Editorial comment
Renal denervation in heart failure: Modulating the sympathetic nervous system
Desnervação renal na insuficiência cardíaca: modular o sistema nervoso simpático
Joana Delgado Silva
Centro Hospitalar e Universitário de Coimbra, Hospital Geral, Coimbra, Portugal
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RDN: renal denervation.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Jun-Qing Gao, Yun Xie, Wei Yang, Jian-Pu Zheng, Zong-Jun Liu" "autores" => array:5 [ 0 => array:2 [ "nombre" => "Jun-Qing" "apellidos" => "Gao" ] 1 => array:2 [ "nombre" => "Yun" "apellidos" => "Xie" ] 2 => array:2 [ "nombre" => "Wei" "apellidos" => "Yang" ] 3 => array:2 [ "nombre" => "Jian-Pu" "apellidos" => "Zheng" ] 4 => array:2 [ "nombre" => "Zong-Jun" "apellidos" => "Liu" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S0870255116303559" "doi" => "10.1016/j.repc.2016.07.007" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255116303559?idApp=UINPBA00004E" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204916302719?idApp=UINPBA00004E" "url" => "/21742049/0000003600000001/v1_201701200114/S2174204916302719/v1_201701200114/en/main.assets" ] "en" => array:12 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Editorial comment</span>" "titulo" => "Renal denervation in heart failure: Modulating the sympathetic nervous system" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "53" "paginaFinal" => "54" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "Joana Delgado Silva" "autores" => array:1 [ 0 => array:3 [ "nombre" => "Joana" "apellidos" => "Delgado Silva" "email" => array:1 [ 0 => "joanadelgadosilva@gmail.com" ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Centro Hospitalar e Universitário de Coimbra, Hospital Geral, Coimbra, Portugal" "identificador" => "aff0005" ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Desnervação renal na insuficiência cardíaca: modular o sistema nervoso simpático" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Heart failure (HF) is frequently the end-stage of many cardiovascular diseases and remains a major cause of morbidity and mortality, with 26 million patients now affected worldwide.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">1</span></a> Its prevalence is around 1-2% in developed countries, rising to ≥10% among people over 70 years of age. The terminology of HF has recently been redefined and patients with an ejection fraction (EF) of 40-49% (the so-called ‘gray area’) now being classified as having ‘heart failure with mid-range ejection fraction’, as opposed to ‘HF with reduced EF’ (<40%) and ‘HF with preserved EF’ (EF ≥50%).<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The pathophysiology of HF is highly complex and involves the activation of compensatory mechanisms including the renin-angiotensin-aldosterone system, the sympathetic nervous system (SNS) and arginine vasopressin release, probably as a consequence of hemodynamic changes induced by a dysfunctional myocardium.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">3</span></a> Activation of the SNS leads to excessive release and decreased uptake of norepinephrine. This autonomic hyperactivity has long been known to be directly related to the worsening of HF, by inducing myocyte enlargement and interstitial growth and remodeling, leading to increased myocardial mass and chamber dilatation.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">4</span></a> The SNS thus became a therapeutic target, and there is evidence that continuing pharmacological beta-blockade has favorable prognostic implications in both ischemic and non-ischemic cardiomyopathies.