National Heart Association of Malaysia(NHAM) International Collaboration Session: Resistant Hypertension
Epidemiology and Medical Therapy, Malaysia Perspective Wan Azman Wan Ahmad FRCP, FAMM, FNHAM, FAsCC, FAPSIC, FESC, FSCAI, FACC
Professor of Medicine and Head of Cardiology University Malaya Medical Centre Kuala Lumpur, Malaysia GHA 10/SHA 24 Joint Scientific Conference, Kingdom of Saudi Arabia, 13th-16th Feb 2013
Disclosure I have no conflict of interest in the context of this presentation
Lecture Outline • • • • • •
Magnitude of Hypertension in Malaysia Treatment and Control Challenges in Hypertension treatment Resistant Hypertension Case Studies Future Development
Magnitude of Hypertension in Malaysia The Third National Health and Morbidity Survey (NHMS III) 2006 - A research project sponsored by Ministry of Health Malaysia • Multi purpose survey designed to describe the health status, health related behaviour and health services utilization for a representative sample of the population of Malaysia • For NHMS III component of blood pressure 33,976 individuals aged 18 or older were eligible
Hypertension • Hypertension is defined as an average of two blood pressure readings at single occasion with: a systolic BP of ≥ 140 mmHg, and/or a diastolic BP of ≥ 90 mmHg, or Currently on antihypertensive medication
• Standard definition used by NHANES, JNC, National surveys
Table 1: Characteristics of respondents for hypertension module of NHMS III (N= 33,976) n
%
Adjusted*%
15,209 18,767
44.8 55.2
50.6 49.4
1,688 7,492 7,107 7,313 5,516 3,072 1,788
5 22.1 20.9 21.5 16.2 9 5.3
6.7 28.4 24.9 18.8 10.9 6.4 3.9
Sex Male Female
Age 18-19 20-29 30-39 40-49 50-59 60-69 ≼70
*adjusted to Malaysian population by age, sex and race
Table 1: Characteristics of respondents for hypertension module of NHMS III (N= 33,976) n
%
Adjusted*%
Ethnicity Malay Chinese Indian Bumiputra Sabah Bumiputra Sarawak Others Foreigner
17995 6771 2685 2473 1302 586 2164
53.0 19.9 7.9 7.3 3.8 1.7 6.4
49 24.8 7.4 5.6 4.1 0.6 8.5
Urban/Rural Urban Rural
20055 13921
59 41
62.1 37.9
*adjusted to Malaysian population by age, sex and race
Prevalence of HPT by race amongst Malaysian residents aged ≼ 18 years in 2006 (N=33,976) 35 34
34.4 33.9
Prevalence (%)
33 32 31
32.4
32.2
31.1
30 29
29.4
28 27 26 All races
Malay
Chinese
Ethnicity
Indians
Bumiputra Sabah
Bumiputra Saraw ak
Prevalence of HPT by sex amongst Malaysian residents aged ≼ 18 years in 2006 (N=33,976) 33.5 33.3
33
Prevalence (%)
32.5 32
32.2
31.5 31 31
30.5 30 29.5 Overall
Male
Female
Gender
Prevalence of hypertension in urban vs. rural area amongst Malaysian residents aged ≼ 18 years in 2006 (N=33,976) 40 35 36.9
Prevalence (%)
30 25
29.3
20 15 10 5 0 Urban
Rural
Area
Estimated number of HPT population by sex and race amongst Malaysian residents aged ≼ 18 years in 2006* Age (Years)
Sex, million population (95% CI) Male
Female
Both sexes
All races
2.2 (2.1, 2.2)
2.6 (2.5, 2.7)
4.8 (4.6, 4.9)
Malay
1.2 (1.1, 1.2)
1.5 (1.5, 1.6)
2.7 (2.6, 2.8)
Chinese
0.5 (0.5, 0.6)
0.5 (0.5, 0.6)
1.0 (1.0, 1.1)
Indians
0.2 (0.1, 0.2)
0.2 (0.2, 0.2)
0.4 (0.3, 0.4)
Other Bumis**
0.2 (0.2, 0.3)
0.2 (0.2, 0.3)
0.5 (0.4, 0.5)
*Rounded up to the closest 0.1 million population ** Comprises of all Non Malay Bumiputras
Prevalence of HPT by race amongst Malaysian residents aged ≼ 30 years in 2006 (N=24,796) 50 45
45.4 42.6
40.6
40
40
34.4
Prevalence (%)
35
31.1
30 25 20 15 10 5 0 All races
Malay
Chinese
Ethnicity
Indians
Bumiputra Sabah
Bumiputra Sarawak
Prevalence of HPT by sex amongst Malaysian residents aged ≼ 30 years in 2006 (N=24,796) 44 43.4
43.5
Prevalence (%)
43 42.6 42.5
42
41.7
41.5 41
40.5 Overall
