Is renal denervation recommended as a first-line treatment for hypertension?

Renal Denervation for Hypertension

Renal denervation is not recommended as a first-line treatment for hypertension due to lack of adequately powered outcomes trials demonstrating its safety and cardiovascular benefits. 1

Current Position of Renal Denervation in Hypertension Management

The 2024 European Society of Cardiology (ESC) guidelines explicitly state that renal denervation should not be used as a first-line blood pressure-lowering intervention for hypertension. Instead, the recommended first-line approach for hypertension management includes:

1. Lifestyle modifications
2. Pharmacological therapy with established antihypertensive medications

First-Line Treatment Recommendations

The ESC guidelines recommend that initial treatment should aim to:

• Lower blood pressure to <140/90 mmHg in all patients
• Target 130/80 mmHg or lower in most patients, if well tolerated
• Specifically target systolic BP of 120-129 mmHg to reduce cardiovascular disease risk 1

Appropriate Use of Renal Denervation

Renal denervation may only be considered in specific circumstances:

1. For resistant hypertension patients with uncontrolled BP despite a three BP-lowering drug combination (including a thiazide or thiazide-like diuretic)
2. For patients with increased cardiovascular disease risk and uncontrolled hypertension on fewer than three drugs

In both scenarios, the procedure should only be:

• Performed at medium-to-high volume centers
• After shared risk-benefit discussion
• Following multidisciplinary assessment
• When patients express a preference for this approach 1

Contraindications for Renal Denervation

Renal denervation is specifically not recommended for:

• Patients with moderately to severely impaired renal function (eGFR <40 mL/min/1.73 m²)
• Patients with secondary causes of hypertension 1

Evidence and Limitations

The evidence supporting renal denervation has been mixed:

• Early uncontrolled studies showed promising results but had significant methodological limitations 1
• The SYMPLICITY HTN-3 trial, the first sham-controlled randomized study, failed to demonstrate significant efficacy of renal denervation in resistant hypertension 1
• More recent studies with improved catheter designs have shown some efficacy, but these were primarily proof-of-principle studies rather than trials in resistant hypertension populations 1

Management Algorithm for Hypertension

1. First-line approach:

   • Lifestyle modifications (sodium restriction <2,300 mg/day, DASH diet, weight loss, physical activity, alcohol limitation) 2
   • Initial pharmacotherapy with evidence-based medications (typically ACE inhibitor/ARB, calcium channel blocker, or thiazide diuretic)

2. For uncontrolled hypertension:

   • Optimize dosing of current medications
   • Consider switching to more effective agents (e.g., chlorthalidone instead of hydrochlorothiazide) 2
   • Add additional agents from different classes

3. For resistant hypertension:

   • Add spironolactone 12.5-25 mg daily as fourth-line agent 2
   • Consider alpha-blockers or vasodilators if BP remains uncontrolled 2
   • Only then consider renal denervation in appropriate candidates 1

Common Pitfalls to Avoid

• Failing to confirm true resistant hypertension before considering advanced interventions 2
• Inadequate diuretic therapy or inappropriate medication combinations 2
• Overlooking medication adherence issues 2
• Neglecting to screen for secondary causes of hypertension 2
• Using renal denervation as a first-line approach rather than after optimized medical therapy 1

The current evidence and guidelines clearly position renal denervation as a specialized intervention for specific patient populations with resistant hypertension, not as a first-line treatment option for general hypertension management.