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">5</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Renal denervation (RDN) is a percutaneous procedure which aims to achieve selective disruption of the sympathetic nerve endings in the renal arterial wall. It is currently under investigation as a promising technique for the treatment not only of hypertension (with varying treatment effects) but also of other clinical entities associated with an increased sympathetic drive such as advanced HF, sleep apnea and life-threatening cardiac arrhythmias.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">6</span></a> Two pilot studies have been published that aimed to prove the effectiveness of RDN in patients with HF. The REACH-Pilot was a first-in-man study which assessed the safety of RDN in seven patients with symptomatic chronic systolic HF (New York Heart Association [NYHA] class III or IV), EF of 45±15% and without hypertension. At six months all patients were symptomatically improved, there was an increase in the six-minute walk distance (Δ=27.1±9.7 m, p=0.03) and diuretics were reduced or stopped in four patients (p=0.046). No significant differences were observed in EF. This study had clear limitations (population and design, among others) and was underpowered for several parameters, but established the need for additional evidence.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">7</span></a> Chen et al. conducted a randomized prospective pilot study which included 60 patients (30 in the RDN group and 30 in the optimal medical therapy group) in NYHA II-IV with EF ≤40%. Renal denervation was performed with a saline irrigated catheter. At six-month follow-up EF (from 31.1±5.7% to 41.9±7.9%, p<0.001), the six-minute walk distance (from 285.5±84.3 m to 374.9±91.9 m, p=0.043), NYHA classification (p<0.001) and NT-pro-BNP levels (p<0.001) were significantly improved in the RDN group. There were no safety concerns and there was no difference in blood pressure between the groups.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">8</span></a> Again, this study had several limitations, such as sample size, and data from two randomized trials which are currently recruiting are eagerly awaited.<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">9,10</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">As the relationship between HF and the SNS is robust and the available clinical data is promising, evaluation of the effects of RDN in patients with reduced EF is appropriate. Is this issue of the <span class="elsevierStyleItalic">Journal</span>, Gao et al.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">11</span></a> present the results of a prospective, open, single-arm study which included fourteen patients with an EF below 45% (eight with ischemic cardiomyopathy), in class NYHA III or IV and on optimized medical therapy. Patients with severe renal failure (glomerular filtration rate below 30 ml/min/1.73 m<span class="elsevierStyleSup">2</span>), type 1 diabetes or hypotension or in the acute phase of myocardial infarction or cerebrovascular accident were excluded. RDN was performed using a radiofrequency catheter with temperature control and 4-6 ablation points were delivered to each artery. At six-month follow-up improvements were observed in the six-minute walk distance (from 152.9±38.0 m to 334.3±94.4 m, p<0.001), EF (from 36±4.1% to 43.8±7.9%, p<0.003), NYHA functional class (p<0.001) and BNP levels (p<0.008). The recovery in EF was more significant in the group of hypertensive patients (34.5±4.3% to 52.3±6.1%, p<0.005) than in the non-hypertensive group (36.6±3.8% to 41±6.2%, p=0.07), a fact that the authors attribute to the blood-pressure lowering effect of RDN and suggesting a more beneficial effect of RDN in HF due to hypertensive disease. There were no safety issues. These results are different from those of the REACH-Pilot study in terms of change in EF, but are comparable to the results published by Chen et al., indicating a favorable effect of RDN in HF patients. However, several limitations must be taken into consideration such as the small sample size, the absence of a control group and non-randomization.