Single Interventions (Pharmacological or Renal Denervation) Are Not Sufficient to Achieve Blood Pressure Control in Resistant Hypertension: A Systematic Review and Meta-Analysis

BACKGROUND: Resistant hypertension remains a major clinical challenge. This systematic review/meta-analysis evaluated whether the addition of a single pharmacological or device-based intervention (renal denervation [RDN]) can achieve effective blood pressure (BP) control in patients with true resistant hypertension. METHODS: A systematic search of MEDLINE/PubMed was performed to identify studies assessing the antihypertensive effects of adding a single pharmacological or device-based intervention in patients with true resistant hypertension. Primary analyses were conducted using a single-arm framework. RESULTS: Sixty-eight studies were included (n=6297; weighted mean age, 60 years; men 60%; diabetes 35%; smoking 16%; cardiovascular disease 27%). Participants received an average of 4.8 antihypertensive medications, with baseline office BP of 164/92 mm Hg and 24-hour ambulatory BP of 148/85 mm Hg. The median follow-up was 6 months. Meta-analysis of 58 studies (n=4579; 52% RDN) demonstrated a pooled mean 24-hour systolic ambulatory BP reduction from baseline of -11.3 mm Hg (95% CI, -12.3 to -10.2). Meta-analysis of 15 studies (n=2700; 15% RDN) showed a pooled hypertension control rate during follow-up of 35% (95% CI, 28-42). No significant differences were observed between RDN and pharmacotherapy or between randomized and nonrandomized studies. CONCLUSIONS: A single intervention-either pharmacological or RDN-on top of guideline-directed background therapy resulted in clinically meaningful BP reduction in patients with true resistant hypertension; however, only one-third of patients achieved BP control. Future clinical trials are needed to evaluate whether combination treatment strategies integrating optimized pharmacological regimens with RDN can provide more effective and durable BP control in this particularly challenging patient population.