Blood pressure changes after renal denervation at 10 European expert centers

We did a subject-level meta-analysis of the changes (Δ) in blood pressure (BP) observed 3 and 6 months after renal denervation (RDN) at 10 European centers. Recruited patients (n=109; 46.8% women; mean age 58.2 years) had essential hypertension confirmed by ambulatory BP. From baseline to 6 months, treatment score declined slightly from 4.7 to 4.4 drugs per day. Systolic/diastolic BP fell by 17.6/7.1 mm Hg for office BP, and by 5.9/3.5, 6.2/3.4, and 4.4/2.5 mm Hg for 24-h, daytime and nighttime BP (P0.03 for all). In 47 patients with 3- and 6-month ambulatory measurements, systolic BP did not change between these two time points (P0.08). Normalization was a systolic BP of <140 mm Hg on office measurement or <130 mm Hg on 24-h monitoring and improvement was a fall of 10 mm Hg, irrespective of measurement technique. For office BP, at 6 months, normalization, improvement or no decrease occurred in 22.9, 59.6 and 22.9% of patients, respectively; for 24-h BP, these proportions were 14.7, 31.2 and 34.9%, respectively. Higher baseline BP predicted greater BP fall at follow-up; higher baseline serum creatinine was associated with lower probability of improvement of 24-h BP (odds ratio for 20-μmol l(-1) increase, 0.60; P=0.05) and higher probability of experiencing no BP decrease (OR, 1.66; P=0.01). In conclusion, BP responses to RDN include regression-to-the-mean and remain to be consolidated in randomized trials based on ambulatory BP monitoring. For now, RDN should remain the last resort in patients in whom all other ways to control BP failed, and it must be cautiously used in patients with renal impairment

Blood pressure response to renal denervation is correlated with baseline blood pressure variability: a patient-level meta-analysis

Background: Sympathetic tone is one of the main determinants of blood pressure (BP) variability and treatment-resistant hypertension. The aim of our study was to assess changes in BP variability after renal denervation (RDN). In addition, on an exploratory basis, we investigated whether baseline BP variability predicted the BP changes after RDN. Methods: We analyzed 24-h BP recordings obtained at baseline and 6 months after RDN in 167 treatmentresistant hypertension patients (40% women; age, 56.7 years; mean 24-h BP, 152/90 mmHg) recruited at 11 expert centers. BP variability was assessed by weighted SD [SD over time weighted for the time interval between consecutive readings (SDiw)], average real variability (ARV), coefficient of variation, and variability independent of the mean (VIM). Results: Mean office and 24-h BP fell by 15.4/6.6 and 5.5/ 3.7 mmHg, respectively (P < 0.001). In multivariable-adjusted analyses, systolic/diastolic SDiw and VIM for 24-h SBP/DBP decreased by 1.18/0.63 mmHg (P 0.01) and 0.86/0.42 mmHg (P 0.05), respectively, whereas no significant changes in ARV or coefficient of variation occurred. Furthermore, baseline SDiw (P ¼ 0.0006), ARV (P ¼ 0.01), and VIM (P ¼ 0.04) predicted the decrease in 24-h DBP but not 24-h SBP after RDN. Conclusion: RDN was associated with a decrease in BP variability independent of the BP level, suggesting that responders may derive benefits from the reduction in BP variability as well. Furthermore, baseline DBP variability estimates significantly correlated with mean DBP decrease after RDN. If confirmed in younger patients with less arterial damage, in the absence of the confounding effect of drugs and drug adherence, baseline BP variability may prove a good predictor of BP response to RDN

Directional atherectomy for treatment of restenosis within coronary stents: clinical, angiographic and histologic results