</p><p id="par0025" class="elsevierStylePara elsevierViewall">To summarize, this article highlights the role of RDN in modulating autonomic tone in specific conditions, including HF, and emphasizes the importance of further investigation in this area. The authors should be encouraged to continue their research on RDN in various clinical settings, and perhaps in the future some light will be shed on RDN's ‘autonomic’ significance.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0030" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:11 [ 0 => array:3 [ "identificador" => "bib0060" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The global health and economic burden of hospitalizations for heart failure: lessons learned from hospitalized heart failure registries" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "A.P. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 4 | 3 | 7 |
| 2024 October | 28 | 26 | 54 |
| 2024 September | 47 | 20 | 67 |
| 2024 August | 39 | 23 | 62 |
| 2024 July | 32 | 26 | 58 |
| 2024 June | 29 | 27 | 56 |
| 2024 May | 28 | 25 | 53 |
| 2024 April | 30 | 29 | 59 |
| 2024 March | 27 | 17 | 44 |
| 2024 February | 23 | 22 | 45 |
| 2024 January | 21 | 31 | 52 |
| 2023 December | 14 | 26 | 40 |
| 2023 November | 30 | 23 | 53 |
| 2023 October | 23 | 20 | 43 |
| 2023 September | 20 | 18 | 38 |
| 2023 August | 16 | 17 | 33 |
| 2023 July | 29 | 14 | 43 |
| 2023 June | 23 | 10 | 33 |
| 2023 May | 42 | 25 | 67 |
| 2023 April | 17 | 7 | 24 |
| 2023 March | 48 | 31 | 79 |
| 2023 February | 33 | 17 | 50 |
| 2023 January | 17 | 22 | 39 |
| 2022 December | 37 | 23 | 60 |
| 2022 November | 49 | 28 | 77 |
| 2022 October | 30 | 20 | 50 |
| 2022 September | 22 | 31 | 53 |
| 2022 August | 36 | 33 | 69 |
| 2022 July | 28 | 32 | 60 |
| 2022 June | 24 | 32 | 56 |
| 2022 May | 16 | 34 | 50 |
| 2022 April | 21 | 28 | 49 |
| 2022 March | 32 | 37 | 69 |
| 2022 February | 30 | 30 | 60 |
| 2022 January | 17 | 23 | 40 |
| 2021 December | 21 | 35 | 56 |
| 2021 November | 35 | 47 | 82 |
| 2021 October | 29 | 45 | 74 |
| 2021 September | 32 | 27 | 59 |
| 2021 August | 32 | 27 | 59 |
| 2021 July | 14 | 30 | 44 |
| 2021 June | 18 | 23 | 41 |
| 2021 May | 32 | 32 | 64 |
| 2021 April | 38 | 40 | 78 |
| 2021 March | 58 | 9 | 67 |
| 2021 February | 51 | 21 | 72 |
| 2021 January | 36 | 6 | 42 |
| 2020 December | 42 | 9 | 51 |
| 2020 November | 19 | 22 | 41 |
| 2020 October | 11 | 11 | 22 |
| 2020 September | 43 | 9 | 52 |
| 2020 August | 17 | 5 | 22 |
| 2020 July | 32 | 11 | 43 |
| 2020 June | 35 | 8 | 43 |
| 2020 May | 30 | 5 | 35 |
| 2020 April | 26 | 8 | 34 |
| 2020 March | 44 | 9 | 53 |
| 2020 February | 48 | 35 | 83 |
| 2020 January | 34 | 8 | 42 |
| 2019 December | 22 | 4 | 26 |
| 2019 November | 17 | 7 | 24 |
| 2019 October | 31 | 9 | 40 |
| 2019 September | 9 | 9 | 18 |
| 2019 August | 24 | 2 | 26 |
| 2019 July | 30 | 9 | 39 |
| 2019 June | 17 | 10 | 27 |
| 2019 May | 32 | 9 | 41 |
| 2019 April | 13 | 12 | 25 |
| 2019 March | 85 | 11 | 96 |
| 2019 February | 92 | 7 | 99 |
| 2019 January | 71 | 4 | 75 |
| 2018 December | 92 | 14 | 106 |
| 2018 November | 63 | 7 | 70 |
| 2018 October | 143 | 11 | 154 |
| 2018 September | 75 | 11 | 86 |
| 2018 August | 33 | 6 | 39 |
| 2018 July | 20 | 3 | 23 |
| 2018 June | 34 | 6 | 40 |
| 2018 May | 48 | 8 | 56 |
| 2018 April | 66 | 2 | 68 |
| 2018 March | 80 | 6 | 86 |
| 2018 February | 57 | 4 | 61 |
| 2018 January | 82 | 5 | 87 |
| 2017 December | 109 | 1 | 110 |
| 2017 November | 33 | 10 | 43 |
| 2017 October | 25 | 8 | 33 |
| 2017 September | 18 | 9 | 27 |
| 2017 August | 21 | 5 | 26 |
| 2017 July | 10 | 3 | 13 |
| 2017 June | 30 | 11 | 41 |
| 2017 May | 37 | 4 | 41 |
| 2017 April | 22 | 13 | 35 |
| 2017 March | 31 | 21 | 52 |
| 2017 February | 64 | 19 | 83 |
| 2017 January | 23 | 4 | 27 |
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