Renal Denervation for Uncontrolled High Blood Pressure

Could a new treatment help people whose high blood pressure remains difficult to control?

High blood pressure affects nearly half of U.S. adults and can increase the risk of heart attack, stroke, kidney disease and heart failure. But for some people, even multiple medications and lifestyle changes aren't enough to bring their blood pressure under control.

In this episode of MedStar Health DocTalk, host Debra Schindler talks with Dr. Brian Case, MedStar Health interventional cardiologist and hypertension specialist, about renal denervation (RDN), an FDA-approved treatment option for certain patients with uncontrolled or resistant hypertension.

Dr. Case explains:
• What high blood pressure does to the heart, kidneys and body
• How doctors determine whether hypertension is truly uncontrolled
• Who may be a candidate for renal denervation
• How the procedure works and why the kidneys are involved
• The difference between ultrasound and radiofrequency renal denervation
• What patients can expect before, during and after the procedure
• How long it takes to see a reduction in blood pressure
• Potential risks and who may not qualify
• Why renal denervation is not a cure for hypertension but can be used alongside medications and healthy lifestyle changes
• What researchers have learned since the earlier studies of renal denervation
• How this emerging treatment could change the future of hypertension care

Dr. Case also shares what he and his colleagues are seeing in patients treated through the MedStar Health hypertension program.

Learn more about renal denervation at MedStar Health:
MedStar Southern Maryland Hospital Center: 301-877-5677
MedStar Washington Hospital Center: 202-877-5975

This podcast is for informational and educational purposes and is not a substitute for medical advice. Talk with your healthcare provider about your individual condition and treatment options.

#MedStarHealth #DocTalk #HighBloodPressure #Hypertension #RenalDenervation #HeartHealth #BloodPressure #Cardiology

For more episodes of MedStar Health DocTalk, go to medstarhealth.org/doctalk.

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Comprehensive, relevant, and insightful conversations about health and medicine happen here on MedStar Health doc talk. These are real conversations with physician experts from around the largest healthcare system in the Maryland DC region. High blood pressure affects nearly half of adults in the US and is one of the biggest contributors for heart attacks, strokes, and kidney disease worldwide. For many people, medications alone aren't enough to keep it under control. Sometimes even when you're doing the right thing, taking your prescriptions, watching your diet, staying active, blood pressure still can remain dangerously high. That's not because people don't care. It's often because managing blood pressure is complicated, involves multiple medications and can be hard to sustain long-term. Today, we're talking about an emerging treatment option for uncontrolled hypertension. It's an FDA approved system called renal denervation or RDN. What is it and how does it fit alongside traditional blood pressure management? Joining me is MedStar Health interventional who specializes in treating patients with complex hypertension. I'm your host, Deborah Schindler. Thanks for being back with me today. Yeah. Thank you so much, Debra, for having me today. This is going to be a really exciting topic to discuss, just hypertension in general and then this new novel therapy that we can offer renal denervation. Well, to start, can you help us understand what hypertension is? Just give us the basics on that and why is it so dangerous? Yeah, so hypertension is the medical term for high blood pressure. And what's blood pressure? It's essentially the blood flow hitting against your arteries and creating a pressure. And we monitor your blood pressure, as everyone knows, by doing non-invasive blood pressure cuffs and a normal blood pressure, that top number, you want it at 120 and that bottom number, the diastolic pressure, you want that at 60. And why is it so important to have your blood pressure controlled? If you have elevated blood pressure, it puts you at an increased risk for a lot of problems down the road, specifically heart attacks, stroke, kidney disease, and even heart failure as well. So this is why we always are checking patients' blood pressures as part of their vital signs when we're seeing them in the office. Are your patients surprised by the connection to kidneys? Because I was surprised by that. I'm not sure how they're related. Yeah. Yeah. So for everyone out there, renal is another word for kidney, right? So renal denervation, the procedure we're going to talk about, you're essentially saying kidney de-inervation. And every time I bring this therapy up to patients, they get confused. Why are we talking about the kidneys when we're dealing with the blood pressure and the heart? But you have to remember that hypertension is a systemic disease and it does not involve just one organ. It involves both the heart, the kidneys, and then also your nervous system. And then also there's a component of the hormonal glands in your body as