stimulation (P<0.05). Plasma renin concentration decreased 20±8% (P<0.05).In conclusion electric carotid baroreceptor stimulation acutely reduces blood pressure through sympathetic inhibition in patients with drug treatment–resistant arterial hypertension. Implantation of the Baroreflex Stimulator The Rheos Baroreflex Hypertension Therapy System (CVRx, Inc) consists of an internal programmable pulse generator, 2 electrode leads, and 2 field electrodes. Stimulation of the vessel wall in the carotid sinus region is thought to lead to the excitation of neural fibers located in the adventitia and media of the artery directly under the cathode.

The device delivers rectangular pulses with intensities between 0.0 and 7.5 V. Moreover, the temporal pattern of electric impulses may be adjusted in terms of duration, frequency, and grouping. Sustained blood pressure reduction by baroreflex hypertension therapy with a chronically implanted system: 2-year data from the Rheos DEBuT-HT study in patients with resistant hypertension.Scheffers I, Schmidli J, Kroon AA, et al.: J Hypertens 2008, 26(Suppl I):S19. 17. Sustained blood pressure reduction by baroreflex hypertension therapy with a chronically implanted system: 3-year data from the Rheos DEBuT study in patients with resistant hypertension.Scheffers I, Schmidli J, Kroon AA, et al.: J Hypertens 2009, 27(Suppl 4):S421.

Clinical trials on carotid receptor stimulation by an implantable device showed a significant reduction in both office systolic (22 or 34 mmHg) and diastolic (18 or 20 mmHg) blood pressure, 24-hour ambulatory blood pressure (14/9 mmHg), and heart rate (12 bpm), which was evident from study onset and was maintained at follow-up. Available data suggest a beneficial effect of carotid baroreceptor stimulation on the reversal of left ventricular hypertrophy and cardiac structure and function, with attenuated mitral A-valve velocity and reduced left atrial dimensions; also carotid baropacing does not impair the renal function of patients with resistant hypertension, even during prolonged follow-up periods. Sustained blood pressure reduction by baroreflex hypertension therapy with a chronically implanted system: 3-year data from the Rheos DEBuT study in patients with resistant hypertensio n.Scheffers I, Schmidli J, Kroon AA, et al.: J Hypertens 2009, 27(Suppl 4):S421. The Effect of Gastric Bypass Surgery on Hypertension in Morbidly Obese Patients Severe obesity is associated with several comorbidities including systemic hypertension. While bariatric surgery is the most effective long term treatment for the management of severe obesity, systemic hypertension is the most poorly resolved comorbidity after the surgery.

The purpose of this study was to compare, in severely obese subject with and without systemic hypertension, body composition changes after bariatric surgery and to identify determinants of systemic hypertension resolution.in patients undergoing biliopancreatic diversion, at baseline and 12 months following a billiopancreatic diversion, 44 % of hypertensive subjects normalized blood pressure (p < 0.001). Subjects who remained hypertensive depicted lesser decrease in weight (-32,2 ± 6,9 vs. -39,3 ± 6.9 %), low-density lipoprotein cholesterol (-14.7 ± 38.4 vs. 37.2 ± 30.0 %), fat mass (-50.7 ± 12.7 vs. -64.4 ± 14.2 %), visceral adipose tissue (-51.5 ± 15.8 vs. -68.3 ± 15.4 %) and sagittal diameter (-26.2 ± 6.4 vs. -33.1 ± 8.8) In 45 patients with diastolic hypertension; 91% were taking an antihypertensive medication. The mean follow-up was 39 months. The mean pre-operative weight was 137 kg and the mean weight loss at 1, 12, and 24 months following surgery was 13, 21, and 45 kg, respectively. Twelve months after surgery, hypertension had resolved in 22 patients (54%) and had improved in six patients (15%).

postoperative weight loss in patients undergoing gastric bypass surgery was associated with resolution or improvement of diastolic hypertension in approximately 70% of cases. Resolution or improvement of hypertension occurred more often in patients with a lower postoperative body mass index. The Effect of Gastric Bypass Surgery on Hypertension in Morbidly Obese Patients.Jeffrey L. Carson, MD; Michael E. Ruddy, MD; Amy E. Duffet al.,Arch Intern Med. 1994;154(2):193-200. (Arch Intern Med. 1994;154:193-200) Catheter-based radiofrequency ablation of renal sympathetic nerves Catheter--based radiofrequency ablation of the renal sympathetic nerves lowers blood pressure in patients with resistant hypertension [20-26]. This procedure was tested in the Symplicity-HTN-2 trial of 106 patients with resistant hypertension despite treatment with an average of five antihypertensive medications including a diuretic [20].

