Authors' objectives: Hypertension is the leading cause of cardiovascular disease, kidney failure and death in the general population. In the U.S., the prevalence of hypertension in adults was 29% in 2012. Hypertension prevalence is even higher in the Medicare population, exceeding 60% for adults older than 65 years to over 90% for Medicare dialysis patients. Evidence-based practice guidelines affirm that treatment of hypertension reduces the risks of cardiovascular disease and death, and multiple medications and lifestyle interventions can reduce blood pressure (BP). Despite guidelines supporting BP control, less than half of adults with hypertension reach goal BP, as defined by the older guidelines (less than 140/90 mm Hg). Recently, the landmark Systolic Blood Pressure Intervention Trial (SPRINT) reported that targeting systolic BP of 120 mm Hg instead of 140 mm Hg reduced rates of cardiovascular events by almost a third and the risk of death by almost a quarter. If this lower BP target is adopted by clinicians, an even greater proportion of US adults with hypertension will be above the goal BP, highlighting the importance of new methods for controlling BP. Failure to reach goal BP despite "adequate" treatment is operationally defined as "Apparent Treatment Resistant Hypertension (aTRH)." The definition was developed to: a) identify patients with secondary causes of hypertension, such as pheochromocytoma, syndrome of apparent mineralocorticoid excess, or renal artery stenosis, that have specific medical or surgical treatments; b) identify patients with uncontrolled BP that may benefit from specialized hypertension care; and c) provide a framework for testing therapies for resistant hypertension. Patients with aTRH can include those with "pseudo-resistance" from dietary, lifestyle, and medication nonadherence and those with "true resistance." Data from 14,684 participants in the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) suggest that irrespective of the mechanism, patients with aTRH are at 30 percent to 50 percent higher risk for death, stroke, or coronary heart disease, and almost 2-fold higher risk of end-stage renal disease compared with patients without aTRH. In this context, innovative methods to reduce BP, such as renal denervation (RDN), may offer a way to improve cardiovascular outcomes and reduce the risk of myocardial infarction, stroke, kidney failure, disability, and death. Clinical trial data are conflicting about the efficacy of RDN in lowering BP, with resulting uncertainty regarding its role in hypertensive patients. Clarifying the role of RDN in routine care of Medicare beneficiaries requires an understanding of: a) the pathogenesis of hypertension in patients over the age of 65 years, disabled individuals, and those on dialysis; b) factors that contribute to aTRH in these subgroups; c) other options for treatment; and d) a synthesis of the available studies.

Project Status: Completed

URL for project: http://www.ahrq.gov/sites/default/files/wysiwyg/research/findings/ta/topicrefinement/renaldenerv_protocol.pdf

Year Published: 2016

URL for published report: https://www.cms.gov/Medicare/Coverage/DeterminationProcess/downloads/id102TA.pdf

English language abstract: An English language summary is available

Publication Type: Not Assigned

Country: United States

Organisation Name: Agency for Healthcare Research and Quality

Contact Address: Center for Outcomes and Evidence Technology Assessment Program, 540 Gaither Road, Rockville, MD 20850, USA. Tel: +1 301 427 1610; Fax: +1 301 427 1639;

Contact Name: martin.erlichman@ahrq.hhs.gov

Contact Email: martin.erlichman@ahrq.hhs.gov

Copyright: <p>Agency for Health Care Research and Quality (AHRQ)</p>