well. So in the kidneys specifically, you have the blood flow going to the kidneys and the blood flow gets to the kidneys through renal arteries. And these renal arteries have a bunch of nerves around them on the outside and they're monitoring the blood flow, the pressure across the renal artery. And based off the highs or lows of that flow, it sends a signal back to the brain and then the brain will activate a bunch of pathways that will subsequently elevate the blood pressure. So it's almost like a feedback loop. The kidneys are monitoring the blood flow. If it thinks the blood pressure needs to be elevated, it says a signal back to the brain and then the brain sends a signal to the heart and other organs to raise the blood pressure. So this constant feedback loop. Some patients who have high blood pressure, this feedback loop is ongoing, constant, almost like revved up. If you think of a stereo speaker, you and I right now, our volume's at like a four, but somebody that has ongoing elevated blood pressure, hypertension, that stereo speaker's a 10 out of 10. The volume's high and it's high all the time and your blood pressure is always elevated and those are the patients that are at risk for problems in the future. Okay. Well, before someone is considered for renal denervation, how do you make sure their blood pressure is truly uncontrolled? Does it have to go be high for a certain length of time while the patient's been on medication? What role does home monitoring play too? Yeah, yeah. No, great question. We do not treat or evaluate hypertension just based off one single reading, one blood pressure reading. We all know when patients come to the office, they can sometimes be nervous or they were fighting for a parking lot spot outside and they might be a little worked up and their blood pressure could be elevated at that moment, but it doesn't mean they truly have hypertension. And then some patients also have something called white coat syndrome, right? Just being in the doctor's office, seeing the doctor can raise their blood pressure, but then when they go home, their blood pressure is actually normal. So from our standpoint, when we want to make the clinical diagnosis of hypertension, high blood pressure, we want to get blood pressure readings on multiple visits and in multiple settings. So of course in the office, but then we want another blood pressure check at home and then potentially even a third blood pressure check at a different doctor's store or at your local community center. And if multiple readings are showing elevated blood pressure, then that's when we can make the formal diagnosis of hypertension. And that's also important once we have made the diagnosis and we put a patient on treatment, we want to know how they're responding to it. And again, we want to have a log, a blood pressure log, both in the office and outside the office and get that overall trend of how a patient's blood pressure is doing to understand is a treatment we're delivering to them effective? Do we need to add on therapy or do we need to consider something like renal denervation to help treat their blood pressure? I mentioned to you that my mom just recently had a stroke, but she's never had high blood pressure and now she has high blood pressure to the point that they had to double her medications. Does that automatically qualify her to become a patient for renal denervation? Yeah. I'm so sorry to hear about your mom. I'm glad she's doing better now. Thank you. 50% of Americans, US patients have high blood pressure. And of those 50% of patients, 80% have uncontrolled hypertension. And the problem with hypertension blood pressure is it's the quote unquote, it's a bad term to say, but the silent killer, meaning people can have high blood pressure for a long That elevated blood pressure for a long time is doing damage to your body and you may not even realize it. And unfortunately, sometimes you don't realize you have high blood pressure until you come in with a stroke or you come in with a heart attack after an event has happened. And that's why it's so important to do blood pressure screenings, get evaluated to see if you have high blood pressure, and then get on treatments if you have high blood pressure to prevent these events from happening. Once you have a diagnosis of hypertension, the goal is to lower to get to that top number, the systolic blood pressure of 120. Every 10 millimeters of mercury drop, meaning if you go from 140 to 130, you decrease your risk of having a heart attack or a stroke or kidney disease or heart failure by a relative risk reduction of 20%. So every small increment decrease in your blood pressure, you're having a profound impact on preventing problems If you have high blood pressure and you're on three or more therapies and you've had a stroke or you've had a heart attack, you could potentially be a candidate for renal denervation and you could get evaluated for the treatment. Okay. So if a patient is considering renal denervation, let's help them prepare for this. From the evaluation to recovery, what should they expect? Yeah. So first and foremost, we need to just identify those patients who would qualify for renal denervation. And those patients are patients that