Interventional procedures and future drug therapy for hypertension

Abstract

Hypertension management poses a major challenge to clinicians globally once non-drug (lifestyle) measures have failed to control blood pressure (BP). Although drug treatment strategies to lower BP are well described, poor control rates of hypertension, even in the first world, suggest that more needs to be done to surmount the problem. A major issue is non-adherence to antihypertensive drugs, which is caused in part by drug intolerance due to side effects. More effective antihypertensive drugs are therefore required which have excellent tolerability and safety profiles in addition to being efficacious. For those patients who either do not tolerate or wish to take medication for hypertension or in whom BP control is not attained despite multiple antihypertensives, a novel class of interventional procedures to manage hypertension has emerged. While most of these target various aspects of the sympathetic nervous system regulation of BP, an additional procedure is now available, which addresses mechanical aspects of the circulation. Most of these new devices are supported by early and encouraging evidence for both safety and efficacy, although it is clear that more rigorous randomized controlled trial data will be essential before any of the technologies can be adopted as a standard of care.

Keywords: Arteriovenous anastomosis; Baroreflex activation; Drug therapy; Hypertension; Renal denervation; Sympathetic nervous system.

Figure 1

Interventional procedures for hypertension.

Figure 2

Randomized controlled trials of renal denervation SBP, systolic BP; ABP, ambulatory BP. Image supplied courtesy of Dr K Chan.

Figure 3

(A) ROX device and placement under fluoroscopic guidance. (B) Immediate, verifiable BP reduction with coupler opening and reversal with closure. (images reproduced with permission of ROX Medical).

Figure 4

Drugs targeting the renin–angiotensin–aldosterone system. Neprilysin also contributes to breakdown of Angiotensin II and thus Neprilysin inhibition is combined with angiotensin receptor blockade in the ARNI class of drugs (angiotensin receptor neprilysin inhibitor). ACE, angiotensin-converting enzyme; Ang, angiotensin; APA, aminopeptidase A; APN, aminopeptidase N; AS, aldosterone synthase; MR, mineralocorticoid receptor; AT, angiotensin; AT1-R/AT2-R, angiotensin 1-, 2-receptor; ANP, atrial natriuretic peptide; BNP, brain natriuretic peptide.