Male
Gender
Female
Awareness, Treatment and Control of HPT by sex amongst Malaysian Residents aged ≼ 30 years, 2006 Sex, % (95%CI) Male
Female
Both sexes
Hypertensives (N=11,673) Aware
31.5 (30.1,32.9)
40.0 ( 38.7,41.2)
35.8 (34.8, 36.8)
Currently Treated
27.3 (26.0, 28.6)
35.4 (34.2, 36.7)
31.4 (30.4,32.3)
7.7 (7.0, 8.6)
8.7 (8.0, 9.5)
8.2 (7.7, 8.8)
Controlled
Treatment and Control of HPT by sex amongst Those Aware of Hypertension Status aged ≼ 30 years, 2006 (N= 3,927) Sex, % (95%CI) Male
Female
Both sexes
Aware & treated
86.5 (84.7, 88.1)
88.7 (87.3.89.9)
87.7 (86.6.88.7)
Treated & Controlled
28.4 (26.0, 30.9)
24.7 (22.9, 26.5)
26.3 (24.8, 27.8)
The ‘Malaysian Rule’ All hypertensive 64%
36% 69%
Aware 31%
92%
Treated 8% Controlled
Magnitude of Hypertension in Malaysia L. Rampal, S.Rampal, M.Z. Azhar, A.R. Rahman. Public Health (2008) 122, 11-18
• Prevalence, awareness, treatment and control of Hypertension in Malaysia: A national study of 16,440 subjects. • A cross-sectional study conducted in all states of Malaysia to determine the prevalence, awareness, treatment and control of Hypertension (study was conducted 2004)
Results • The prevalence of HPT for respondents age ≥ 30yrs was 40.5%(42.6% in NHMS III) • Males 29.6% vs females 26.0% • Multivariate logistic regression showed the odds of having Hypertension – Increasing age – Males – Family history of HPT – Increasing body mass index (BMI ≥ 30) – Non-smoker – Decreasing level of education
Results • Only 34.6% of the subjects with HPT were aware of their Hypertension status (36% in NHMS III) • 32.4% were taking antihypertensive medication (31% in NHMS III) • Among those taking antihypertensive medication only 26.8% had their blood pressure under control. (26.3% in NHMS III) • Blood pressure control was only achieved in 8.6% of the respondents who has HPT (8% in NHMS III)
National Cardiovascular Disease Database ACS Registry (est. 2006) PCI Registry (est. 2007)
NCVD-ACS Registry Active Sites HTF HSB
QEH
HRPZ II
PH
HPRPB HTAA UMMC IJN HKL HTAR
SGH
HTJ HM
HSAJB NCVD-ACS Registry, Malaysia (Established 1st January 2006
Total sites = 15
NCVD-PCI Registry Active Sites QEH (2008)
SBH PH
KPJSSH SH
SGH
UMMC IJN HUKM MMC (2009)
HSAJB
Total sites = 11
NCVD-PCI Registry, Malaysia ( Established 1st January 2007 )
PUBLICATIONS
Demographics 2006 (N=3442)
2007 (N=3645)
2008 (N=2848)
Age Mean Âą sd Min, Max
59 + 12 years 21, 100 years
25, 95 years
21, 94 years
Male
75 %
77 %
75 %
Female
25 %
23 %
25 %
Gender
Malaysians develop ACS at a younger age (mean age 59 yrs old) when compared to people in Thailand (65 yrs), mainland China (63 yrs) and western countries (Grace Registry 66 yrs)
Percentage of CV Risk Factors 2006 (N=3442)
2007 (N=3645)
2008 (N=2848)
Dyslipidaemia
33
35
31
Hypertension
61
63
56
Diabetes
44
44
39
Family History of premature CVD
12
13
9
MI history
16
18
13
Documented CAD
15
18
15
New onset angina (< 2 weeks)
45
53
48
Chronic angina (onset > 2 weeks ago)
15
11
8
Chronic Lung Disease
4
3
3
Renal disease
7
6
5
Peripheral vascular disease
1
1
1
Cerebrovascular disease
4
3
3
Heart Failure
8
7
5
Annual Report of the Acute Coronary Syndrome (ACS) Registry 2006 - 2008
10,602 patients 11,498 PCI Procedures Mean Age 57 years old Risk factors • hypertension (73.6%) • dyslipidemia (73.4%) • diabetes (46.2%) • smoking (47.1%)
National Essential Hypertension Audit Institute of Health Management, Ministry of Health ( IHM MOH 2006 )
Rates of BP control by Hospital/clinic • Hospital with specialist
31.2%
• Hospital without specialist
26.6%
• Clinics with FMS/ MO
28.8%
• Clinics without FMS/MO
26.9%
National Essential Hypertension Audit Institute of Health Management, Ministry of Health ( IHM MOH 2006 )
