Renal denervation for hypertension management: convergence and divergence across international guidelines

Renal denervation (RDN) has emerged as an interventional option for hypertension management. Three major international guidelines have recently addressed RDN indications and recommendations. To compare and synthesize the positions of the European Society of Cardiology (ESC) 2024, European Society of Hypertension (ESH) 2023, and American College of Cardiology/American Heart Association (ACC/AHA) 2025 guidelines regarding RDN. Structured comparative analysis of guideline recommendations using predefined domains: patient selection criteria, recommendation strength and level of evidence, procedural requirements, and clinical positioning. Each guideline was independently reviewed by two authors, with discrepancies resolved by consensus. All three guidelines converge on four major indications: uncontrolled hypertension, resistant hypertension, drug intolerance, and patient preference. Key divergences relate to the strength of recommendations and specific patient selection criteria. Although differences in recommendation classes (ACC/AHA 2b vs. ESC/ESH IIb) appear discordant, they largely reflect structural variations in grading frameworks rather than genuine differences in evidence appraisal. The modest expected blood pressure reduction (4–6 mmHg ambulatory systolic), equivalent to approximately one antihypertensive medication, translates into an estimated 10% reduction in major cardiovascular events, though individual responses vary considerably. RDN represents a complementary therapeutic option requiring multidisciplinary evaluation and shared decision-making.