fall in one of three categories. One is they have resistant hypertension. And what is resistant hypertension? That's ongoing elevated blood pressure despite being on three anti-hypertensive medications. At the same time or at different times? At the same time. Yeah. Or if they're on four or five medications, and even if their blood pressure is controlled, they're on four or five medications, they still might be a candidate for renal denervation. The second one is, and we see a lot of patients for this reason, they just have a lot of bad reactions or side effects or allergies to antihypertensive medications. There's a lot of great anti-hypertensive medications out there. If you're on three or four medications, they can make you feel not the best. You can feel fatigued, you can feel dizzy, it can make some abnormalities to your blood work, and that could be challenging to take those medications because of all the side effects and then also doing what they're supposed to do, controlling your blood pressure. We've had patients who are only on one or two antihypertensive medications, but they've had such bad reactions to five or 10 other antihypertensive medications that they can qualify for the renal denervation as well. The third bucket is actually patients that have documentation of poor compliance, and not in a bad way, but just meaning that they really struggle with taking an antihypertensive medication three times a day due to work or due to family constraints or whatever it may be, that they just really struggle with taking all of their medications consistently and effectively to lower their blood pressure. A lot of cardiac patients out there are on 12, 14 medications and it's just hard to keep it all in line. Patients are trying their best, but they're struggling and renal denervation could be a therapy for them as well. So that's kind of the buckets of patients that we're considering. So if a patient could potentially qualify for renal denervation, we would bring them into the clinic to do a one-time evaluation to essentially make sure that they have elevated resistant hypertension and go through their medications, go through their blood pressure log, make sure they have a high blood pressure. And then the second part of it, which is the important part, is doing a secondary hypertension evaluation. Sometimes patients could have a disease process going on in their body that in result causes your blood pressure to be elevated. Like cancer? Yep, exactly. Like cancer, primary hyperaldosteronism, long word, but essentially aldosterone that's high in your blood and it can cause your blood pressure to be elevated. A couple other causes. Sometimes if you have narrowing in those arteries of your kidneys, that can elevate your blood pressure as well. We want to rule those things out because if you have that, we could treat that and we don't need to do renal denervation because treat the underlying issue that's going on for you. It's a basic blood test and an ultrasound of the kidney. We do that. We make sure you don't have those secondary causes. If you don't and you've checked all the other boxes, you're a candidate for renal denervation. Next part of it before doing the procedure itself is we have a shared decision making. I bring you back, we talk, we go over the results, we say everything looks good, you have no secondary causes. Now let me tell you about the procedure, which I'm sure we'll talk about in a second. And then also a big thing to stress is I always want to make sure that the patient realizes that renal denervation is not a cure for hypertension. We're not going to do this procedure and your blood pressure's going to be normal and we're going to get you off every medication you've ever been on and it's going to be a cure. It's an adjunctive therapy, right? We still want you not to smoke. We still want you to exercise. We still want you to eat healthy. The goal with the renal denervation is to get that blood pressure to a goal and then hopefully maybe get you off one or two of your antihypertensive medications so you don't have all those bad side effects and you can have a good quality of life. So that's kind of the steps that we do as the outpatient clinic. And then if a patient's agreeable, then we would move forward to do the actual procedure itself. Now, not everybody offers the renal denervation system. So I imagine patients are coming from other places. Are they being referred by other cardiologists? And is the consult that you just described available on telehealth because it's not available everywhere? Yeah. Fantastic question. So renal denervation is a newer device. The technology's been around for 10 years, but it's been FDA approved for over a year now. Centers are creating programs. We're lucky here at MedStar Health that we have a pretty robust program and we have sites in both Maryland and DC where we can evaluate patients. The referrals are coming from, at the moment, cardiologists, my colleagues, along with nephrologists, kidney doctors. A lot of kidney doctors will manage high blood pressure and they are referring to me as well and they have a lot of knowledge about renal denervation. Another option is referrals from primary care doctors. Us as a community need to do