Rates of BP control by ethnicity • Malay
24.3%
• Indians
30.8%
• Chinese
37.6%
• Others
30.8%
National Essential Hypertension Audit Institute of Health Management, Ministry of Health ( IHM MOH 2006 )
Rates of BP control by age • 30-39
19.4%
• 40-49
27.1%
• 50-59
29.1%
• >60
29.2%
Points to ponder! Why Malaysian patients have poor BP control
• Patients’ non compliance/denial • Doctors not sure when to treat and what the treatment goals are • Doctors not using the right drug/drugs • Patients has undiagnosed secondary hypertension or complications of hypertension which makes optimum control difficult
Strategies to improve management of hypertensive patients in Malaysia?
Soft copy available at: www.moh.gov.my www.acadmed.org.my www.msh.org.my
Classification of blood pressure for adults age 18 and older: Malâ&#x20AC;&#x2122; CPG 2008
Ref: Lim TO, Ding LM, Goh BL, et al. Distribution of Blood Pressure in a National Sample of Malaysian Adults. Med J Malaysia 2000;55:90-107. Source: Clinical Practice Guideline on Management of Hypertension 2008 (3 rd Edition).
Treatment targets Mal’ CPG 2008 • <140/85 mmHg for most • < 130/80 mmHg for patients with diabetes or chronic kidney disease • < 125/75 mmHg for patients with proteinuria > 1g/24hours
Prevalence of Hypertension in Malaysia (NHMS IV 2011) Year
Age group Definition of hypertension Prevalence
1986 NHMS I
1996 NHMS II
1996 NHMS II
≥ 25
≥ 18
≥ 30
≥ 18
≥ 30
> 18
≥160/95
≥140/90
≥140/90
≥140/90
≥ 140/90
≥ 140/90
14.4%
29.9%
32.9%
32.2%
42.6%
*32.7%
Refer * •12.8% are known to have hypertension •19.8% are previously undiagnosed with hypertension
2006 2006 NHMS III NHMS III
2011 NHMS IV
Target BP better in NHMS IV Only 26% achieved target BP while on treatment (NHMS III- 2006) NHMS IV -2011 34.8% achieved target BP • • • • • • •
BP controlled was seen highest in Age > 60 years Males Chinese Those with secondary education Retirees Those with earning > RM5000 per month Urban residents
Malaysian Untreated Hypertensives (Acta Cardiol. 1999;54:277-282 )
NT SBP * 120 (112-130) DBP* 80 ( 78-82 ) MAP * 94 ( 91-97 ) PWV* 8.8 (8.3- 9.6)
HT 169 ( 160-180 ) 100 ( 100-110 ) 123 ( 119-130 ) 11.7 ( 10.9- 12.9 )
Our population most likely needs combination antihypertensive agents
Malaysian Untreated Hypertensives (Acta Cardiol. 1999;54:277-282 )
NT
HT
Se Na *
142.18 + 0.78
146.83 + 2.30
UNaV *
140.58 + 15.65
100.55 + 17.28
Se i Ca*
1.25 + 0.01
1.17 + 0.01
PRA
0.89 + 0.19
0.79 + 0.2
PRC
3.09 + 0.74
4.23 + 1.43
Se Aldo
275 + 21.51
257 + 16.22
“Malaysian hypertensives are salt retainers “ “ Malaysian hypertensives are normoreninaemic hypertensives “
Effective Combinations in Malaysia - Retrospective Review of Record ( Asia Pac J Pharmacol.; 2001:17-24 )
SBP * DBP * dSBP * dDBP
Diuretics ( n=100 ) 140 +2 85+1 30+3 13+2
No Diuretics ( n=100 ) 151+3 88+1 21+3 13+2
Effective Combinations in Malaysia Diuretics
Controlled
66%
No Diuretics
38%
p < 0.0001
What predicts BP control ? By univariate analysis • Statin on admission • Presence of IHD • Diuretics on admission • ACEI on admission • > 2 drugs
Odds 2.53 2.21 2.12 1.97 1.92
p 0.000 0.001 0.002 0.006 0.007
Malaysian Statistics on Medicine 2005 â&#x20AC;˘ reported that 81% of hypertensive patients were on mono-therapy â&#x20AC;&#x201C; hardly sufficient to achieve BP control
Percentage of Patients Requiring ≥ 2 Antihypertensive Drugs to Reach BP Targets 100
90
90
Percent
80 70 60
73
78
63
60
50 40 30 20 10 0
HOT
LIFE
1. HOT: Hansson et al. Lancet. 1998;351:1755–62. 2. LIFE: Dahlöf et al. Lancet. Lancet. 2002;359:995-1003. 3. ALLHAT: Cushman et al. J Clin Hypertens. 2002;4:393–404.
