Renal Denervation: A Potential Solution for Uncontrolled Hypertension

Q: Renal Denervation: A Potential Solution for Uncontrolled Hypertension

Hello Winnie： The causes of hypertension are believed by the academic community to involve three main physiological mechanisms： excessive sympathetic nervous system activation, salt/water retention, and the renin-angiotensin system. <br>Antihypertensive medications target these m

Regarding renal denervation (RDN) for hypertension?

Hello Doctor, my mother is 56 years old and is obese with a history of hypertension that has been treated for many years.
Currently, her hypertension medication has been unstable, with episodes of tachycardia, elevated blood pressure, and dizziness occurring every few days.
The doctor has been continuously changing her medications, but so far, none have been effective in stabilizing her blood pressure.
Recently, I came across "renal denervation," also known as the Renal Denervation system (RDN), but there is limited information available for reference.
I would like to ask if this procedure is currently considered a relatively effective treatment for hypertension.
Would you recommend this treatment option, or should we continue to try different medications? Here are the potential side effects of the treatment: blood pressure fluctuations, arrhythmias (such as bradycardia), blood clots, vascular damage requiring surgical intervention, side effects from contrast agents, and side effects from pain or anti-anxiety medications.
Thank you for your help, Doctor.

winnie, 30~39 year old female. Ask Date: 2022/07/01

Dr. Huang Yinghe reply Cardiology

Hello Winnie: The causes of hypertension are believed by the academic community to involve three main physiological mechanisms: excessive sympathetic nervous system activation, salt/water retention, and the renin-angiotensin system.
Antihypertensive medications target these mechanisms for regulation.
Hypertension can be classified as primary (no identifiable cause) or secondary (due to abnormalities in other organs/endocrine systems, with kidney disease being the most common).
If a patient requires three or more antihypertensive medications (including diuretics) and still does not reach the treatment goal, it is termed resistant hypertension.
Renal denervation (RDN) is a procedure that uses catheter-based radiofrequency ablation to disrupt sympathetic nerve activity in the renal arteries to lower blood pressure.
Recent clinical trials have shown that it can reduce systolic blood pressure by approximately 10 mmHg and may be considered for specific populations with resistant hypertension, though it is not recommended as a routine treatment for hypertension.
In 2019, the Taiwan Society of Cardiology published treatment guidelines suggesting the following for RDN in hypertension management: 1.
A CT scan or MRI should be performed to assess the suitability of the renal vasculature for the procedure.
2.
A 24-hour blood pressure monitoring should confirm poor blood pressure control.
3.
Any underlying causes of secondary hypertension should be identified and managed.
Therefore, I recommend that your mother first confirm her blood pressure is elevated: measure her blood pressure at home, recording it twice daily for at least one week (since 24-hour blood pressure monitoring is not commonly covered by insurance in Taiwan, home measurements can serve as an alternative).
Additionally, lifestyle modifications are also crucial for managing hypertension, such as weight loss, smoking cessation, a low-sodium diet, and exercise.
Although these changes may take time to implement, they can lead to significant improvements.
Discuss further with her physician; if pharmacological treatment fails to achieve targets and RDN is being considered, a detailed evaluation at a major hospital is typically required before making a decision.

Reply Date: 2022/07/01

More Info

Renal denervation (RDN) is an emerging treatment option for patients with resistant hypertension, particularly those who have not achieved adequate blood pressure control despite multiple antihypertensive medications. This procedure involves the ablation of renal sympathetic nerves, which are believed to play a significant role in the regulation of blood pressure. By disrupting these nerves, RDN aims to reduce sympathetic nervous system activity, thereby lowering blood pressure.

In your mother's case, where she has been struggling with uncontrolled hypertension despite various medications, RDN could be a potential solution. However, it is essential to consider several factors before proceeding with this treatment.

Efficacy of Renal Denervation
Clinical studies have shown that RDN can lead to significant reductions in blood pressure in patients with resistant hypertension. The SYMPLICITY HTN-3 trial, for instance, demonstrated that while RDN did not show a statistically significant reduction in blood pressure compared to a sham procedure, subsequent studies have suggested that the technique may be more effective in specific patient populations, particularly those with higher baseline blood pressure and less severe renal artery disease.

Recommendations for Treatment
1. Assessment of Current Medications: Before considering RDN, it is crucial to ensure that your mother’s current medication regimen is optimized. This includes evaluating the dosages and combinations of antihypertensive medications. Sometimes, adding a diuretic or switching to a different class of medications can yield better results.

2. Lifestyle Modifications: Encourage your mother to adopt lifestyle changes that can help manage her hypertension. This includes dietary changes (such as reducing sodium intake), regular physical activity, weight management, and stress reduction techniques. These changes can have a significant impact on blood pressure control.

3. Evaluation for RDN: If her blood pressure remains uncontrolled despite optimized medical therapy and lifestyle changes, discussing RDN with her healthcare provider may be appropriate. It is essential to have a thorough evaluation, including imaging studies to assess renal artery anatomy and ensure there are no contraindications to the procedure.

Risks and Considerations
As you mentioned, there are potential risks associated with RDN, including:
- Blood Pressure Fluctuations: Some patients may experience changes in blood pressure regulation post-procedure.

- Heart Rhythm Disturbances: There is a risk of bradycardia (slow heart rate) or other arrhythmias.

- Vascular Complications: Damage to blood vessels can occur, which may require surgical intervention.

- Contrast Reactions: If imaging with contrast agents is necessary, there is a risk of allergic reactions or kidney injury.

Conclusion
In summary, renal denervation may be a viable option for your mother if her hypertension remains uncontrolled despite optimal medical management and lifestyle changes. However, it is essential to have a detailed discussion with her healthcare provider about the potential benefits and risks of the procedure. They can provide personalized recommendations based on her specific health status and history. Continuing to explore medication options and lifestyle modifications should also remain a priority in her hypertension management plan.

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