Renovascular hypertension update

Abstract

Hypertension detected in patients with renovascular disease poses a major clinical challenge. The rapid expansion of noninvasive imaging, effective antihypertensive drug therapy, and endovascular interventional procedures combine to make optimal management a moving target. Renal arterial disease accelerates the development of hypertension associated with activation of multiple pressor systems and accelerated target organ injury. Younger individuals with fibromuscular lesions often respond well to renal revascularization with minor associated risks. Care must be taken in cases of complex vascular anomalies, such as renal artery aneurysms. Atherosclerotic renal artery stenosis is detected more commonly than ever before and affects more than 85% of patients referred for revascularization. Most are older patients with long-standing hypertension, diabetes, and pre-existing complications of vascular disease. The benefits of extensive workup and intervention in this group of patients are controversial. Antihypertensive drug therapy is most effectively achieved with drugs that block the renin-angiotensin system, but most require multiple agents. Selection of patients for renal revascularization in this group is far more controversial than with fibromuscular disease. Several small trials failed to identify major benefits with renal artery angioplasty as compared to closely monitored drug therapy, although crossover rates from medical to interventional arms were high. The Cardiovascular Outcomes in Renal Atherosclerotic Lesions (CORAL) seeks to randomly assign subjects with proven, high-grade renal artery lesions to optimal medical management with and without stenting. This important trial employs distal embolic protection to prevent deterioration of renal function. Understanding the optimal role for renal revascularization depends heavily upon the successful conduct of such trials.

Doxycycline Dose‐dependently Inhibits MMP‐2‐Mediated Vascular Changes in 2K1C Hypertension

“…Hypertension is a major cardiovascular disease that is associated with vascular remodelling characterized by degradation and reorganization of extracellular matrix in the vessel wall [1]. Vascular remodelling is an adaptive response to elevation of arterial pressure to normalize the wall tension [2] and has been clearly described in experimental models of hypertension, including the 2‐kidney, 1‐clip (2K1C) Goldblatt model, which involves the activation of the renin–angiotensin–aldosterone axis [3,4].…”

Renovascular Hypertension: An Update

“…One of the major controversies in renovascular hypertension today is the expanding role of cardiologists in the “fortuitous” diagnosis and subsequent immediate, catheter‐based management of renal artery stenosis 7,10,17,34 . Much of the 3.9‐fold increase in Medicare claims for renal artery revascularization between 1996 and 2000 has been attributed to cardiologists doing “drive‐by” renal arterial injections after coronary angiography.…”

“…In a multicenter British experience involving 85 patients with incidentally discovered renal artery stenosis, few required renal revascularization, and 24 of the 27 deaths during 2 years of follow‐up were unrelated to the renal arteries 37 . The real hazards associated with stent placement (atheroemboli, dissections, thrombosis, and renal failure) must be weighed against the very controversial but potential benefits on BP, progressive renal disease, and/or recurrent pulmonary edema 4,7,10,34,38 . It is not yet clear that renal artery stenosis discovered “fortuitously” has the same response to therapy as one found after an intensive, premeditated search based on prior probabilities.…”

“…In most industrialized countries, renovascular disease is the most common remediable cause of elevated blood pressure (BP), especially among older hypertensive patients 1–8 . Although Goldblatt and colleagues developed the animal model that led to understanding its pathophysiology more than 70 years ago, 9 the diagnosis and management of renovascular hypertension have markedly changed over the last 40 years, due to more accurate diagnostic procedures, more specific and effective antihypertensive medications, and the results of randomized clinical trials 3,4,6,8 .…”

A Case of Hyperreninemic Hypertension with Bilateral Positive Captopril Renography but without Renovascular Stenosis

“…The common cause of renovascular hypertension (RVH) in elderly subjects is renal stenosis caused by atherosclerosis and that in young women is medial fibromuscular dysplasia (1). Captopril renography is a very useful technique for diagnosing RVH, since it has a sensitivity and specificity of approximately 90%, for each (2,3).…”