ALLHAT
CONVINCE
ASCOT
4. CONVINCE: Black et al. JAMA. 2003;289:2073-2082. 5. ASCOT: Dahlöf et al. Lancet. 2005;366:895-906.
A typical Malaysian Hypertensive - Back to Reality !
• Diagnosed late • Has other concomitant cardiovascular risk factors • Has complications of hypertension including target organ damage and target organ complications • BP not optimally controlled -Poor compliance -On monotherapy -Not on right medication and right dose
Resistant Hypertension-Definition • Blood pressure remaining above goal in spite of concurrent use of 3 anti- hypertensive agents of different classes. • Ideally, 1 of the 3 agents should be a diuretic and all agents should be prescribed at optimal dose . • The BP goal is <140/90 mmHg in general, and <130/90 mmHg in hypertensive patients with diabetes or chronic kidney disease
Resistant Hypertension-Definition for diagnosing resistant hypertension â&#x20AC;˘ Use of diuretic is recommended but not required. â&#x20AC;˘ Doses should be optimal but not necessarily maximal.
Controlled Resistant Hypertension Patients who require 4 or more medications to control their BP are considered to have resistant hypertension
Pseudoresistance
(appearance lack of BP control) Causes • Inaccurate measurement of BP • Inappropriate drug choices/doses • Suboptimal treatment- frequently due to clinical inertia(provider’s failure to increase therapy when the treatment goal is not reached) • Nonadherence to prescribed therapy • White coat effect - mean daytime BP<135/85mmHG
Contributing Factors for RH Volume expansion • Excess sodium intake • Volume retention secondary to CKD • Inadequate diuretic therapy Obesity
Contributing Factors-Exogenous Substances • • • • • • • • •
Nonsteroidal anti-inflammatory agents/COX-2 Inhibitors Oral contraceptives Alcohol Corticosteroids/anabolic steroids Sympathomimetic agents-nasal decongestants Caffeine Cyclosporine Erythropoietin Antidepressants
Secondary Causes of RH Common • • • •
OSA Renal parenchymal diseases Hyperaldosteronism Renal Artery Stenosis
Uncommon • • • •
Pheochromocytoma Cushing’s disease Hyperparathyroidism Coarctation of aorta
Prevalence of RH â&#x20AC;˘ 5-30% of the overall hypertensive population have resistant hypertension Mancia G. J Hypertens 2007;25: 1105-87
â&#x20AC;˘ Only about 10% of patients have true resistant hypertension Mancia G. J. Hypertens 2007: 25:1105-87 Kaplan NM. J. Hypertens 2005 : 23 :1441-44
Prevalence of RH in Malaysia Prevalence of resistant Hypertension in a multiethnic cohort of hypertensive patients Y.Chia, J. of Hyper Vol 30,e-SupplementA, April 2012,e627
• 1,222 patients attending Primary Care Medicine at UMMC • Target BP : <140/90 mmHG : <130/80 mmHg for diabetic • Overall prevalence of resistant hypertension was 11% 8.1% without DM 13.3% with DM
Prevalence of white coat RH The prevalence of white-coat resistant hypertension(WC-RH) amongst patients referred for catheter based renal denervation(RDN) procedure for true resistant hypertension at National Heart Institute of Malaysia; R. Zambahari •37 patients were enrolled. Inclusion criteria for RDN are those used in Symplicity HPT 1&2 •WC-RH is defined as average daytime ABPM <135/85 •All patients had ABPM assessment •13(35%) had WC-RH and 24(65%) were classified as TRH •The use of ABPM may avoid mislabelling patient with TRH thus avoiding unnecessary tests to look for secondary HPT and expensive invasive procedures
Evaluation • • • •
Measurement technique. Is patient compliant ? Confirm appropriate treatment. Obtain home, work or ambulatory B.P. to exclude white coat HTN. • Identify causes – secondary ? • Look for co-morbid conditions. • Document target organ damage.
