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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Among percutaneous techniques&#44; renal sympathetic denervation has probably generated the greatest expectations in recent years&#46; The possibility of non-pharmacological treatment of hypertension has aroused interest not only in the medical and scientific community but also in the non-specialist media and the general population&#46; Pilot studies<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a> reported results that many considered too good to be true&#44; but despite this skepticism&#44; they were also too good to be ignored&#44; given the large scale of this health problem&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4</span></a> The technique is commercially available in many countries and has been applied primarily in patients with resistant hypertension&#46; It is estimated that&#44; two years after the publication of the Symplicity HTN-2 study&#44; over 5000 patients have been treated&#46; The initial experience of centers using the technique has been similar to that reported in the pilot studies&#44;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6</span></a> although with a higher but still acceptable rate of non-responders&#46; Registries have been established whose preliminary results have gone some way to validating the method&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#8211;9</span></a> Another important development has been the widening of selection criteria to include less severe forms of hypertension&#44; which is contrary to the recommendations of medical societies&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#8211;14</span></a> Nevertheless&#44; even here the results have been favorable in terms of safety and hemodynamic benefits&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> Other benefits have also been reported&#44;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> including improvements in glucose metabolism and diabetic status&#44; left ventricular mass index and diastolic function&#44; reduced recurrence of atrial fibrillation following pulmonary vein isolation&#44; and control of ventricular arrhythmias refractory to medical therapy&#46; Other conditions that are characterized by hyperactivation of the sympathetic nervous or renin&#8211;angiotensin&#8211;aldosterone systems&#44; such as heart failure&#44; have been suggested as therapeutic targets and clinical trials have begun&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> Many companies have joined the &#8216;gold rush&#8217; and developed renal denervation systems using radiofrequency&#44; ultrasound&#44; cryoablation or neurotoxins&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> Many other systems have appeared on the European market and pilot studies report similar results to the original model&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Interest in the technique grew exponentially until January 9&#44; 2014&#44; when the announcement<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> that the Symplicity HTN-3 study had failed to meet the primary efficacy endpoint curbed this enthusiasm&#46; Although details are still awaited&#44; many clinical trials have been suspended &#40;HTN-Japan&#44; HTN-India and Symplicity HTN-4 in the US&#41;&#44; as has the activity of many centers&#46; The Symplicity HTN-3 trial<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> was designed to meet the requirements of the US Food and Drug Administration for possible approval&#46; The differences between this and previous Symplicity HTN studies included the larger sample size &#40;530 patients&#41;&#44; use of ambulatory blood pressure monitoring in patient selection&#44; and a sham procedure in a control group&#44; blinded to the patients and investigators responsible for blood pressure measurement&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> The primary efficacy endpoint was whether renal sympathetic denervation reduced office systolic blood pressure at six months&#44; but it did not&#44; which in the absence of additional data has led to much speculation&#46; An important aspect of the trial was the fact that blinding was ended at six months&#44; with control group patients being offered the procedure&#46; This invalidates any comparison between the groups in a longer follow-up&#44; which may well be necessary for the placebo effect to wear off&#46; Previous studies suggest that the placebo effect may help control stage 1 and 2 hypertension for 12 months in a third of patients&#44; with a similar adverse effect rate to active treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> The rate of major blood pressure elevation is higher&#44; but this occurred after more than 12 months in over 50&#37; of cases&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> Thus&#44; the placebo effect appears to lose its therapeutic effect over time and a high crossover rate in the Symplicity HTN-3 trial may compromise any analysis&#46; The insignificant difference between blood pressure at baseline and at six months in the group undergoing renal denervation is a more serious concern for the future of the technique&#46; It also calls into question the results not only of the previous Symplicity trials but also of the Global Symplicity Registry&#44; pilot studies using other systems&#44; and single-center registries and experiences like the one by Dores et al&#46; published in this issue of the <span class="elsevierStyleItalic">Journal</span>&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">What lies behind the conflicting results&#63; In Kant&#39;s philosophy&#44; phenomena represent the world as we perceive it&#44; as distinguished from noumena or things-in-themselves&#44; the world that exists independently of our experience&#46; How important are the patient&#39;s perception&#44; the investigator&#39;s bias and the procedure itself&#63; Is renal sympathetic denervation and associated blood pressure reduction phenomenon or noumenon&#63;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0020" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare&#46;</p></span></span>"
    "textoCompletoSecciones" => array:1 [
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Infante de Oliveira E&#46; Desnerva&#231;&#227;o simp&#225;tica renal &#8211; fen&#243;meno ou n&#250;meno&#63; Rev Port Cardiol&#46; 2014&#59;33&#58;205&#8211;206&#46;</p>"
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