Four Questions Can Help Identify Patients Who May Benefit from Renal Denervation
A four-question framework helps clinicians confirm uncontrolled hypertension, optimize treatment, identify underlying causes and discuss whether renal denervation fits a patient’s needs and preferences.
Key Takeaways
- Renal denervation is a minimally invasive procedure intended to help lower blood pressure by targeting nerves surrounding the renal arteries.
- Clinicians should confirm that a patient has sustained, uncontrolled hypertension using ambulatory or home blood pressure measurements.
- Treatment, including lifestyle changes and medication, should be optimized before a procedure is considered.
- Patients should be evaluated for identifiable and treatable causes of hypertension.
- The final decision should reflect expected benefits, limitations, medication burden and the patient’s preferences.
As renal denervation emerges as a new treatment option for patients with difficult-to-control high blood pressure, experts are calling for a more practical and systematic approach to determine who stands to benefit most from the procedure.
In a new commentary published in the journal Hypertension, Maria Delgado-Lelievre, M.D., assistant professor of cardiovascular medicine at the University of Miami Miller School of Medicine and director of UHealth—University of Miami Health System’s American Heart Association-Certified Comprehensive Hypertension Center, and colleagues outline a four-step framework to help clinicians evaluate patients for renal denervation.
The minimally invasive procedure is designed to lower blood pressure by disrupting overactive nerves surrounding the renal arteries.
“For a lot of patients, getting blood pressure under control is a long, frustrating road. They’ve changed their diet, they’re exercising, they’re taking three or four medications and their numbers still aren’t where they need to be,” said Dr. Delgado-Lelievre. “Renal denervation gives us a real new option for those patients. The evidence that it lowers blood pressure is there.”
Dr. Delgado-Lelievre said that “the question we face in clinic now is which patients are most likely to benefit and how do we make that decision together with them? That’s what this paper is about. We wanted to give clinicians a practical, step-by-step way to think it through, from confirming that blood pressure is truly uncontrolled to ruling out other causes to talking honestly with patients about what the procedure can and can’t do.”
Dr. Delgado-Lelievre co-authored the paper with Michel Azizi, M.D., Ph.D., from Paris Cité University and Naomi Fisher, M.D., from Brigham and Women’s Hospital.
“I was fortunate to write it with two colleagues I deeply respect,” said Dr. Delgado-Lelievre. “Bringing our experience from both sides of the Atlantic together made the framework stronger and more useful for clinicians wherever they practice.”
What Is Renal Denervation?
Renal denervation gained momentum in the United States after two devices received FDA approval in late 2023. The procedure is indicated as an adjunctive treatment for adults with hypertension whose blood pressure remains inadequately controlled despite lifestyle changes and medication.
“Renal denervation has been proven safe and effective at lowering blood pressure, but questions remain about how and when patients should be referred,” the authors write.
Their article aims to provide health care providers with a practical roadmap that can be applied across diverse clinical settings.
Four key questions
The proposed framework centers on four fundamental questions:
Does the patient truly have sustained, uncontrolled hypertension?
The authors emphasize that office blood pressure measurements alone are not enough. Patients should undergo out-of-office monitoring through ambulatory or home blood pressure measurements to confirm persistently elevated readings and rule out “white coat” hypertension.
Has treatment been optimized?
Before considering a procedure, clinicians should ensure patients have received guideline-directed therapy, including lifestyle interventions and appropriate medication regimens. The review notes that medication nonadherence remains one of the most common reasons blood pressure appears resistant to treatment.
Is there an identifiable and treatable cause of hypertension?
The authors stress the importance of screening for secondary causes, particularly primary aldosteronism, an underdiagnosed hormonal disorder that may account for roughly one in four cases of resistant hypertension and has targeted treatment options available.
Is renal denervation the right choice for this individual patient?
Shared decision-making is essential, the authors note. Discussions should consider medication burden, side effects, quality of life, expected blood pressure reductions and the patient’s treatment preferences.
About the Comprehensive Hypertension Center
UHealth is a national leader in hypertension care and innovation. Its Comprehensive Hypertension Center provides advanced therapies, including renal denervation and clinical research aimed at improving cardiovascular outcomes.
Clinical trials have consistently demonstrated meaningful blood pressure reductions with renal denervation across a range of patient populations, from treatment-naïve individuals to those taking multiple antihypertensive medications. However, the authors caution that the procedure is not a cure and should be viewed as part of a broader hypertension management strategy.
Average reductions in systolic blood pressure have ranged from approximately 5 to 10 mm Hg, with some patients experiencing substantially greater benefits. Higher baseline blood pressure remains the most reliable predictor of a stronger response.
Keeping Patients at the Center of the Decision
According to the authors, the goal is not simply determining procedural eligibility, but ensuring that every patient receives the treatment strategy best suited to their needs and health goals. A systematic evaluation can help identify those most likely to benefit while avoiding unnecessary procedures.
“Renal denervation is not a replacement for healthy lifestyle habits or medications, but it can be a valuable complementary treatment for selected patients,” said Dr. Delgado-Lelievre. “Equally important is engaging patients in shared decision-making so they understand both the potential benefits and the limitations of the procedure.”
The article concludes that confirming uncontrolled hypertension, optimizing treatment, identifying treatable underlying causes and engaging patients in informed, shared decision-making provide a practical framework for determining when referral for renal denervation is appropriate.
“High blood pressure remains one of the leading causes of heart attack, stroke and kidney disease worldwide,” said Dr. Delgado-Lelievre.
By taking a systematic approach to evaluating patients, we can ensure that renal denervation is considered for the right individuals while continuing to optimize all other aspects of hypertension care.”
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Tags: Cardiovascular Division, Comprehensive Hypertension Center, Dr. Maria Delgado-Lelievre, renal denervation