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CLINICAL STATEMENTS AND GUIDELINES

Circulation. 2025;152:e114–e218. DOI: 10.1161/CIR.0000000000001356 September 16, 2025 e179

and the presence of supine hypertension with OH were exclusion criteria in most RDN trials; therefore, evaluation should include measure­ ment of 24-hour ambulatory BP and orthostatic vital signs in addition to screening for second­ ary hypertension. The presence of renal artery disease (stenosis, dissection, renal stenting) is considered a contraindication to the procedure. After RDN, it is estimated that the risk of renal artery stenosis requiring intervention is approxi­ mately 0.2% per year, with the highest risk within the first 6 months.48 Thus, surveillance for renal artery stenosis or dissection using noninvasive imaging studies (eg, duplex Doppler, computed tomography angiogram, or magnetic resonance angiography) is suggested after RDN. 6.	 Shared medical decision-making with patients

regarding the procedural risks and potential cardio­ vascular benefits from lowering BP is essential to ensure the outcome meets the patient’s expecta­ tions. Predictors of BP response to RDN have not been consistently demonstrated among clinical trials.49 Only 60% to 70% of patients undergoing RDN experienced a meaningful reduction in ambu­ latory SBP of at least 5 mm Hg in clinical trials.12,50 RDN is currently performed strictly via the femoral artery approach, with the immediate risk associated with an RDN procedure not significantly greater than the risk associated with femoral access alone.51–53 Due to the risk for renal artery stenosis after the procedure, patients will require ongoing surveillance imaging.

6 COMPLICATIONS OF MANAGEMENT

6.1 Management of OH

Recommendations for Management of OH Referenced studies that support the recommendations are summarized in the Evidence Table. COR LOE Recommendations

1 A 1.	 In adults with hypertension, improved BP control is

recommended to reduce the risk for OH.1–4

2a A 2 In adults receiving intensive BP-lowering therapy

with asymptomatic OH, treatment with a goal of SBP <130 mm Hg is reasonable due to increased CVD and mortality benefit.3,5

2a B-R 3 In adults with hypertension initiating treatment or

adding medication with a goal of SBP <130 mm Hg, assessment for symptomatic OH is reasonable to detect other chronic conditions.1–4,6,7

Synopsis

Emerging evidence for the benefits of intensive ver­ sus standard BP treatment among the general pop­ ulation of middle- and older-aged adults has raised questions about the approach to patients with OH. OH affects an estimated 7% to 10% of communitydwelling adults with hypertension, especially older adults, and is predictive of adverse health outcomes, including CVD events.7–11 Institutionalized older adults (age >65 years) have a much higher prevalence of OH and are not included in the scope of these rec­ ommendations, nor are persons with neurologic eti­ ologies of OH, such as Parkinson disease and other autonomic neuropathies. OH is also associated with antihypertensive medication and specific classes of medication use.6,7,12–15 These association studies led to recommendations for screening to identify OH prior to initiation or intensification of antihyperten­ sive treatment and for monitoring of hypotensionrelated safety during treatment. Concerns about worsening OH have also contributed to advice against more intensive BP treatment, particularly among older adults, and for deprescribing antihypertensive medica­ tions.16,17 Contrary to this perspective that intensive BP therapy increases risk of hypotension-associated adverse events, evidence from RCTs demonstrates no association between OH and intensive BP treatment using first-line antihypertensive medication classes.1–3 However, because antihypertensive agents may some­ times unmask OH in patients with an underlying auto­ nomic or other impairment, thoughtful assessment is warranted. Taken together, these results support the assessment for OH symptoms as helpful in the man­ agement of adults with hypertension.

Recommendation-Specific Supportive Text

1 Individual analyses of large randomized BP-lowering

trials, plus a meta-analysis of several well-conducted

Table 25.  Patient Selection for Renal Denervation Resistant hypertension OR uncontrolled hypertension* •	 Patients with stage 2 hypertension (with both office SBP ≥140 mm Hg and office DBP ≥90 mm Hg) in whom BP is not at goal despite taking ≥4 antihypertensive medications at optimal dosages (ACEi/ARB +CCB +thiazide-type diuretics, and MRA)38,47 •	 Patients with stage 2 hypertension (with both office SBP ≥140 mm Hg and office DBP ≥90 mm Hg) who are unable to take antihypertensive medications at the optimal dosages or additional medications11,12,14 Contraindications13,14,26–28,46 •	 Neurogenic orthostatic hypotension •	 Pregnancy •	 Fibromuscular dysplasia •	 Stented renal artery •	 Renal artery aneurysm •	 Significant renal artery stenosis •	 Known kidney or secreting adrenal tumors *After evaluation by a multidisciplinary team to screen for secondary hyper­ tension and contraindications and following a shared decision-making process.49 ACEi indicates angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker; CCB, calcium channel blocker; DBP, diastolic blood pressure; MRA, mineralocorticoid receptor antagonist; and SBP, systolic blood pressure.

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