Hypertension is one of the most important cardiovascular risk factors [1]. However, the control rates among people with hypertension in 2019 were 23% for women and 18% for men [2], and its causes are thought to include suboptimal adherence, economics, drug intolerance, and clinical inertia [3]. Non-adherence in particular is one of the limitations of pharmacotherapy, and may not necessarily be due to forgetfulness, but may involve patient preferences such as refusal to take medication, which should be taken to action. Non- adherence to antihypertensive medications has been reported in at least 50% of patients [4], and associated with uncontrolled blood pressure (BP), poor clinical outcomes [5] and consequently with increased health care costs [6]. Device therapies such as renal denervation (RDN) are antihypertensive treatments that can eliminate drug adherence. However, it is invasive and there are responder and non-responder issues, and it is necessary to select patients for whom it is indicated. Patient perspectives on treatment strategy are vital in controlling hypertension and, from the patient’s point of view, he or she has the right to choose between medical therapy and device therapy. Patient preference has been emphasized to be considered during hypertension treatment strategy determination through shared decision making in almost all recently published consensus documents and papers on RDN [7,8,9]. On the other hand, patient preferences are greatly influenced by the information provided by the medical providers, so it is important to provide unbiased and up-to-date medical information.

Three previous studies on patient preferences for RDN and pharmacotherapy for hypertension were reported. The first is based on 1011 patients in Germany [10], the second on 2768 patients in Western Europe and the United States [11], and the third reports patient preferences for RDN based on a survey of 2392 patients in Japan [12]. These studies were done without presurvey education of updated medical information about RDN, which is not an appropriate environment for shared decision making. In this issue of the Journal, Zhang et al. reported patient preferences for RDN on a survey of 402 patients in China [13], who were explained about RDN in advance, which would have made shared decision making possible. The results are similar to previous survey investigations. 30% hypertensive patients were willing to choose RDN as a BP control strategy. These patients were younger, more likely to be males, took more antihypertensive drugs, and had concomitant metabolic disorders. Interestingly, Zhang et al. reported that perspectives of patients on RDN were not dependent on their education levels. In Zhang’s study, 83.9% of patients expected that RDN will decrease their BP by > 15 mmHg, while 68.8% of patients expected that the efficacy of RDN could span for more than 15 years if they underwent the invasive procedure and no patient would choose RDN therapy if the efficacy in less than 5 years. Among patients surveyed in Japan and Germany, 40% expected RDN to reduce SBP at least 15 mmHg, with higher expectations in China. These four surveys show that although expectations for RDN are high, there is a gap between the expected BP reduction and the effect obtained in randomized clinical trials [14, 15]. In fact, even a BP reduction of 5 mmHg is sufficient to prevent cardiovascular events [16, 17], but patients are not adequately provided updated information for RDN and prevention for CV events.

In this issue of the Journal, Panchavinnin et al. reported that the reduction of systolic BP was −30.0 ± 12.7 mmHg at 9 years in performed 18 RDNs in 17 patients with resistant hypertension in Thai and there was heterogenous BP responses after RDN. Effectiveness of the RDN outcome were achieved (a reduction of office systolic BP ≧10 mmHg, or a reduction of the number of antihypertensive drugs taken, or both outcomes) in 88% at 1 year and more than 75% of patients during the entire follow-up at each time point up to 9 years follow-up without any intervention related adverse events [18]. The GSR reported that systolic BP reduction after RDN was sustained over 3 years, with office systolic BP (−16.5 ± 28.6 mmHg) [19] and (−32 ± 18.8 mmHg) in GSR Korea [20]. Mahfoud et al. demonstrated that 24-h ambulatory systolic BP reduction was 10.0 mmHg (95% CI −16.6 to −3.3; p = 0.0039) at 36 months in SPYRAL HTN-ON MED trial, independent of concomitant antihypertensive medications and without major safety events. Fengler et al. showed that, among 296 patients treated with RDN, 180 patients with 24-h ambulatory systolic BP reduction of ≧5 mmHg at 3 months had a 47% reduction in major adverse cardiovascular events, compared to those with <5 mmHg reduction, during a median follow-up of 48 months. Thus, the long-term efficacy and safety of RDN is being reported but has not yet reached the expected effect for patients. However, instead of simply providing information on only the antihypertensive value, all these updated information for clinical outcomes should be provided to patients before assessing patient preference.

In Asians, the slope of the association between increasing BP and the risk of cardiovascular events is steeper than in Westerners [21]. Kario et al. reported that uncontrolled morning hypertension and residual nocturnal hypertension despite antihypertensive pharmacotherapy are promising targets for the use of RDN in Asia [22, 23]. Although there are issues to be resolved for RDNs, such as responder and non-responder identification and intraoperative endpoints, RDN could provide an adjunctive treatment modality in the management of patients with hypertension.