How to handle renovascular hypertension.

2001 
Introduction. Renovascular hypertension (RVH) is defined as the elevation of arterial pressure precipitated by a hemodynamically significant stenosis of a renal artery or arteries (that is, stenosis caliber greater than 75% of the vessel lumen or than 50% with post-stenotic dilation). When the lesion affects both renal arteries or a single functioning kidney and is accompanied by renal failure (plasma creatinine concentration above 1.5 mg/dl), it is called ischemic nephropathy (1,2). The rate of renovascular hypertension (RVH) is less than 1% when a mild-moderate hypertension population is assessed but this increases according to the severity of the hypertension and population age (3). In 4,429 patients with arterial hypertension, Anderson et al. (4) found a prevalence of 3.1%, (2.7% attributed to atherosclerosis and 0.4% to fibromuscular dysplasia). Screening test. Signs and symptoms which point to RVH are: sudden onset of hypertension, especially in young ages subjects a particularly in women (due to fibrodysplastic lesion); the existence of severe hypertension in males over 60 years, with signs of atherosclerosis in other vascular territories (5-7); hypertension and abdominal bruit; grade III retinopathy in 25%-40% of the patients (8), elevation of serum creatinine after the administration of angiotensin converting enzyme (ACE) inhibitor (9-10); episodes of cardiac failure and acute pulmonary edema (11); hypertension refractory to treatment with >3 antihypertensive drugs. In all of these patients, the existence of RVH should be suspected. Although the renal arteriography is the "gold standard" for the diagnosis of RVH, it is an invasive method with possible complications so several non-invasive procedures can be used for the first diagnostic approximation. Those procedures which are used the most are the: i Renal scintigraphy following ACE inhibitor: Its sensitivity and specificity is 78% - 90% and 88% - 95% respectively (12-14), which decreases when there is bilateral lesion and renal insufficiency.
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