Treatment of RH Non pharmacologic therapies • Weight loss • Regular exercise • Low salt intake • Limit alcohol ingestion • Low fat / High fiber diet Interfering subtances should be withdrawn or down titrated Secondary causes should be treated
Pharmacologic Treatment of RH • Full doses of appropriate combination such as ACE I or ARB + CCB + Thiazides diuretics • Long acting thiazides(eg chlorthalidone)are effective.
• Consider adding mineralocorticoid receptor antagonist. -Spironolactone -Eplerenone(more selective and better tolerated • Use of loop diuretic in CKD(Cr Cl < 30 ml/min)
Renal Nerve & Sympathetic Activity:
Kidney as Origin & Recipient of Central Sympathetic Drive
• Vasoconstriction • Atherosclerosis
Afferent Nerves
Efferent Nerves
Blood Pressure
↑ Renin Release RAAS activation ↑ Sodium Retention ↓ Renal Blood Flow ↓ Kidney function
+ Increase co-morbidities
Schlaich et al. Hypertension. 2009;54(6):1195-1201.
• ↑ Contractility • ↑ Heart rate • Hypertrophy • Arrhythmia • Heart Failure
60
Symplicity HTN-2: RDN Superior to Medical Management, Reductions Sustained to 18M Primary Endpoint (6M post Randomisation) RDN (n=49)
∆ from Baseline to 6 Months (mmHg)
Control (n=51)
Systolic Diastolic Diastolic
Systolic
Latest Follow-up (18M post Randomisation)
p <0.0001 for ∆ between RDN and Control
RDN (n=43)
∆ from Baseline to 18 Months (mmHg)
Diastolic
Systolic p <0.01 for ∆ from baseline
Primary Endpoint: •>80% of RDN patients had ≥10 mmHg reduction in SBP •5 patients had ≤ 5mmHG reduction in SBP
Case 1 • • • •
JAR 57 year old Malay lady Hypertension : 1995 No secondary cause found Diabetes Mellitus : since 1995 Rt corona-radiata and internal capsule stroke early 2005 – fully recovered • IHD had PCI to LCx Dec 2005 • Hyperlipidaemia 2005 • BMI 32
Medication Dec 2010: • • • • • • • •
Amlodipine 10 mg o.d Metoprolol 100 mg b.d Perindopril 8 mg o.d Hydrochlorothiazide 25 mg o.d Simvastatin 40 mg o.d Metformin SR 850 mg b.d Diamicron 160 mg b.d Caspirin 100 mg o.d From 2006 to 2010 her BP range 120 -150 systolic 70 – 90 diastolic
• 30 March 2011 presented to ED with Heart Failure. BP was 190/95 mmHg. IV Frusemide 40mg was given. After 24 hrs BP normalised. She was discharged and continued on the same medication • 24 Nov 2011 BP= 200/98 mmHg, 192/93 mmHg after 10 min rest Spironolactone 25 mg was added 24 Hour Ambulatory BP was requested • 26 Jan 2012 BP= 190/95 pulse rate 76/min Prazosin 0.5 mg b.d was added
Ambulatory Blood Pressuring monitoring 18 Jan 2012
• Renal Function Test Electrolyte normal Serum Creatinine 99 umol/L (GFR 61.3ml/min)
• BP Medication: – – – – – –
Amlodipine 10 mg o.d Metoprolol 100 mg b.d Perindopril 8 mg o.d Hydrochlorothiazide 25 mg o.d Spironolactone 25mg o.d Prazosin 0.5mg b.d
Diagnosed as Resistant Hypertension
• What Next? • Renal Artery Denervation
RT Renal Angiogram • Procedure begin at 16:15 • 6 Fr 55cm RDC GC • Selective renal angiogram taken using diluted contrast 1:1
RT Renal Artery Ablation
• Simplicity catheter inserted • 6 ablation given from distal to proximal
• Temp 55°C • 8 Watts for 120 seconds • 15% impedance drop
RT Renal Angiogram Pre & Post Ablation
• Pre Ablation
• Post Ablation
LT Renal Angiogram Pre & Post Ablation
• Pre Ablation
• Post Ablation • Procedure completed 17:15
• Medications given during procedure – – – – –
Heparin 7000 units, IA Fentanyl 0.3mL, IV Midazolan 1mL/h, IV Maxolan 10mg, IV Morphine 5mg, IV
• No post procedure complications • No change in medications • BP on the following day was 140/90 mmHg before discharge