a better job of educating primary care doctors of this therapy. I'm glad this podcast is going to come out because they need to be aware that this is available also and they can refer their patients. Patients themselves can actually go online. There's some search engines and registries that they can look up physicians in their area that are doing renal denervation and they Unfortunately, I wish telehealth was available at the moment, but because of CMS guidelines, that initial visit I described has to be in office at the moment. And I think the big reason is because they want us to do proper blood pressure checks. In. The office. But I would imagine maybe three, five years down the road that telehealth could be an option as well. That you could accept the blood pressure records or information from somewhere else. Yeah, absolutely. So there's two renal denervation systems. There's ultrasound and radio frequency. Tell us how they work and how they're different and do you have a preference? Yeah. So there's two companies out there, two devices. There is the Recore Paradise device, which utilizes a balloon ultrasound based system. And then there's the Medtronic Simplicity device, which uses a spiral catheter and delivers radiofrequency. It's a radiofrequency ablation. It's the same radiofrequency ablation that our EP colleagues do as well. They are both FDA approved. They are both effective. They are both effective in the same degree and they're both safe. So in my mind, from a clinical standpoint, they both do the same goal, which is lower your blood pressure on average around 10 millimeters of mercury for that top number. At MedStar, we have both systems and we utilize both systems. When you look at the renal artery vasculature, it's There's some branch arteries as well. And these branch arteries have nerves around them in addition to that main artery. And with the simplicity device, you can actually get to those branch arteries and deliver radiofrequency ablation in those branch arteries and de-innervate in that area as well. So conceptually, you can de-innervate more of the kidney with the simplicity device versus the recour, which only kind of works on the main part of the renal artery. But again, that being said, all the clinical data shows that they're both effective and they both lower the blood pressure and they're both safe. The results of these procedures, is it immediate? So it's not. So the procedure itself is a one-time procedure. You do the denervation. Once you've done it, the nerves are de-innervated and they're always on, meaning the therapy you delivered doesn't go away over X amount of time. The blood pressure drops are not immediate. Yo won't leave the hospital that day with better blood pressures. It takes about one to three months to see a gradual decline in the blood pressure, usually around one or two months, but you will see that decline. The nice thing that we're seeing clinically is that decline continues. There's evidence, registry evidence to show that you have further lowering of blood pressure almost up to 20 millimeters of mercury at three years. And clinically for the patients we've treated so far, we are seeing that. We see that initial 10 millimeters of mercury drop around three months, and then when we continue to follow up with them, we're seeing even more of a drop in their blood pressure as well. So it's effective, no doubt about. It. That's important information to manage expectations for patients. Yeah, absolutely. So it's not a surgery in the traditional sense. It's conducted in the cardiac catheterization lab. Is the patient asleep or are they in a twilight? And how long does it take? Yeah. So it's an outpatient procedure, meaning the patients will come in and they'll go home the same day. If anyone's ever had a heart catheterization before, it feels very similar to that. So the patient comes into our cath lab. They do not have to go under general anesthesia. They'll be put under. They get moderate sedation where they'll be calm, relaxed, sleeping, but they'll be able to answer questions and stuff like that. At the moment, we access the artery in the groin, the femoral artery, but there is technology that's being created and should be out in about a year. Well, we'll have the option to go through the radial wrist as well to do this therapy, which will be exciting. But at the moment, we go through the groin and then we bring a very small catheter up to the kidneys. We wire the kidneys like we do with a coronary wire. And then over that wire, we deliver the therapy and literally it's like touching an on button, off button. We deliver the therapy over 45 seconds to a minute and then we deliver it and then we pick a different part of the kidney and deliver the therapy again, de-innervate the whole renal artery vasculature system on both sides of the kidneys. All said and done, the procedure takes around 45 minutes from access to closure. And then afterwards, the patients have to recover in the cath lab area for four hours, just like they would do for any other heart catheterization. And that's really just because we access the groin area and we want to make sure the patient's safe to go home. The femoral. Artery. Yeah, the femoral artery to make sure