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

Background: Renal denervation (RDN) has emerged as an interventional option for hypertension management. Three major international guidelines have recently addressed RDN indications and recommendations. Objectives: 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. Methods: 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. Conclusions: 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.