BP and no. of medications pre and post RDN Pre RDN
Discharge 24/2/2012
19/04/2012
30/08/2012
1/11/2012
BP
190/95
140/90
184/84
120/80
160/80
No. of medications
• Amlodipine 10 mg od • Metoprolol 100 mg bd • Perindopril 8 mg od • HCT 25 mg od • Spironolac 25mg od • Prazosin 0.5mg bd
Se Creatinine
99 umol/L
• Prazocin 1mg b.d • Perindopril 8mg o.d • Amlodipine 10mg o.d • Spironolac 12.5mg o.d
123 umol/L
Case 2 • • • • • •
SCM (06821944) 50 yr old Malay man DM 20 years HPT for 20 years- Uncontrolled for the past one year End stage renal failure on HD for 8 years History of Lacunar stroke Medications: - Ibersartan 300mg od - Metoprolol 100mg bd - Methyldopa 250mg tds - Adalat SR 40mg bd - Physiotens 0.4mg od - Rocatriol, CaCo3 - Ticlid 250mg od
• On 25/4/2012 developed LVF due to uncontrolled HPT- BP 222/94mmHg • What next?
RDN using Ardian Catheter • • • • • • •
IV Fentanyl and IV Midazolam RFA approach 6F RDC Lt Renal artery 5sites Rt Renal artery 5 sites Uneventful procedure Discharged the following day with BP 150/80
BP and no. of medications pre and post RDN Pre RDN
Discharge 31/5/2012
25/06/2012
10/09/2012
05/11/2012
BP
192/84
150/80
204/98
122/58
130/70
No. of medications
• Ibersartan 300mg od • Metoprolol 100mg bd • Methyldopa 250mg tds • Adalat SR 40mg bd •Physiotens 0.4mg od
• Physiotens 0.4mg od • Metoprolol 50mg bd • Adalat SR 40mg od
Case 3 â&#x20AC;˘ Vagal Response during Renal Denervation - A prolonged response ?
• 73 year old Male • stable coronary artery disease ( last EST 2011 negative) • Hypertensive • Diabetic • Hyperlipidaemia
Medications : • Valsartan 80 mg o.d • Hydrochlorothiazide 25 mg o.d • Metoprolol 100 mg b.d • Amlodipine 10 mg o.d • Atovastatin 20 mg o.d • Metformin 500 mg t.d.s • Glicazide 80 mg b.d
Echocardiography • LVIDd : 5.0 cm • LVIDs : 3.3 cm • IVSd : 1.7 cm • LVEF : 60% • Trivial mitral and aortic regurgitation
Blood Pressure • Office BP : 165/97 • Average 24-hr BP : 154/90 • Average Day BP : 162/96 • Average Night BP : 138/81
Hemodynamics pre ablation
(L) Renal Angiogram pre ablation
First Ablation
Second Ablation
Status post ablation - Cath Report
Hemodynamics post 2nd ablation
Hemodynamics during procedure (Anaesthetistâ&#x20AC;&#x2122;s chart)
Vasopressin infusion given
BP monitoring during ablation
(L) Renal Angiogram pre ablation
(L) Renal Angiogram post 2 ablations
• Taken to CCU for monitoring • All anti hypertensives stopped • BP gradually pick up over 24 hours • Transferred well to the normal ward after 2 days CCU monitoring • Discharged home well with no antihypertensives • BP on discharge : 110/70 mmHg
Progress
Pre ablation
2 weeks post ablation
1 month post ablation
3 months post ablation
Office BP
165/97
120/80
156/83
160/85
Average 24hr BP
154/90
127/79
150/80
140/83
Average Day BP
162/96
134/84
160/87
146/86
Average Night BP
138/80
118/74
131/71
131/87
Anti HPT drugs
None
None
Norvasc 10 mg dly
Norvasc 10 mg dly Valsartan 160 mg dly
Case 4 • • • • •
Mr HBM 66 year old Malay man Stable Angina with 3 vessel disease for CABG HPT for 10 years. SBP always in 200 mmHg range. Hyperlipidemia BMI 27
Medication : • Metoprolol 50 mg BD • Amlodipine 10 mg OD • Valsartan 160 mg OD • HCTZ 12.5 mg OD Renal function: Serum Creatinine 117 umol/L (GFR 60 mls / min)
Serial Office BP 16.1.2013
29.1.2013
4.2.2013
200/ 120
192/92
230/ 100
mmHg
No ABPM done RDN was offered for BP control prior to CABG
Hemodynamics before RDN
200
Hemodynamics During first ablation
160
Hemodynamics at the end of 2nd ablation
