From the Guidelines
Radiofrequency ablation is not recommended as a primary treatment for resistant hypertension, and its use should be considered only in specific cases where other treatments have failed, as stated in the 2024 ESC guidelines for the management of elevated blood pressure and hypertension 1. The treatment of resistant hypertension typically involves reinforcement of lifestyle measures, addition of low-dose spironolactone to existing treatment, or the addition of further diuretic therapy if intolerant to spironolactone, with either eplerenone, amiloride, a higher dose thiazide/thiazide-like diuretic, or a loop diuretic 1. Some key points to consider in the treatment of resistant hypertension include:
- Reinforcement of lifestyle measures, especially sodium restriction
- Addition of low-dose spironolactone to existing treatment
- Addition of further diuretic therapy if intolerant to spironolactone
- Consideration of catheter-based renal denervation in patients with uncontrolled BP despite a three BP-lowering drug combination, and who express a preference to undergo renal denervation after a shared risk-benefit discussion and multidisciplinary assessment 1 The role of radiofrequency ablation in treating resistant hypertension is still uncertain, as evidenced by the results of the SYMPLICITY HTN-3 trial, which showed no significant difference between renal denervation and a sham procedure in reducing systolic blood pressure 1. In real-life clinical practice, the decision to use radiofrequency ablation should be made on a case-by-case basis, taking into account the individual patient's circumstances and the potential risks and benefits of the procedure. It is essential to prioritize the patient's morbidity, mortality, and quality of life when making treatment decisions, and to consider the latest evidence-based guidelines and recommendations 1.
From the Research
Role of Radiofrequency Ablation in Treating Resistant Hypertension
- Radiofrequency ablation is a technique used in renal denervation (RDN) to treat resistant hypertension by ablating renal sympathetic nerve fibers within the adventitial layer of the renal arteries 2.
- The procedure has been shown to have an excellent safety profile and results in a modest reduction of blood pressure in a wide range of hypertensive phenotypes, including resistant hypertension 2, 3.
- Studies have demonstrated that RDN using radiofrequency ablation can lower blood pressure in patients with resistant hypertension, with significant reductions in office, 24-hour ambulatory, and home blood pressure measurements 3, 4.
- The use of radiofrequency ablation in RDN has been found to be feasible and safe, with no significant vascular complications or worsening of renal function reported in short-term follow-up 3, 4.
Mechanism and Efficacy
- The renal nerves contribute to hypertension through effects in the kidney that enhance sodium retention and renin secretion, and by effects in the central nervous system that increase systemic sympathetic activity 5.
- Radiofrequency ablation targets the renal nerves, providing a logical basis for treating hypertension by reducing sympathetic activity and lowering blood pressure 5, 6.
- Clinical trials have shown that radiofrequency-based renal denervation is effective in lowering blood pressure in hypertensive patients, with and without concomitant antihypertensive medication 6.
Patient Selection and Future Directions
- Patient selection is critical to demonstrate a meaningful benefit of RDN, and future studies are necessary to determine predictors and measures of response to RDN 2.
- Further research is needed to establish the long-term efficacy and safety of radiofrequency ablation in RDN, as well as to compare available technologies and improve patient outcomes 2, 6.