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BackgroundSystemic hypertension is an important public health problem and a significant cause of cardiovascular mortality. Its high prevalence and the low rates of blood pressure control have resulted in the search for alternative therapeutic strategies. Percutaneous renal sympathetic denervation emerged as a perspective in the treatment of patients with resistant hypertension. ObjectiveTo evaluate the feasibility and safety of renal denervation using an irrigated catheter. MethodsTen patients with resistant hypertension underwent the procedure. The primary endpoint was safety, as assessed by periprocedural adverse events, renal function and renal vascular abnormalities at 6 months. The secondary endpoints were changes in blood pressure levels (office and ambulatory monitoring) and in the number of antihypertensive drugs at 6 months. ResultsThe mean age was 47.3 (± 12) years, and 90% of patients were women. In the first case, renal artery dissection occurred as a result of trauma due to the long sheath; no further cases were observed after technical adjustments, thus showing an effect of the learning curve. No cases of thrombosis/renal infarction or death were reported. Elevation of serum creatinine levels was not observed during follow-up. At 6 months, one case of significant renal artery stenosis with no clinical consequences was diagnosed. Renal denervation reduced office blood pressure levels by 14.6/6.6 mmHg, on average (p = 0.4 both for systolic and diastolic blood pressure). Blood pressure levels on ambulatory monitoring decreased by 28/17.6 mmHg (p = 0.02 and p = 0.07 for systolic and diastolic blood pressure, respectively). A mean reduction of 2.1 antihypertensive drugs was observed. ConclusionRenal denervation is feasible and safe in the treatment of resistant systemic arterial hypertension. Larger studies are required to confirm our findings.

BackgroundIt remains unclear into which level the systolic blood pressure (SBP) should be lowered in order to provide the best cardiovascular protection among older people. Hypertension guidelines recommendation on attaining SBP levels <150 mmHg in this population is currently based on experts’ opinion. To clarify this issue, we systematically reviewed and quantified available evidence on the impact of achieving different SBP levels <150 mmHg on various adverse outcomes in subjects aged ≥60 years old receiving antihypertensive drug treatment.MethodsWe searched 8 databases to identify randomized controlled trials (RCTs) and post-hoc analyses or subanalyses of RCTs reporting the effects of attaining different SBP levels <150 mmHg on the risk of stroke, acute myocardial infarction, heart failure, cardiovascular mortality and all-cause mortality in participants aged ≥60 years. We performed random-effects meta-analyses stratified by study design.ResultsEleven studies (> 33,600 participants) were included. Compared with attaining SBP levels ≥140 mmHg, levels of 130 to <140 mmHg were not associated with lower risk of outcomes in the meta-analysis of RCTs, whereas there was an associated reduction of cardiovascular mortality (RR 0.72, 95% CI 0.59–0.88) and all-cause mortality (RR 0.86, 95% CI 0.75–0.99) in the meta-analysis of post-hoc analyses or subanalyses of RCTs. Limited and conflicting data were available for the SBP levels of <130 mmHg and 140 to <150 mmHg.ConclusionsAmong older people, there is suggestive evidence that achieving SBP levels of 130 to <140 mmHg is associated with lower risks of cardiovascular and all-cause mortality. Future trials are required to confirm these findings and to provide additional evidence regarding the <130 and 140 to <150 mmHg SBP levels.Electronic supplementary materialThe online version of this article (10.1186/s12877-017-0672-4) contains supplementary material, which is available to authorized users.