100
Hemodynamics post procedure after IV Atropine and IV Normal Saline
130
Next day review BP overnight 140/80 mmHg Medications: • Bisoprolol 5 mg OD • Amlodipine 10 mg OD
Future Development in the Horizon
New Drugs for Hypertension Several pharmacological targets have been discovered with promising pre-clinical results, however the clinical development of novel antihypertensive drugs have been more difficult and less productive than expected
Comprehensive SYMPLICITY Clinical Trial Program follows over 5000 patients across multiple indications First-in-Man First-in-Man(AU) (AU)
Symplicity HTN-1 Series SeriesofofPilot PilotStudies Studies (EU, US & AU) (EU, US & AU) Symplicity SymplicityHTN-2 HTN-2 Initial InitialRCT RCT (EU & AU) (EU & AU)
SYMPLICITY SYMPLICITYHTN-3 HTN-3 US USPivotal PivotalTrial Trial(US) (US)
Global GlobalSYMPLICITY SYMPLICITY Registry Registry (Approved (ApprovedRegions) Regions)
Expand ExpandHTN HTNIndication Indication (Approved (ApprovedRegions) Regions)
Trials under way
Pilot PilotStudies Studiesinin New NewIndications Indications (Approved (ApprovedRegions) Regions)
Conclusion • In Malaysia, the prevalence of HPT is high but levels of awareness, treatment and control are low. • Successful treatment of hypertension is difficult despite the availability of several classes of antihypertensive drug and strategies to tackle the effect of adverse lifestyle behaviors on blood pressure • A substantial subset of patients exists in whom adequate control of blood pressure cannot be achieve despite prescribing and taking of several appropriate antihypertensive medication
Conclusion • Renal Denervation therapy(RDN) is a novel and exciting technology which offers an organ-specific strategy to decrease SNS activity and to manage HPT • Many centres are gaining experience and plenty more to be learn-more data will be presented/published • Appropriate patient selection is crucial for treatment success of RDN and emphasize the importance of F/U care and continued adherence to all antiHPT medication • Many new devices and procedures are in the pipeline, thus leading to a new era of outcome trials and evidence-based guidelines
This is not the end. It is not even the beginning of the end. But it is, perhaps the end of the beginning (Sir Winston S. Churchill)
-Thank You-
Original Entry Criteria
Reasons
1)
Renal artery ≥ 4mm in diameter and ≥ 20mm length
Large enough artery to deliver energy
2)
Age ≥ 18
Able to consent for study
3)
Systolic BP ≥ 160mmHG (average of 3 office reading)
Ensure consistency in the study population
4)
Adhering to 3+ anti-HTN drugs
Ensure consistency in the study population
5)
eGFR at ≥ 45
Extra careful in FIM and early clinical experience
Original Entry Criteria
Reasons
6)
Wanted to treat ideal anatomies
7)
No renal arterial abnormality – No significant renal artery stenosis – No prior renal artery intervention – No multiple renal arteries in either kidney No ACS or CVA within 6 months at screening No wide spread atherosclerosis
Not to confuse events due to underlying disease from events associated with renal denervation
8)
No heamodynamically significant valvular heart disease
Drops in BP in these patient may not be desirable
9)
No Type 1 DM
Long-standing Type 1 DM have much higher rates of CV complication and renal failure
10) No ICD or pacemaker
The devices may be adversely affected by RF ablation
11) Not pregnant, nursing
Radiation, contrast and procedure have not been studied in the setting of pregnancy