Renal denervation has been on a long winding path. While Eurtope has been using the ineffective first generation denervation systems for over a decade, the US has not had this therapy available until now. On November 7, Recor Medical and Otsuka Medical Devices announced Recor’s Paradise Ultrasound Renal Denervation system received approval for the treatment of hypertension.

It will be exciting to see how this therapy is incorporated into the widening options for blood pressure therapy.

Here are the final results of the SPYRAL HTN-ON MED Study. This sham-controlled trial showed a modest effect on blood pressure (drop of 6.5 mmHg in SBP) that was no better than the sham-treated cohort (drop of 4.5 mmHg). There were a number of secondary outcomes where renal denervation was superior to sham, but this is weak sauce. With all of the excitement brewing in hypertension, it is hard to get too excited about an intervention that fails its primary outcome.

This was a open label, multi-center, randomized controlled trial of stopping or continuing RAS inhibition 1-2 days prior to non-cardiac surgery. The primary outcome was cardiac injury, as measured by high sensitivity troponin. The investigators found a 20% increased risk myocardial injury, more than double the risk of hypertensive events, and no difference in hypotensive events. Of note, there was no difference in AKI, but there was a trend to lower rates with continuing the RAS inhibition.

This study continues the trend of studies that reverse physicians tendency to stop or hold RASi everytime the patient quivers.

For a long time medical dogma stated that older people needed higher blood pressures to maintain cerebral perfusion but it is increasingly looking like lower blood pressure protect the brain from dementia. 

We had an initial hint of this from the Sprint Mind Investigators. In 2019, in JAMA Internal Medicine, they found a small, but not statistically significant, reduction in dementia during the SPRINT Blood Pressure trial. 

Now, this week-end, at AHA, a new study was able to show a small but meaningful difference in dementia with aggressive blood pressure control. The risk of dementia fell from 1.31% to 1.12% per year, RR 0.85, P=0.0035. This is an NNT of about 500. The intervention was a stepped-care protocol targeting a blood pressure less than 130/80. Patients in the intensive BP lowering arm achieved an average SBP 22 mm Hg lower than the usual care. Diastolics were 9.3 mm Hg lower. 

In case you needed yet another reason to be more aggressive with blood pressure, here's one. I'm going to want to dig into this paper when it is published. 

In 2020, the American College of Radiology admitted that the risk of clinically meaningful AKI followng venous contrast is minimal in patients with at least 30 ml/min of GFR. Since then, some emergency rooms and radiology departments have removed the requirements for checking a creatinine before the scan. This article reports on the effect, which is reducing the time from an order for a contrasted CT scan to the scan being done. Hallelujah!