Device Therapies for Resistant Hypertension

Abstract

Purpose: Resistant hypertension (RH) is a major and growing public health problem. While noncompliance to antihypertensive medication is a major concern in RH patients, it is estimated that even with adequate multi-drug regimens, approximately 10% of patients diagnosed with hypertension fulfill the criteria of true RH. Patients with sustained blood pressure (BP) elevation display high risk for development of target organ damage and associated cardiovascular morbidity and mortality. While optimized pharmacologic therapy, including the use of mineralocorticoid receptor antagonists to guideline-based antihypertensive drug therapy, is effective for improving BP control in this patient cohort, a sizable proportion of RH patients' BP remains uncontrolled, and alternative therapeutic strategies are warranted.

Methods: In the past few years, device-based approaches have been studied extensively. Among these, robust clinical experience in patients with RH exists for renal denervation, baroreflex activation therapy, central arteriovenous anastomosis, and, to a lesser extent, deep brain stimulation. Carotid body modulation is the most recent approach under clinical investigation. The common aim of these approaches is direct targeting of relevant pathophysiologic mechanisms involved in BP control, most commonly activation of the sympathetic nervous system.

Findings: This review article briefly summarizes relevant clinical and experimental evidence and highlights the potential utility, as well as limitations, of each approach.

Implications: Several device-based approaches show promise in the treatment of RH and have been associated with improved BP control, while generally finding an acceptable side effect profile. Ongoing research is addressing relevant issues relating to patient selection and technical and procedural aspects, and will help to define the future role of device-based approaches for RH in the next few years.

Keywords: baroreflex; denervation; devices; resistant hypertension; sympathetic.