A 29-year-old woman with essential resistant systemic hypertension for 17 years was referred for catheterbased renal sympatethic denervation (RSD). Despite optimal medical therapy including 9 different antihypertensive drugs (thiazides, angiotensin-converting enzyme inhibitors, calcium channel blockers, espironolactone, a-agonists, hidralazine, b-blockers, a-blockers, and amiloride), her mean blood pressure (BP) was 142/ 102 mm Hg (ambulatory BP monitoring measurement). The patient was hospitalized for 1 week before the procedure to exclude the diagnosis of pseudo-resistant hypertension. The benefits and complications were explained in detail before signing informed consent.Under conscious sedation, an 8F-long sheath was introduced into the right femoral artery and advanced to the aorta. Bilateral angiography revealed a left renal artery with a diameter of 5.2 mm and length of 10.9 mm and a right renal artery with a diameter of 5.1 mm and a length of 24 mm. A total of 5 lesions were circumferentially applied to the right renal artery with a distance of at least 5 mm between each lesion using an open-irrigated catheter. The duration of each lesion was 60 seconds. Satisfactory impedance drop was observed during each ablation point signifying appropriate tissue heating. At the end of the ablation, dye injection demonstrated signs of dissection most likely due to trauma caused by the long sheath at the ostia. A stent was immediately deployed with success and there were no apparent complications. Given that, in addition to unfavorable left renal artery anatomy, the decision was made to stop the procedure. The catheters were removed and manual compression was carried out. The patient was discharged 3 days later in stable condition and on 2 antihypertensive drugs. At 1-month follow-up, one more antihypertensive agent was added to the therapy (BP = 146/106 mm Hg). Ambulatory BP monitoring at 3 months demonstrated a mean BP of 133/ 82 mm Hg. At 6 months, the patient was still taking 3 medications, and mean BP was 132/78 mm Hg (Table). Renal angiography at 6 months revealed patent stent and no renal artery abnormalities. DISCUSSIONThis unique case suggests that unilateral catheter-based RSD may reduce BP in patients with resistant hypertension. Radiofrequency catheter ablation has been used for the treatment of cardiac arrhythmias for several decades. Recent studies have shown benefits of catheterbased RSD as an alternative strategy for BP control in patients with resistant chronic hypertension. Lesion formation depends on several factors such as proper electrode-tissue contact, power and duration applied, and type of catheter used, among others. In several clinical settings such as left ventricular tachycardia ablation, it is crucial to generate lesions deeply enough to penetrate into the myocardial tissue. However, excessive electrode tip temperature may lead to coagulum and char formation, which limits power delivery. That being said, many efforts have been undertaken in order to optimize power delivery into the myocar...

This study evaluated the daily practice in a regional PICU, and it demonstrated that analgesic and sedative infusions in children submitted to mechanical ventilation are used according to an uncontrolled pattern (average 1.7 drugs/patient/day) and those classified as clinical patients used these drugs for longer periods, what could explain the higher prevalence of abstinence syndrome in this group.

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Background: Renal sympathetic denervation (RSD) is a promising strategy in the treatment of resistant hypertension. No studies have assessed the effect of RSD on quality of life in our country, which was the aim of this study. Methods: The EuroQol 5 Dimensions questionnaire (EQ 5D 5L) was chosen to evaluate quality of life in 10 patients undergoing RSD, and it was applied before and 3 months after the procedure. Results: Mean age was 47.3 ± 12 years and 90% of the patients were female. Baseline blood pressure was 187 ± 37.5/104 ± 18.5 mmHg and the number of antihypertensive drugs was 7.6 ± 1.3. Before the procedure, the value assigned to health status was 37.5 ± 22.7, increasing at 3 months to 70.5 ± 20.9 (P = 0.01). In the follow-up, in addition to a decrease in the number of antihypertensive drugs (7.6 ± 1.3 vs. 6 ± 2.2; P = 0.05), a trend towards reduced levels of systolic blood pressure (187 ± 36 mmHg vs 170 ± 44 mmHg; P = 0.10) and diastolic blood pressure (104 ± 18 mmHg vs 98 ± 20 mmHg; P = 0.20) was observed. Health status improvement resulted from a reduction of problems related to mobility, usual activities, pain/discomfort and anxiety/depression. The magnitude of blood pressure reduction was not associated with improved quality in all of the patients. On the other hand, those who had a decrease in the number of antihypertensive drugs reported a better health status. Conclusions: Patients with resistant hypertension have poor health status scores. RSD improved quality of life in most patients. Further studies are required to confirm consistent benefits.

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