The patients were randomly assigned to renal sympathetic denervation or maintenance of previous medical therapy. At six months, radiofrequency ablation significantly decreased the office blood pressure from 178/97 to 143/85 mmHg compared with no decrease in blood pressure in patients maintained on baseline antihypertensive therapy. In addition, a systolic pressure of less than 140 mmHg was attained significantly more often with radiofrequency ablation (39 versus 6 percent). and it is not known whether the antihypertensive effect of radiofrequency ablation may be due in part to improved adherence. In one study, for example, 18 patients diagnosed with resistant hypertension were referred for radiofrequency ablation [27]. Of these, only six patients had true resistant hypertension based upon ambulatory blood pressure monitoring performed after directly observed antihypertensive therapy.

Radiofrequency ablation in these six patients lowered the blood pressure in only two. Long-term data regarding efficacy and safety of radiofrequency ablation remain limited. In a cohort study of 153 patients with resistant hypertension treated with catheter-based radiofrequency ablation, medical evaluation was performed in 64 patients at 12 months and 18 patients at 24 months [28]. Compared with baseline, blood pressure was reduced by 23/11 mmHg at 12 months and 32/14 mmHg at 24 months.

The average number of antihypertensive medications used was the same at last follow-up as it was at baseline. Renal artery stenosis was diagnosed and stented in one patient six months after radiofrequency ablation. 1- Fadl Elmula FE, Hoffmann P, Fossum E, et al. Renal sympathetic denervation in patients with treatment-resistant hypertension after witnessed intake of medication before qualifying ambulatory blood pressure. Hypertension 2013; 62:526. 2- Symplicity HTN-1 Investigators. Catheter-based renal sympathetic denervation for resistant hypertension: durability of blood pressure reduction out to 24 months. Hypertension 2011; 57:911. According to the European Society of Cardiology (ESC) consensus statement, radiofrequency ablation of the renal sympathetic nerves should be reserved for patients who meet all of the following criteria [32]: ● Resistant hypertension is present (blood pressure above goal despite at least three antihypertensive medications, including a diuretic, plus lifestyle modification). ● Pseudoresistant hypertension has been excluded (eg, white coat effect, medication nonadherence).

(See “Definition, risk factors, and evaluation of resistant hypertension”, section on ‘Apparent, true, and pseudoresistant hypertension’.) ● Identifiable secondary causes of resistant hypertension, such as primary aldosteronism, have been excluded. ● Renal function is preserved (estimated glomerular filtration rate greater than or equal to 45 mL/min/1.73 m2). ● The renal artery anatomy is eligible (ie, there are no accessory renal arteries and no renal artery stenosis or renal artery revascularization).

The association between increased renal sympathetic activity and components of metabolic syndrome (MS) was already demonstrated. A group of 50 patients was evaluated, with 37 being subjected to RSD and 13 maintained under conservative treatment. Initial mean BP in both groups was of 178/96 mmHg. After three months of procedure, we observed significant decreases in BP (−32/−12 mmHg), fasting blood glucose (from 118 mg/dl to 108 mg/dL), of insulin levels (from 20.8 UI/ml to 9.3 UI/ml) and levels of C-peptide (from 5.3 ng/ml to 3.0 ng/ml). Authors also tested the impact on insulin sensitivity, calculated through homeostasis model assessment-insulin resistance (HOMA-IR), and observed the decreased level of insulin resistance with RSD (from 6 to 2.4). Glucose, after two hours of stimulation, also improved after the procedure, with a decrease of 27 mg/dl compared to baseline. There were no changes on BP and metabolic parameters in the control group25. Mahfoud F, Schlaich M, Kindermann I, Ukena C, Cremers B, Brandt MC, et al. Effect of renal sympathetic denervation on glucose metabolism in patients with resistant hypertension: a pilot study.

Circulation. 2011;123(18):1940-6. In another study in Ninety-five obese patients with documented hypertension and being treated with antihypertensive medication(s) and after undergoing astric bypass , after 12 months of follow-up, 44 (46%) patients had complete resolution of hypertension while 18 (19%) patients had improvement. Patients with complete resolution had a shorter duration of disease as compared to patients without resolution (53 vs. 95 months, respectively, p = 0.01). Marcelo W. Hinojosa, J. Esteban Varela, et al.,Resolution of Systemic Hypertension after Laparoscopic Gastric Bypass Journal of Gastrointestinal Surgery April 2009, Volume 13, Issue 4, pp 793