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Aldosterone antagonists and renal denervation: friends or foes?

See related article, pp 407–413

Activation of the sympathetic nervous system plays an important role in the development and disease progression of hypertension and its comorbidities.1 Antihypertensive treatment approaches have focused on abrogation of activated neurohormonal systems associated with these conditions, including the renin–angiotensin–aldosterone system and the sympathetic nervous system. Despite the availability of effective antihypertensive drugs, certain patients remain uncontrolled to target blood pressure (BP) values.2 For these patients with uncontrolled hypertension, new device-based treatments have been developed, such as surgically implanted baroreceptor stimulators and catheter-based renal denervation.3 The available evidence suggests that renal denervation reduces renal sympathetic activity and office BP, as well as ambulatory BP in open-label registries and randomized, controlled trials in certain patients, but not in all patients.4 The BP-lowering effect of intensified drug treatment, with special focus on aldosterone antagonist treatment, compared with catheter-based renal denervation has not been investigated in detail.

In this issue, the prospective, randomized, open-label multicenter PRAGUE-15 trial by Rosa et al5 investigated the efficacy and safety of catheter-based renal denervation (using Medtronic’s Symplicity device) versus intensified pharmacological treatment, including spironolactone in patients with mild to moderate resistant hypertension (office systolic BP [SBP] at the baseline, >140 mm Hg; 24-hour BP at the baseline, >130 mm Hg). The adherence of patients was confirmed by plasma toxicological analyses at the beginning (but unfortunately not after 6 months), and secondary causes of hypertension were excluded systematically. The study provides interesting insights about the efficacy and safety of intensified drug treatment and catheter-based renal denervation in patients with resistant hypertension.

The significant BP change (24-hour SBP, −8.1 mm Hg; P =0.001 and office SBP, −14.3 mm Hg; P <0.001) in the intensified drug treatment group of PRAGUE-15 was mostly driven by patients in whom spironolactone was added and …