Abstract OBJECTIVES: The safety and long-term results of directional coronary atherectomy in stented coronary arteries were determined. In addition, tissue studies were performed to characterize the development of restenosis. METHODS: Directional coronary atherectomy was performed in restenosed stents in nine patients (10 procedures) 82 to 1,179 days after stenting. The tissue was assessed for histologic features of restenosis, smooth muscle cell phenotype, markers of cell proliferation and cell density. A control (no stenting) group consisted of 13 patients treated with directional coronary atherectomy for restenosis 14 to 597 days after coronary angioplasty, directional coronary atherectomy or laser intervention. RESULTS: Directional coronary atherectomy procedures within the stent were technically successful with results similar to those of the initial stenting procedure (2.31 +/- 0.38 vs. 2.44 +/- 0.35 mm). Of five patients with angiographic follow-up, three had restenosis requiring reintervention (surgery in two and repeat atherectomy followed by laser angioplasty in one). Intimal hyperplasia was identified in 80% of specimens after stenting and in 77% after coronary angioplasty or atherectomy. In three patients with stenting, 70% to 76% of the intimal cells showed morphologic features of a contractile phenotype by electron microscopy 47 to 185 days after coronary intervention. Evidence of ongoing proliferation (proliferating cell nuclear antigen antibody studies) was absent in all specimens studied. Although wide individual variability was present in the maximal cell density of the intimal hyperplasia, there was a trend toward a reduction in cell density over time. CONCLUSIONS: Although atherectomy is feasible for the treatment of restenosis in stented coronary arteries and initial results are excellent, recurrence of restenosis is common. Intimal hyperplasia is a nonspecific response to injury regardless of the device used and accounts for about 80% of cases of restenosis. Smooth muscle cell proliferation and phenotypic modulation toward a contractile phenotype are early events and largely completed by the time of clinical presentation of restenosis. Restenotic lesions may be predominantly cellular, matrix or a combination at a particular time after a coronary procedure

Balloon angioplasty in the treatment of coronary artery disease : clinical and angiographic assessment

Cardiac catheterisation began with the self-demonstration by Forssmann in 1929 of the feasibility of introducing a catheter into the human heart without complication. In the early 1930’s, Castellanos and others performed the first visualization of cardiac anatomy using opaque media and X-rays. Later on, in the 1940’s, Cournand and others pioneers, including Lenegre and Lequime, performed right heart catheterization providing valuable information about cardiovascular physiology and from 1945 catheterization was used for diagnostic purpose in living patients. With the development of selective angiography, imaging information was added and the heart became one of the most accessible organs for physiologists and clinicians. During the first decades, catheterization growth was essentially related to the continuing progress in surgical technique for treating congenital cardiac disease, acquired valvular disease, which remains the prime killer in western countries, has led to an explosive growth of selective coronary arteriography since the first case performed by Sones in 1958. A new field of activity – and probably a new area) emerged in 1977 when Gruentzig introduced percutaneous transluminal coronary angioplasty, becoming the pioneer of interventional cardiology. Since this successful experience, catheterization laboratory practice has moved from an exclusively diagnostic to an interventional therapeutic approach for different cardiovascular disorders, but essentially for coronary artery disease. This was also the case in our laboratory since the year 1981. Our initial experience demonstrated that angina could be substantially relieved by successful balloon angioplasty in symptomatic patients with single or double vessel disease, allowing to rapidly extend the technique to more complex clinical and anatomical cases. Application of angioplasty in patients with unstable angina or impending myocardial infarction confirmed the efficacy of the technique in selected cases with complex, fissured plaques, even in the presence of partial or extensive thrombus formation, as observed in total coronary occlusion. Finally, experience demonstrated that angioplasty, usually in combination with the use of thrombolytic drugs, could be performed with success in evolving or recent acute myocardial infarction. In this broad spectrum of clinical indication, the goal of angioplasty as revascularization procedure may vary. In elective procedures for stable angina, the goal of suppressing coronary obstruction is to relieve symptomatic exercise induced myocardial ischemia in order to improve the quality of life of these patients. Part A of this work reviews general data on immediate and long term results in a large group of consecutive patients, focusing on the clinical follow-up and the restenosis probability and detection. In acute coronary syndromes, angioplasty procedure aims not only at the coronary vessel patency but essentially at the reperfusion of the jeopardized myocardial area in order to prevent or limit the usually present left ventricular dysfunction, which is the strongest predictive parameter for mortality on patients with coronary artery disease. Part B deals with the effects of successful angioplasty on left ventricular function in patients with impending or evolving myocardial infarction. In summary, this work was aimed to critically analysis some specific aspects of coronary angioplasty used as a therapeutic tool in clinical practice. The intent was not to compile extensive theoretical, technical or experimental data but to concentrate on the observations and results proceeding from our clinical experience in this field. This work is far from being a textbook or an encyclopaedia, but perhaps the lessons emerging will improve our daily practice and benefit the patient. In absence of such final results, it would not have achieved its purposeThèse d'agrégation de l'enseignement supérieur (faculté de médecine) -- UCL, 199

