Is renal denervation a recommended treatment for resistant hypertension?

Renal Denervation for Resistant Hypertension

Renal denervation is not recommended as a first-line treatment for resistant hypertension, but may be considered as an adjunctive option in highly selected patients with true resistant hypertension who remain uncontrolled on optimal three-drug therapy (including a diuretic) and are treated at experienced centers after multidisciplinary evaluation. 1

Treatment Algorithm for Resistant Hypertension

The recommended stepwise approach prioritizes pharmacological optimization before considering renal denervation:

First-Line Interventions

• Intensify lifestyle modifications, particularly sodium restriction 1, 2
• Add low-dose spironolactone to existing three-drug regimen (RAS blocker + CCB + thiazide/thiazide-like diuretic) 1, 2

Second-Line Pharmacological Options

If spironolactone is ineffective or not tolerated 1, 2:

• Eplerenone as alternative mineralocorticoid receptor antagonist
• Higher-dose thiazide/thiazide-like diuretic or loop diuretic
• Amiloride (potassium-sparing diuretic)

Third-Line Pharmacological Options

• Beta-blocker (bisoprolol) if not already prescribed 1, 2
• Alpha-blocker (doxazosin) 1, 2
• Centrally acting agents 1
• Hydralazine 1

Device-Based Therapy Consideration

Catheter-based renal denervation may be considered only after exhausting pharmacological options 1, 2

Patient Selection Criteria for Renal Denervation

Eligible Candidates

• Confirmed true resistant hypertension: Uncontrolled BP despite three-drug combination including a diuretic 1, 2
• Documented medication adherence (pseudo-resistance excluded) 2
• Secondary hypertension ruled out 2
• White-coat hypertension excluded 2
• eGFR ≥40 mL/min/1.73 m² 1
• Patient preference after shared risk-benefit discussion 1
• Multidisciplinary team assessment completed 1, 2

Contraindications

• Moderate-to-severe renal impairment (eGFR <40 mL/min/1.73 m²) 1
• Secondary causes of hypertension 1

Evidence Quality and Limitations

Blood Pressure Effects

Moderate-certainty evidence suggests renal denervation may reduce 3:

• 24-hour ambulatory systolic BP by approximately 5.3 mmHg (95% CI -10.46 to -0.13)
• 24-hour ambulatory diastolic BP by approximately 3.8 mmHg (95% CI -7.10 to -0.39)
• Office diastolic BP by approximately 4.6 mmHg (95% CI -8.23 to -0.99)

However, the effect on office systolic BP remains uncertain 3

Clinical Outcomes

Critical limitation: Low-certainty evidence shows renal denervation has little or no effect on 3:

• Myocardial infarction risk (RR 1.31,95% CI 0.45 to 3.84)
• Ischemic stroke risk (RR 0.98,95% CI 0.33 to 2.95)
• Hospitalization rates (RR 1.24,95% CI 0.50 to 3.11)
• Renal function (serum creatinine MD 0.03 mg/dL; eGFR MD -2.56 mL/min)

Why Not First-Line

The procedure lacks adequately powered outcomes trials demonstrating safety and cardiovascular benefits, which is why guidelines explicitly recommend against first-line use 1, 2

Procedural Requirements

Center Qualifications

• Perform only at medium-to-high volume centers to ensure procedural quality and safety 1, 2
• Multidisciplinary team involvement required 1, 2

Special Consideration

The 2024 ESC guidelines also note that renal denervation may be considered for patients with increased CVD risk and uncontrolled hypertension on fewer than three drugs if they express preference after shared decision-making, though this remains controversial given the lack of outcomes data 1

Common Pitfalls to Avoid

• Do not use renal denervation before optimizing pharmacological therapy - this violates guideline recommendations 1
• Do not proceed without confirming true treatment resistance - exclude non-adherence, white-coat effect, and secondary causes first 2
• Do not perform in low-volume centers - procedural expertise matters for safety 1, 2
• Do not use in patients with eGFR <40 mL/min/1.73 m² - safety data lacking 1
• Do not present as definitive solution - effects are modest and clinical outcome benefits unproven 3