there's no problems or complications there. And then after that, they go home and there's no restrictions, there's no recovery or anything like that. To be honest with you, they can go to work next day. There's no restrictions. Is there pain involved and will they feel differently when they go home? Yeah. So there is pain with delivery of the therapy itself. When I press the on button and for those 45 seconds, there is a little bit of discomfort for the patient, but we do give sedation. We actually give some other medications like IV Tylenol that helps minimize it. And to be honest with you, once the patient's gotten off the table and they're in the recovery and they've woken up more, I go talk to them, tell them everything went well. And I always ask them, "Do you remember the pain that you felt, the discomfort?" And they always say no. I was going to ask you how they describe the pain. I guess they. Can't. Yeah. Honestly, I guess we're really good with our sedation or by the and have recovered, they don't even remember the discomfort that they were feeling during the procedure itself. That's interesting. Yeah. Yeah. Can you be put to sleep all the way? You could, you could. So the actual initial clinical trials, they did it under general anesthesia, the intubated patients, but they realized fairly quickly that that wasn't needed because there's risk of going under general anesthesia. But if there was a patient that was just like,"I can't deal with the fear of this. I want the therapy, I can't deal with the fear," we could offer general anesthesia if needed. That's for me. That's what I would need, especially when you said there's pain. So is there anything that would disqualify a patient from having this procedure? Yeah. A few things come to mind. One is if unfortunately you just truly don't have uncontrolled resistant hypertension. Maybe when you go see your doctor, you have white coat syndrome, but then we tell you to do some blood pressure checks at home and your blood pressure is well controlled at home, there's going to be no point to do the therapy. The second biggest thing is if we identify a secondary cause, we're going to treat that secondary cause and not do innovation. But I have to say one of the best things about this hypertensive program that we have at MedStar now is we are unmasking a lot of secondary causes for people's blood pressure.People have had high blood pressure for five, 10 years and physicians have prescribed medications, but they haven't looked for these secondary causes. And we've identified a few patients who have had primary hyperaldosteronism and we've been able to target and treat that as well. So even if we're not doing the procedure on some patients, just the fact that they're getting this comprehensive evaluation and care, I think is helping for the overall general population of patients with hypertension. The two other things that would exclude us is advanced kidney disease. So we can do it with patients that have renal insufficiency, but there's a number or cutoff that if their kidney function is worse than that cutoff, then unfortunately we won't be able to do the procedure on them. There's research being done right now to see the benefit of patients with end stage renal disease like those patients on dialysis, but at the moment it's not FDA approved. And the last one is more of an anatomical reason. If a patient has a stenosis or a narrowing of their renal artery, more than 50%, we're advised not to do the therapy because A, it might be hard to deliver the equipment past the stenosis, the blockage, and then B, technically you could maybe fix that blockage and that that might help lower the blood pressure also. Is there a way to know that that is the case before you get in there? Yeah. So that's why we do a renal ultrasound to look at the renal arteries to see if there's a narrowing or blockage. However, sometimes it could be missed on the renal ultrasound and there has been a couple of times where we've gone in and we've identified that there was narrowing, but again, we could fix that by putting a stent in and that could help with the patient's blood pressure also. That would have to be pretty narrow because the cath is very small, isn't it what you're putting in? Yeah. Yeah. It would have to be narrow, but we do see it sometimes. A renal stent? A renal artery stent. And then a key thing to also note is, I'm sure there's patients out there listening that have renal artery stents. They've had that done before, and you can get renal denervation after having a renal artery stent. It's possible. If the stent is open and flow is good, you can do renal denervation in those patients. You just obviously don't ablate where the stent is. You just avoid that area. Yeah. Now you mentioned that the technology is not new. It came out about 10 years ago, but it was only about a year ago that the FDA approved it. And there's been a lot of excitement about it obviously since. Back when it came out 10 years ago, renal denervation generated a lot of excitement, but there was a study that came out that raised a lot of questions about how effective it really was. Since then, what has happened? What did researchers learn from that experience? What's changed in the studies