At today’s CX Renal Denervation Session Great Debate, delegates voted 3:1 against the motion that renal denervation should be used routinely to treat hypertension. As all of the speakers, regardless of which side of the debate they were, agreed that renal denervation should only be used to treat patients with resistant hypertension, the real focus of the debate centred on what was meant by the word “routine”.
Mel Lobo (London, UK), who was supporting the motion that renal denervation should be part of routine clinical practice to treat hypertension, claimed that the definition of routine was a “key issue” in the debate. He explained that patients who were suitable candidates for the intervention belonged to a highly selective group of patients, who had true resistant hypertension (ie. non-concordance with medication and other causes of resistant hypertension had been ruled out) and who would be managed by hypertension specialists rather than by primary care physicians. Lobo added that, in his view, renal denervation should become “step five” of the UK National Institute for Health and Clinical Excellence (NICE) pathway for the management of hypertension, commenting: “We do not have any randomised controlled trial data for step four [the use of spironolactone; only observational data are available], so why not have renal denervation as step five? Believe me when I say adding in a sixth or seventh antihypertensive drug is not going to work.”
Felix Mahfoud (Homburg, Germany), who was Lobo’s co-proponent of the motion, agreed that the routine use of renal denervation referred to it being used only in the “very specialised” group of patients with true resistant hypertension. He said: “Is it really ethical not to offer patients a modality that could benefit them?”
Speaking against the motion, Mark Caulfield (London, UK) disputed that “routine” could refer to an intervention being used in a highly selected group of patients. Caulfield commented: “Routine use means everybody; it implies that the intervention should probably be used in a large number of patients. Renal denervation is not ready to be used in routine clinical practice because there is not evidence base to support it being used in this way.” He added that the NICE consensus document on renal denervation, of which he was a co-author, was specifically drawn up because there were concerns that the doctors would use the intervention for all patients with hypertension rather than just those with true resistant hypertension.
Also speaking against the motion was Bryan Williams (London, UK), who said he was doubtful about the data from renal denervation studies. He commented: “What is critical is how many patients in these studies were actually taking their antihypertensive medication? If the drop in blood pressure observed in these studies is really a result of renal denervation on top of antihypertensive medication, then that is impressive. But if it is actually a result of patients starting to take their drugs [because they are now in a clinical trial], then it is not impressive.”
Lobo responded by saying there had to be element of trust and that “We have to believe our patients when they say they take their medication. We are not able to follow them home and check up on them.”
At the end of the debate, 3:1 delegates voted to support Caulfield and Williams that renal denervation should not be part of routine clinical practice for managing hypertension. Summing up the data, the chair of the session Neil Poulter (London, UK) said he hoped that by the time of CX36 (12–15 April 2014), more data on renal denervation would be available and the issue could be further discussed.