Novel Invasive Methods as the Third Pillar for the Treatment of Essential Uncontrolled Hypertension

Pharmacologic therapies remain the treatment of choice for patients with essential hypertension, as endorsed by international guidelines. However, several cases warrant additional modalities, such as invasive antihypertensive therapeutics. The major target of these interventions is the modulation of the sympathetic nervous system, which is a common pathophysiologic mechanism in essential hypertension. In this narrative review, we elaborate on the role of invasive antihypertensive treatments with a focus on renal denervation, stressing their potential as well as the drawbacks that prevent their widespread implementation in everyday clinical practice. In the field of renal denervation, several trials have shown significant and sustained reductions in the level of office and ambulatory blood pressure, regardless of the type of energy that was used (radiofrequency or ultrasound). Critically, renal denervation is considered a safe intervention, as evidenced by follow-up data from large clinical trials. Baroreflex activation therapy may result in enhanced parasympathetic nervous system activation, thus lowering blood pressure levels. Along the same lines, carotid body ablation could also produce a significant antihypertensive effect, which has not been tested in appropriately designed randomized trials. Moreover, cardiac neuromodulation therapy could prove efficacious by altering the duration of the atrioventricular interval in order to regulate the preload of the left ventricle and, therefore, lower blood pressure.