title: A Network Meta-Analysis of Clinical Management Strategies for Treatment-Resistant Hypertension: Making Optimal Use of the Evidence.
abstract: BACKGROUND
  With the addition of surgical interventions to current medicinal treatments, it is increasingly challenging for clinicians to rationally choose among the various options for treating patients with apparent treatment-resistant hypertension (ATRHTN). This study aims to establish the comparative effectiveness of mineralocorticoid receptor antagonists (MRA), renal denervation (RDN), darusentan and central arteriovenous anastomosis (CAA) for patients with ATRHTN by performing a network meta-analysis.
  
  
  METHODS
  Data Sources: Studies from recent meta-analyses for RDN and placebo effect were supplemented with a systematic search for MRAs in ATRHTN in the Pubmed, EMBASE, CINAHL and Cochrane databases through November 2016.
  
  
  METHODS
  Randomized controlled trials comparing treatment options for patients with ATRHTN.
  
  
  METHODS
  Data were extracted using predefined data extraction forms, including the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria. A Bayesian random effects model was used to conduct a network meta-analysis. Spironolactone was used as the main comparator. Main Outcomes and Measures: Reduction in 24-h ambulatory blood pressure measurement (ABPM).
  
  
  RESULTS
  Twenty articles met our inclusion criteria, and seven treatment alternatives were compared. Compared to MRA, CAA had the highest probability of being more effective, further reducing 24-h SBP (-4.8 mmHg [-13.0, 3.7]) and 24-h DBP (-9.7 mmHg [-18, -0.63]). This difference is likely to be clinically meaningful, with a probability of 78 and 96% at a threshold of a 2-mmHg reduction in blood pressure.
  
  
  CONCLUSIONS
  When compared to MRA as anchor, darusentan, CAA and RDN are not more effective in achieving a clinically significant reduction in ambulatory blood pressure in individuals with apparent treatment-resistant hypertension.
authors.affiliation: Department for Health Evidence, Health Technology Assessment Group, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands. Peter.Makai@Radboudumc.nl.
authors.forename: Peter
authors.initials: P
authors.lastname: Makai
authors.affiliation: Department for Health Evidence, Health Technology Assessment Group, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands.
authors.forename: Joanna
authors.initials: J
authors.lastname: IntHout
authors.affiliation: Department for Health Evidence, Health Technology Assessment Group, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands.
authors.forename: Jaap
authors.initials: J
authors.lastname: Deinum
authors.affiliation: Julius Center, University Medical Center Utrecht, Utrecht, The Netherlands.
authors.forename: Kevin
authors.initials: K
authors.lastname: Jenniskens
authors.affiliation: Department for Health Evidence, Health Technology Assessment Group, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands.
authors.forename: Gert Jan van der
authors.initials: GJV
authors.lastname: Wilt
mesh_terms: D001794:Blood Pressure / Q000502:physiology*; D019468:Disease Management; D006801:Humans; D006973:Hypertension / Q000503:physiopathology / Q000628:therapy*; D017410:Practice Guidelines as Topic
keywords: MRAs; network meta-analysis; treatment-resistant hypertension