and the technology that made it excitable again and allowed FDA to approve it? Yeah. Yeah. There's a lot of controversy with the initial clinical trials about 10 years ago for renal denervation. And there's two reasons why those are negative trials. One was the trial design. These trials were poorly designed, meaning they were rolling patients with hypertension, just saying,"You have hypertension, you can get enrolled." And it was either getting renal denervation or standard of care, but there was no structure around hypertension definition like I just talked about with resistant uncontrolled hypertension. And then the patients that didn't get renal denervation, all of a sudden were in this clinical trial and they had study coordinators calling them every week, making sure they're taking their meds, keeping an eye on their blood pressure at home. They're being seen in the office all the time, having their blood pressure checked. So they were getting really intensive monitoring and care for their blood pressure. And this naturally, if I checked your blood pressure every day and I change your medications daily, your blood pressure would be pristine, right? So we were seeing that in the trial. So the effect of the device itself was being masked by just the effectiveness of the monitoring for the patients that weren't getting the device. However, the updated trials noted this deficiency in their study design and they did some changes to have a better definition of resistant hypertension and then to control for those factors I just described about. So that was the first thing. The second thing is both companies updated their devices and their design to be much more effective and to be better at de-innervating more of the renal artery vasculature to be effective with their treatment as well. I just think it was important to shed some light on that history because maybe someone explored this option years ago and is still skeptical about it. Yeah. No, and that's a great point. And another important point with that is sometimes I hear from referring doctors that they are like, "Oh, renal denervation, that's still a thing? Oh, I though that didn't work." Okay. Yeah. So there's that concept from some of the physicians out there in the community that this is a voodoo therapy that doesn't work. It's not effective. Be your own advocate. If you have high blood pressure, difficult to control, bring it up to your physician. If they think it's nonsense, go to a center like ours that has hypertension and treat you and see if you're a good candidate. Okay. Well, in fairness, though low, we have to sort of give the fine print, right? The risks that we should mention- Of course. Include slow heart rate, leaking in the artery that may cause a bruise, renal artery stenosis. So it could actually cause the narrowing that would also prevent this treatment or tears in the renal artery, which sounds very serious. Yeah. No, absolutely. Of course. Any procedure you do, there's always going to be risk. There's always going to be risk. Any heart catheterization, any type of procedures could be risk. For this one, the biggest concern is A, damage or injury to the access site, that femoral artery. And that risk is about 0.3% for bleeding or a tear like you described. And then the second one is injury to the renal artery itself. And that could be a nick dissection or God forbid a perforation of bleed. But luckily that risk is also about 0.1% to 0.3%. And that's in the clinical trials. In the grand scheme of thing, it is a super, super safe procedure. Very, very safe, even more safe than putting a stent in or something like that. Only to get better next year when you're doing it radially. Yeah. Radial. Yeah. Yeah. So once we have the radial system out there next year, yeah, all those concerns about that groin complication will go away, which is incredible and we're excited for that. Complications can always happen, but we're prepared. We're ready to treat them if that were to happen. The other thing, there is contrast with this and for patients who have renal insufficiency, renal disease, they're always worried about getting exposed to contrast. But there is data to show that you can do this safely in patients with mild to moderate renal insufficiency and it will not make their kidney function worse. It has no impact on their kidney function. What is that renal insufficiency? Yeah. So a chronic kidney disease, an elevated creatinine or a low GFR when you talk to your doctors. If the creatinine is mild to moderately elevated, so you have a stage one, two, or three CKD, we can still do the procedure on you. And so those patients that have truly end stage kidney disease or already on hemodialysis, that is a limitation for us to do renal denervation. Okay. So after the procedure, how do you follow patients? Do they continue to check their blood pressure at home and might the medications need to be adjusted again and how soon? Yeah. So like I said before, it usually takes about one to three months for the therapy to fully become effective. So we have a little bit of time. But they're going to go home taking the same medications, same routine. Yeah. They're going to go home. They're going to take the same medication, same routine, continue