Perfect. Thanks so much, Tai and Eric, for having me here. So my job here today is—and it's a perfect segue, I think, from the discussion we just had—is to make a point that I think it is important to encourage large hospital systems and smaller hospital systems to have a focus on hypertension and create these hypertension centers. And I'm going to talk about our approach at Ceta-Sinai. There are many ways you can skin a cat, but I think there's this one relatively established program now that's over 12 years old at Ceta-Sinai. So we all have seen similar slides on that. It is important to reduce blood pressure because it saves lives and it saves cardiovascular events. And it's also important to do this in older patients, in younger patients, in fit patients or in frail patients. So the SPRINT trial taught us all that. And that's all good, but the problem is follow-up data. As soon as these patients in SPRINT were not intensely monitored anymore, you can see that the blood pressure in the left panel sort of slowly drifted back up. So I think that's why it is important to maintain focus on blood pressure control. And this maintained focus is one major obligation of a hypertension center in a hospital system. So we can see here to the right here, long-term follow-up data for renal denervation showed that there was actually none of this upward drift. And although follow-up for these patients was not intense at all anymore, at this point three years out, we saw no change in blood pressure. So that's good. So why is a hypertension center important and how does it pertain to renal denervation? So first of all, I think it is really crucial now that we have this new technology to figure out who should get this. So the evaluation of a hypertensive patient by somebody who is specialty trained, I think it's always of benefit because we said renal denervation is not going to be for everyone. What's even more crucial, I think, is the accurate assessment of blood pressure. So to use validated devices in the clinic, to have ambulatory blood pressure monitor available and to teach patients how to measure their blood pressure at home is really crucial. Screen, confirm, and treat secondary causes of hypertension because these patients may not be appropriate for renal denervation for sure. And then just having the environment of all specialty trained colleagues who are needed to really appropriately treat these cases of secondary hypertension. They're not very common and that's why a really specialized approach is important. Optimal medical therapy, education of the patient, of colleagues who prescribe medications to have hypertension, education programs within a health system is what we do really on a monthly basis at Ceta-Sinai. And then also once we drizzle down to the patient, we decided, yes, this patient might be appropriate for renal denervation, having appropriate imaging approaches for these patients and then hopefully also some experienced renal denervation operators. And we just discussed what the requirements of that might be. And then also we just talked about renal denervation is not the end of it all. Almost no patients will come off the blood pressure medication. So continued medical therapy will absolutely be crucial for these patients and appropriate follow-up to make sure they are continuing on a pathway of blood pressure control will be crucial to make this procedure long-term successfully. This is sort of the Ceta-Sinai Hypertension Center. It's situated in the Department of Cardiology, the Smith Heart Institute, and then the roles of our Hypertension Center, which we just got the EHA stamp of approval also a couple of weeks ago. I didn't even have time to add the logo to my slides. But one is clearly hypertension research. So we do a lot of clinical trials, including renal denervation, but also community outreach and health disparity research. We educate within the hospital system and outside of the hospital system. And then really our clinical mission is really focused on resistant or difficult hypertension. We certainly don't want to see the garden variety, one medication will fix it type of hypertension. Adrenal hypertension, we have a solid program of identifying aldosteronism and treating aldosteronism, both with medications or surgery. And then there are still a few cases of renal vascular hypertension and finally renal denervation. This is my team. Importantly, right in the middle, I want to point out Dr. Blyler, our pharmacist, who's really crucial for medication titration, team aldosteronism. I'm pretty confident with working up hyperprimary aldosteronism, but there are some complicated patients that need more in-depth endocrine evaluation. And those patients I will gladly send to my astute colleague, Dr. Cooper. We have a very talented adrenal vein sampling person, Mark Friedman. Then once we have identified these patients with unilateral hypaldosteronism, we also have a specialty fellowship-trained adrenal surgeon. Team RDN seems kind of small, but all our intervention cardiologists essentially have signed up to be interested once this therapy becomes available. I talked a little bit about blood pressure measurements. In the office, we have blood pressure assessment protocols to make sure we're getting an idea in the office what the blood pressure, the true blood pressure really looks like. We do in some patients automated office blood pressure, so unsupervised blood pressure measurements to help get rid of the white coat effect a little bit more. Home blood pressure measurement protocols, every patient will get that, and they get little sign-in sheets where they can monitor their numbers and then bring it to the next visit. Ambulatory blood pressure monitoring is absolutely crucial, I think, in the treatment of hypertension. You can see here some of many indications, and to the right bottom, you can see how ambulatory blood pressure monitors have increased. We're this year on track to getting probably 550 or so. Very successful program. A lot of work. Not very well reimbursed, but I think it's crucial for appropriate blood pressure management. So just one slide. Very briefly, obviously, this is not exhaustive at all. Secondary hypertension, I think we have to think about it, we have to screen for it, and screening really is very easy. Primary aldosteronism, which is very prevalent, as we have heard. Just check your renin and aldosterone level, ignore the ratio, and you will at least identify those who are at possible risk for having primary aldosteronism. If you don't feel confident in working this further up, you can refer to endocrinology, and I'm sure they can take care of that. Chronic kidney disease and diabetes are important to recognize as strong predictors of resistant hypertension and maybe those patients who may need a little bit more beyond medications. Sleep apnea is easy to screen for. Concomitant interfering medications is important to think about when you see your patient. Attempting withdrawal of these interfering medications might help control their blood pressure. Fibromuscular dysplasia, rare, but there are some higher risk groups. Penile artery stenosis, I think, is a little bit debatable how much you have to screen for it because the treatment, for the most part these days, is really medical. But to recognize those patients, having high cardiovascular risk is important. Pre-achromocytoma, you will not see many of those, but screening with plasma midoniferins is just so easy that I think it would be silly not to do that. Pre-renal denervation requirements, and we just heard about the SCI document that I was fortunate to be part of the discussion. I think it is important that uncontrolled hypertension is the main driver, I think, of patients being referred to renal denervation. So uncontrolled hypertension, despite multiple repeated attempts of controlling blood pressure, and I wouldn't want to be too strict in terms of defining whether or not this needs to be resistant hypertension. I think if patients have shown or demonstrated that their blood pressure cannot be controlled or is very difficult to control, then they might be potential candidates for this. Assessment of out-of-office blood pressure is absolutely crucial to make sure we're not treating white coat hypertension here with renal denervation. Make sure the secondary causes that do play a role are ruled out. And then the pre-cat lab evaluation of the renal artery anatomy, I think, is debatable. There might be a discussion about this later. And then finally, the shared decision-making to either add additional medications or not add medications but refer to renal denervation. Post-renal denervation, I think vascular access problems have become so rare that it's probably not going to be required that the conventional list has to see the patient after renal denervation, so I think we can take care of that. But blood pressure assessment in the office and out of the office will be crucial. Medication adjustment, because 130 over 80 is still the goal, regardless if renal denervation was performed or not. And then post-renal denervation, renal artery stenosis, I think, is such a rare case that I don't think it has to be part of the regular assessment, but at least we have to think about it. And that's the end for me, and I'm happy to discuss any of the other points that I raised or some more later on, so thank you.

hypertension centers

specialized approach

blood pressure measurement

renal denervation

Ceta-Sinai Hypertension Center