Renal Denervation to Treat Hypertension: A Clinical State-of-the-Art Review

Hypertension represents the leading risk factor for death globally, affecting one in two adults. Despite dozens of inexpensive medications and lifestyle changes that effectively lower blood pressure (BP), hypertension control rates remain poor. Renal denervation (RDN) is a procedural therapy indicated as an adjunctive treatment for high BP. FDA approval in late 2023 followed the publication of a series of rigorous, second-generation, randomized clinical trials that demonstrated safety and efficacy of the procedure. Two catheters employing radiofrequency (Spyral) and ultrasound (Paradise) are currently approved to ablate renal sympathetic nerves. In randomized sham-controlled trials, RDN lowered BP in patients with mild-to-moderate and true resistant hypertension, and in patients both on and off antihypertensive medication. When evaluating patients for RDN, shared decision-making is a critical element, which should include potential benefits and that a minority may not respond to the therapy. There is only one constant predictor of magnitude of response: magnitude of baseline SBP, which is one reason why guidelines recommend prioritization of patients with resistant hypertension, together with patients whose BP cannot be effectively managed with medication. Before referring patients to a trained interventionalist, it is important to optimize medical therapy and adherence, and confirm uncontrolled hypertension out-of-office. Patients should be screened for primary aldosteronism and for other secondary causes of hypertension if clinically indicated, though sleep apnea is not a contraindication to RDN. A team approach is advised, with hypertension specialists and interventionalists collaborating. Data from global registries will augment our knowledge and guide future implementation.