with blood pressure monitoring at home like they've been doing. Usually they'll have them follow up with me in the clinic in about two to four weeks. That's really just a check-in."Hey, your groin's feeling okay. Procedure went well. How are you feeling initially? After that, they go back to see their referring doctor who was the cardiologist or the primary care doctor. And really it's another check-in around three months and a check-in at six months from the time of the procedure. And at that whole time, they're keeping a log at home and we're monitoring it. And hopefully we're going to see that nice dip in the blood pressure. And then at that three month and six month follow-up, the physician can start to peel back on some of the medication, either the dose of the medication or even better, maybe getting them off one or two of their medications that they're on. But it's not like an immediate thing. Again, it's like a slow, gradual decline over time. We could do it in a controlled manner for sure. What. Have you seen so far in your patients? Yeah. Great success? Great success. We've been very successful. So again, we can offer this therapy at two locations within the MedStar Health System, DC at MedStar Washington Hospital Center and also in Maryland at MedStar Southern Maryland Hospital. And I'm confident to say that they've all been successful and we've all seen significant drops in blood pressure. Patients have been very satisfied with the procedure. We've been able to get some medications off on some of the patients. I had one patient that his initial blood pressure was 220. He had been living in 220 for 30, 40 years. And again, normal is 120. And. He's tried every medication, whatever. We did the therapy. Last time I saw him in clinic, he was at 170. So we saw a 40, 50 millimeter drop in his blood pressure. Wow. Did he feel better? Yeah, he. Felt better. And he's like,"I haven't seen this number since I was a teenager." So he was very, very happy about it. So yeah, it's been very rewarding to see the impact we're having on patients. I am going to give the number for anyone interested in Maryland or in DC at the end. But what if a listener is not from this area, what do you recommend that they do if they have uncontrolled hypertension or they just want to get off of the medications? Try to find, again, these renal denervation programs are becoming more and more popular in large health centers across the US. So wherever city you're in or town, talk to your local physician and see if they know somebody in the area that they can refer you to. If they don't know anybody, there's some resources online that you can access. For example, Medtronic, the company itself has a registry where you can put your zip code in and they can tell you the closest RDN specialists in the region that you could go see. And if you are having high blood pressure or you're really struggling with the medications, be your best advocate. Don't take no for your answer. Find that specialist that can help you. Do you think the future for hypertension and treatment might lower the bar for qualifying for this procedure? Yeah, I do. Again, we're focusing on the really resistant uncontrolled hypertensive patients at the moment, but as we understand the therapy more and more, we're going to understand other indications that other problems like health problems that doing the RDN might be helpful for that as well. For example, your mom, she had a stroke. A big thing is having the blood pressure controlled, right? Why give her five blood pressure medications or even three? Why can't we do RDN to really get that blood pressure low so she'll never have her stroke again? Patients who have had heart attacks or heart failure or problems with their aorta, should we be more aggressive and offer RDN earlier in their care pathway to get them more controlled with their blood pressure earlier to prevent further problems down the road? That's where research comes to play and we're doing more and more research locally at MedStar. And then obviously there's nationally, internationally, a lot of investigators are looking into this. So I think we've only scratched the surface when it comes into renal denervation, and I think there's a lot of opportunities going forward. Hypertension is the forgotten diagnosis sometimes, but it's the most common diagnosis. Again, 50% of patients in the US have hypertension and of those 80% uncontrolled blood pressure. Us as a community could do a better job. And I truly think our hypertension program at MedStar and this novel therapy can really help a lot of patients in the future. Well, thank you for bringing it to us. Yeah, no, my pleasure. Uncontrolled hypertension remains one of the biggest risk factors for heart attack, stroke, and kidney disease, but innovation is creating new options for patients who need them. While renal denervation isn't for everyone and it's not a cure, for the right patient, it may offer meaningful lasting blood pressure control with medication and lifestyle changes. To learn more about this treatment at MedStar Southern Maryland Hospital Center, call 301-877-5677. And if Washington DC is closer, call 202-877-5975 and talk to the experts at MedStar Washington Hospital Center.