When should we get a renal ultrasound in patients with resistant hypertension?
We always talk about renal artery stenosis in the differential for young patients presenting with secondary hypertension, but this week the question came up re: this diagnostic test in older patients requiring three or four medications for BP control. I wasn’t sure about the prevalence here so went looking at the literature. It turns out that somewhere between 14 and 24% of patients with resistant hypertension have significant atherosclerotic disease in their renal artery(ies). Check out the attached article from Europe which nicely reviews this disease process and our current literature on management. I also learned that the diagnostic value of ultrasound is limited in patients with obesity to the point where we should probably be getting a CT or MR in those cases, and that treating this disease process can drop BP by 14/6 points, at least in one study.
I’m not sure that 14-24% is high enough to justify routinely getting this study in older patients with resistant hypertension. After reading this paper, I think I’ll be more aggressive about considering this diagnosis in patients with other vascular disease, with previous HFpEF hospitalizations, and with declining renal function, in addition to a significant number of anti-hypertensives. I will also share with you this table of who might truly benefit from intervention:
Table 5: Indications of PTRA in patients with ARVD
Would love to hear how often you order this diagnostic testing. Happy reading!
Sarafidis PA, Marieta Theodorakopoulou, Ortíz A, et al. Atherosclerotic renovascular disease: a clinical practice document by the European Renal Best Practice (ERBP) board of the European Renal Association (ERA) and the Working Group Hypertension and the Kidney of the European Society of Hypertension (ESH). Nephrology Dialysis Transplantation. Published online May 18, 2023.