Histoire de l’angioplastie coronaire : 40 ans déjà !

Depuis son introduction en 1977 par Andreas Grüntzig à Zurich, l’angioplastie coronaire a pris une place prépondérante dans les techniques de revascularisation myocardique grâce à des développements techniques et pharmacologiques constants. Une dizaine d’années après les premiers cathéters à ballonnet, l’introduction des endoprothèses (stents) a permis d’une part de réduire les complications aiguës et les récidives tardives mais aussi d’appliquer avec succès cette technique aux syndromes coronariens aigus. Une décennie plus tard le développement des stents à élution de drogue a permis de positionner l’angioplastie comme alternative crédible par rapport au pontage coronarien et devenir le traitement de référence en matière de maladie coronarienne. Cet article va parcourir l’histoire de ces quatre décennies, en préciser les étapes marquantes, les réussites mais aussi les doutes et les difficultés inhérentes aux avancées médicales successives

Clinical benefit of angiotensin converting enzyme inhibition after acute myocardial infarction: myocardial reperfusion revisited.

BACKGROUND: Beneficial effect has been reported from angiotensin converting enzyme (ACE) inhibition after acute myocardial infarction (AMI) in several experimental and large clinical studies showing improvements in haemodynamics, left ventricular remodelling and mortality. However, this benefit has not been prospectively evaluated after AMI effectively reperfused using current coronary recanalization techniques. CLINICAL ISSUE: The clinical relevance of reperfusion therapies including thrombolysis or percutaneous transluminal coronary angioplasty relates to their ability to limit infarct size and left ventricular dysfunction and reduce infarct-related morbidity and mortality. The clinical issue is to determine whether ACE inhibitors should be routinely proposed as an adjunct therapy in patients with a patent infarct-related vessel after AMI. RESULTS OF RECENT STUDIES: Three placebo-controlled randomized trials addressed this issue in evaluating the left ventricular remodelling process (i.e. left ventricular volumes and ejection fraction changes) during a 3 to 4-month follow-up period. The Captopril and Thrombolysis Study and the Captopril plus Tissue plasminogen activator after Myocardial Infarction trials failed to show any significant preventive effect of early captopril therapy on remodelling in patients admitted for anterior AMI and treated with conventional use of streptokinase and alteplase, respectively. In the Salvage from Perindopril in Reperfused Infarction Trial, no beneficial effect on global left ventricular remodelling was observed from perindopril therapy in a population with effective myocardial reperfusion confirmed at angiography and moderately depressed left ventricular function. However, in this study ACE inhibition seemed to favourably alter remodeling in a subgroup of AMI patients with anterior location and large infarct size despite successful reperfusion. CONCLUSION: Recommendation for ACE inhibition as a routine adjunct therapy to reperfusion techniques is not supported by current data on short-term left ventricular function changes

The place of the analysis of exhaled breath condensate in obstructive pulmonary diseases

peer reviewedThe number of publications on the analysis of the exhaled breath condensate (EBC) has increased considerably over the last five years. The EBC is a new, noninvasive and inexpensive technique which requires a minimum of cooperation on behalf of the patient. The condensate obtained consists of more than 99.99% of water vapour, to which are added various substances which reflect the inflammatory status of the airways. It is now especially used to characterize the inflammatory state of chronic respiratory diseases such as asthma and COPD. This article describes the technique and reviews the main data from the current literature