The authors of the article entitled “Management of resistant hypertension in a multidisciplinary renal denervation unit: protocol and results”1 thank Dr. Bonaque for his interest in our work. The observations made on our study are highly relevant but require some comment.
Indeed, hypertension is defined in current guidelines as arterial blood pressure values >130-135/85mmHg in an ambulatory blood pressure monitoring recording during a period of activity.2 From a conceptual point of view, establishing this cutoff to select candidates for renal denervation would be as incorrect as including patients with blood pressure of ≥140/90mmHg in the office setting, the definition of hypertension in the same guidelines. The cut-off to indicate renal denervation should not only include the “presence of hypertension” but also “poor control”. Hence, in the Symplicity-HTN2 trial,3 the cutoff was an office systolic pressure of 160mmHg and, in our study, an ambulatory blood pressure monitoring value of 140/90mmHg. Our study cannot therefore be said to have an inclusion bias.
We also agree that the definition of resistant hypertension implies the use of at least 1 diuretic,4 but this is not always feasible in clinical practice due to intolerance or the adverse effects of these drugs. In addition to being reasonable, a figure of 90% of patients receiving diuretic therapy is almost identical to the population undergoing denervation in Symplicity-HTN2,3 in which 89% of patients were receiving diuretics.
All patients in our study were attending the Hypertension Unit of our hospital, which is accredited as a Center of Excellence by the European Society of Hypertension. This unit routinely screens for drug-induced hypertension and investigates secondary causes in all patients with poor control. Patients with sleep apnea were included because they continued to be poorly controlled despite specific treatment for the sleep apnea. There was no “pharmacological optimization” in any of the patients after denervation (except for a reduction in the dose and number of drugs), given that drug therapy was optimized before ablation in all patients.
In view of all these considerations, we do not believe that our series included patients with secondary hypertension or drug-induced hypertension or patients receiving suboptimal drug therapy that could have influenced our results.