Advancement in management of hypertension: Renal denervation therapy

Overview

This presentation explores the evolution, mechanism, clinical evidence, and patient selection for renal denervation (RDN) as a therapy for hypertension, especially resistant cases.

1. Background and Need

• Resistant Hypertension is highlighted as a major clinical challenge, defined as blood pressure above target despite using at least three antihypertensive agents (including a diuretic) at maximum tolerated doses, or controlled BP requiring four or more medications. The presentation emphasizes the global struggle with hypertension control rates.

2. Pathophysiology

• The overactive sympathetic nervous system (SNA) is identified as a key driver of hypertension, leading to increased renin release, RAAS activation, sodium retention, and reduced renal blood flow—all culminating in elevated blood pressure.
• Historical context is provided with references to early surgical sympathectomy procedures.

3. Renal Denervation: Mechanism and Procedure

• Renal denervation disrupts the sympathetic signaling between the kidneys and the brain, reducing blood pressure by ablating renal nerves using targeted radiofrequency energy. This is a minimally invasive, device-based approach with no permanent implant and is independent of patient adherence.
• The Symplicity Spyral™ system is described in detail, including its catheter and generator technology, which allows precise, safe, and versatile ablation of renal nerves in both main and branch arteries.

4. Anatomical and Functional Evidence

• The presentation provides anatomical evidence for RDN efficacy, showing that treating both main and branch renal arteries results in greater nerve destruction and less variability in outcomes.
• Functional evidence includes histological findings and clinical trial data demonstrating sustained blood pressure reduction for up to 3 years and beyond in over 3,200 patients.

5. Patient Selection

• Ideal candidates for RDN include:
  • Patients with resistant hypertension
  • Those with uncontrolled hypertension on fewer medications due to intolerance or non-adherence
  • High cardiovascular risk patients (e.g., with end-organ damage or prior CV events).

6. Safety and Efficacy

• RDN has demonstrated an excellent safety profile, with minimal impact on renal function and vascular safety events. No significant decline in kidney function or device-related adverse events has been reported in large clinical programs and meta-analyses.
• The European Society of Hypertension now recommends RDN as a safe and effective complementary treatment strategy.

7. Real-World Experience and Case Studies

• The presentation includes real-world case studies of patients with complex hypertension, polypharmacy, and non-compliance, demonstrating the practical benefits and outcomes of RDN.

Key Takeaways

• Renal denervation is a promising, procedure-based therapy for hypertension, especially in patients who are difficult to treat with medications alone.
• It offers sustained blood pressure reduction, a favorable safety profile, and is now endorsed by major hypertension societies as a complementary option to lifestyle and pharmacological therapy.

Dr. Amitabh Yaduvanshi is a distinguished Senior Interventional Cardiologist and Head of Cardiology at Holy Family Hospital, New Delhi. With over 20 years of expertise, he excels in managing complex cardiac conditions through innovative, patient-focused interventions. A gold medalist in MBBS and MD from Maulana Azad Medical College, he holds a DM from G.B. Pant Hospital. Prestigious fellowships include FACC, FESC, FSCAI, and FICC; he serves as Honorary Professor, International College of Cardiology. His proficiency covers thousands of coronary angioplasties, RF ablations for SVT/AF, and device implantations (AICDs, CRT-Ds, MRI pacemakers). Pioneering Renal Denervation for resistant hypertension and ECMO advancements, he introduced Rotational Angiography and Bluetooth pacemakers regionally. As Asia-Pacific Heart Rhythm Society's sole Indian representative, he speaks globally and has 6+ publications.