High blood pressure at ESC 2022: what to think about

Drs Romain Boulestreau and Julien Doublet (CHU de Bordeaux) from the Club des Jeunes Hypertensiologues comment on three important presentations on arterial hypertension presented at the European Society of Cardiology (ESC) Congress 2022: the European consensus on renal denervation and the test results of TIME and SECURE.


Julien doublet – Hello everyone and welcome to Medscape, in partnership with the Club des Jeunes Hypertensiologues. I have the honor to interview Romain Boulestreau, PH at Bordeaux University Hospital, Hypertension Unit today. I myself am Julien Doublet, PH in the same department at Bordeaux University Hospital.

TIME: similar frequency of cardiovascular events, regardless of whether antihypertensive drugs were taken in the evening or in the morning

Julien doublet – First of all, an essential study came out at the ESC 2022, it is ZEIT. [1] What was the purpose of this study?

Romain Boulestreau Indeed, TIME is a flagship study at ESC 2022 on arterial hypertension, as the aim was to evaluate the effectiveness of an antihypertensive treatment taken in the evening compared to cardiovascular protection in the morning. You know that the Hygia study by Hermida et al. in Spain, which a few years ago attracted a lot of attention because it showed a 50% reduction in cardiovascular risk in mortality, in strokes, in heart failure, etc. heart attacks, by all criteria… by 50% just by taking the treatment in the evening. They randomized 19,000 patients and followed them for six years. In fact, this study was too good to be true – it was published inEuropean heart, so an excellent newspaper, but there had been no reason for recommendations because no one believed in it. So there was still the doubt of saying “and if it were true, finally? What if by applying the treatments in the evening we could lower blood pressure at night? It’s the most prognostic push – we repeat it all the time – and isn’t it ultimately what you need to do anyway?

So we were looking forward to TIME: 21,000 patients followed for five years, randomized 1:1 treatment AM or PM – these are the same patients as in the Hygia study, ie. 65 on average, 60% male, exclusively white, 14% diabetic – and they are treated in the evening instead of in the morning, that’s the only difference.

Julien doublet – What are the results?

Romain Boulestreau It’s a bit of a surprise that no one expected this, or that some did, because there are a lot of people who didn’t believe in Hygia. There is no difference between the two groups after five years. There is one group that does 3.3% of the events, the other 3.7%, there is no difference. And whatever the subgroup is – most at risk, least at risk, diabetics, obese…none of the subgroups come out, it doesn’t work to do the evening treatments. In any case, it no longer protects.

A lot of people are saying TIME is ending the debate, and it probably is. The upside is that we have two other large studies that have the same goal, specifically BedMed in Canada, in Alberta, so we’ll see if they confirm the TIME or Hygia results, it won’t stay one against one though it’s interesting.

I don’t know what you think about this: is it a negative study or a study that allows us to say, ‘We end up taking the treatment when we want. How are you going to use it, you, this study?

Julien doublet This is quite a study that will not force me to prescribe treatments in the evening but will continue my practice of asking patients when they should take their medications most often? In any case, I write my prescription adapting to each patient and asking them: “Do you prefer the treatment in the morning or in the evening?” » and really adapt to patients to encourage compliance.

Romain Boulestreau I remember as you do: it is the patient who says when they will do their treatments and when they will not forget them.

ESC consensus on renal denervation

Julien doublet We have received very important information on renal denervation, can you tell us more?

Romain Boulestreau We finally have consensus comes to the renal denervation. You, like everyone else, followed the explosion of this new technology from Medtronic a few years ago with -30mm Hg blood pressure, very impressive things that completely collapsed with SIMPLICITY HTN-3 – we almost gave up the technique – and who went with the DENER-HTN test and then the various well-done tests versus procedures billetc., and now the data is very clear and most importantly very reproducible. Basically, denervation acts like a drug, it lowers blood pressure by an average of 10 mm Hg with a big problem of variability in response.

So 10 mmHg, a drug for whom? This is very useful for the young patient that we want to try to cure – more treatments, more hypertension – and what we’re doing a little less in the department but also doing a lot is with the resistant hypertensive patient that we want to bring back blood pressure control with a tri- or quadri-therapy in two tablets. So it’s really a technology now in our daily lives, in the centers of excellence, and we’re happy that there are recommendations, like the European recommendations that are coming out, that insist on patient selection, as that’s an extremely important criterion; Therefore, it is the hypertension centers of excellence that perform very accurate screening, eliminate “white coat hypertension”, eliminate secondary hypertension and select the right patients. They are the ones who will give the go-ahead for renal denervation.

Then the denervation is not abandoned at all. On the contrary, it is offered, but therefore to good candidates or best candidates. Importantly, after this European consensus, there is a French consensus that will come out at the end of the year. And you know, in France we have a temporary reimbursement of the SPYRAL probe technology for one year in resistant hypertensive patients if it is a center of excellence that has given “go” again. So I believe that this technology is not buried at all, but in its place, in a place to be measured.

Julien doublet – This likely marks the beginning of the practice of renal denervation in a well-established setting, outside of therapeutic studies.

SAFE: Secondary CV prevention benefits from Polypill’s promises

Julien doublet Last but not least, Romain, did you fall in love with a study presented during this ESC?

Romain Boulestreau One study I really liked is SAFE. [2]

It’s a post-infarction cardiovascular prevention study, so secondary prevention, where we have 2500-3500 patients in each arm and half of the post-infarction patients; They get aspirin, statins, and ACE inhibitors in varying doses in combination therapy—a single pill—and the other half of people have all three but in one free regimen.

In arterial hypertension, combination therapy is a subject we really like, we find that it improves compliance, and besides, you know our dogma that you keep repeating: you don’t need more than two tablets to treat arterial hypertension – two tablets are four molecules and that’s more than enough and draws attention. So of course I agree, I share that idea with you, but we didn’t have that in post-ACS coronary artery disease, and we have it now with this SECURE trial.

The results are quite impressive as we have a 30 percent reduction in cardiovascular events whether non-fatal heart attacks, non-fatal strokes and 3-year post-infarction mortality. And so we reduce events by 25% in a relatively short period of time with combination therapy alone. Maybe it will improve compliance – we are convinced of that. Somewhat surprisingly, LDL and blood pressure are the same in both groups, so it appears that unless aspirin is poorly taken, treatments in both groups are well taken. But in any case, what is certain is that it shows that combined therapies are effective, work well, better than free therapies in any area other than arterial hypertension, and we’re going to need that. There we’re talking about heart failure, and yet another issue of quadritherapy, other molecules are emerging, we’re not going to be able to ask people to take 12, 15, 20 pills if they have other comorbidities.

The results from SECURE are quite impressive as we have a 30 percent reduction in cardiovascular events.
dr Romain Boulestreau

So, the combined spellings, we’ve all long believed in hypertension that this is the future, and we have evidence in other areas. So we hope that this will push the reimbursement of the combined triple therapy for hypertension in France and that soon we will also have the quadruple therapy.

Julien doublet So the future means fewer tablets for fewer events.

Romain Boulestreau Right, that’s the last word, it’s well summed up.

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