Renal denervation beyond resistant hypertension: should drug intolerance redefine eligibility?
5 affiliations
- 1Department of Hypertension and Vascular Diseases, Clinical Pharmacology, Strasbourg University Hospitals, Strasbourg, France.
- 2Translational Cardiovascular Medicine, UR 3074, CRBS, University of Strasbourg, Strasbourg, France.
- 3Investigation Network on Venous Thrombo-Embolism-French Clinical Research Infrastructure Network F-CRIN INNOVTE, Saint-Étienne, France.
- 4Department of Nephrology, Strasbourg University Hospitals, Nouvel Hôpital Civil, Strasbourg, France.
- 5Department of Cardiology, Strasbourg University Hospitals, Strasbourg, France.
Abstract
Catheter-based renal denervation (RDN) is endorsed by major international guidelines as an adjunct to antihypertensive therapy, yet most regulatory and reimbursement frameworks still restrict its use to true resistant hypertension, usually defined as uncontrolled blood pressure (BP) despite three or more maximally tolerated antihypertensive drugs including a diuretic. This restriction leaves a clinically important population without an effective escalation pathway: patients with uncontrolled, high-risk hypertension who cannot tolerate the multi-class drug regimens required to qualify as resistant. We argue that this exclusion is increasingly difficult to justify. Contemporary sham-controlled trials enrolling patients on no or limited antihypertensive therapy demonstrate modest but reproducible ambulatory BP reductions in precisely the pharmacological context in which drug-intolerant patients are managed and guidelines published since 2023 acknowledge uncontrolled hypertension on fewer drugs or drug intolerance as clinically relevant scenarios for RDN. The device-attributable ambulatory systolic effect converges on 4-6 mmHg, 25-40% of treated patients derive no meaningful BP reduction, no pre-procedural variable reliably identifies responders, and no trial has been powered for cardiovascular outcomes. Drug intolerance also lacks an objective definition and frequently reflects undisclosed non-adherence. We propose a pragmatic referral pathway in which biochemical adherence testing and a documented trial of a low dose single-pill combination are mandatory steps, followed by out-of-office BP confirmation, secondary hypertension screening, anatomical eligibility and multidisciplinary shared decision-making.
Related
- Clinical Effect of Renal Denervation on Resistant Hypertension in Obese and Nonobese Patients: Insights from Kuwait
- Renal denervation in internal medicine: a FADOI Position Paper on behalf of the Vicenza Hypertension Multidisciplinary Team. Endorsed by the Italian Society of Arterial Hypertension
- Renal Denervation for Hypertension ― Mechanisms, Evidence, and Clinical Integration ―
- Guideline‐Directed Treatment Eligibility and Burden of Untreated Stage‐1 Hypertension Under the 2025 American College of Cardiology/American Heart Association Hypertension Guideline: Insights From NHANES 2015 to 2020
- Real‑World Evaluation of Omadacycline Switch Therapy for Multidrug‑Resistant Bacterial Pneumonia in Patients with Tigecycline Intolerance
BibTeX
@article{cordeanu2026renal,
title = {{Renal denervation beyond resistant hypertension: should drug intolerance redefine eligibility?}},
author = {Elena-Mihaela Cordeanu and Emma Morisot and Corina Mirea and Eric Prinz and Francois Bronner and Dominique Stephan},
journal = {International journal of cardiology. Cardiovascular risk and prevention},
year = {2026},
month = oct,
doi = {10.1016/j.ijcrp.2026.200717},
url = {https://europepmc.org/article/MED/42898641},
note = {CC BY},
}
RIS
TY - JOUR
TI - Renal denervation beyond resistant hypertension: should drug intolerance redefine eligibility?
AU - Elena-Mihaela Cordeanu
AU - Emma Morisot
AU - Corina Mirea
AU - Eric Prinz
AU - Francois Bronner
AU - Dominique Stephan
PY - 2026
DA - 2026/10/06
JO - International journal of cardiology. Cardiovascular risk and prevention
DO - 10.1016/j.ijcrp.2026.200717
UR - https://europepmc.org/article/MED/42898641
AB - Catheter-based renal denervation (RDN) is endorsed by major international guidelines as an adjunct to antihypertensive therapy, yet most regulatory and reimbursement frameworks still restrict its use to true resistant hypertension, usually defined as uncontrolled blood pressure (BP) despite three or more maximally tolerated antihypertensive drugs including a diuretic. This restriction leaves a clinically important population without an effective escalation pathway: patients with uncontrolled, high-risk hypertension who cannot tolerate the multi-class drug regimens required to qualify as resistant. We argue that this exclusion is increasingly difficult to justify. Contemporary sham-controlled trials enrolling patients on no or limited antihypertensive therapy demonstrate modest but reproducible ambulatory BP reductions in precisely the pharmacological context in which drug-intolerant patients are managed and guidelines published since 2023 acknowledge uncontrolled hypertension on fewer drugs or drug intolerance as clinically relevant scenarios for RDN. The device-attributable ambulatory systolic effect converges on 4-6 mmHg, 25-40% of treated patients derive no meaningful BP reduction, no pre-procedural variable reliably identifies responders, and no trial has been powered for cardiovascular outcomes. Drug intolerance also lacks an objective definition and frequently reflects undisclosed non-adherence. We propose a pragmatic referral pathway in which biochemical adherence testing and a documented trial of a low dose single-pill combination are mandatory steps, followed by out-of-office BP confirmation, secondary hypertension screening, anatomical eligibility and multidisciplinary shared decision-making.
SN - 2772-4875
ER -