What are guidelines for the workup of renal artery stenosis (RAS)?

Updated: Nov 02, 2020
  • Author: Bruce S Spinowitz, MD, FACP; Chief Editor: Vecihi Batuman, MD, FASN  more...
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The 2013 ACC/AHA and 2017 ESC guidelines recommend performing diagnostic studies to identify RAS in patients with any of the following [56, 57] :

  • Onset of hypertension before the age of 30
  • Onset of severe hypertension after the age of 55
  • Accelerated hypertension (sudden and persistent worsening of previously controlled hypertension)
  • Resistant hypertension
  • Malignant hypertension (hypertension with coexistent end-organ damage;  ie, acute kidney injury, flash pulmonary edema, hypertensive left ventricular failure, aortic dissection, new visual or neurological disturbance, and/or advanced retinopathy)
  • New azotemia or worsening renal function after the administration of an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin receptor blocker (ARB)
  • Unexplained atrophic kidney or size discrepancy of greater than 1.5 cm between the kidneys
  • Unexplained renal failure
  • Flash pulmonary edema

The ACC/AHA guidelines define resistant hypertension as failure of blood-pressure control despite full doses of an appropriate three-drug regimen including a diuretic. [56] The ESC defines it as failure to achieve target blood pressure despite use of four drug classes, including a diuretic and a mineralocorticoid receptor antagonist in appropriate doses, in cases where another form of secondary hypertension is unlikely. [57]

The ESC also lists the combination of hypertension and abdominal bruit as a possible indication of RAS. [57]

In its 2014 SCAI Expert Consensus Statement for Renal Artery Stenting Appropriate Use, the SCAI utilized the ACC/AHA recommendations. [58]

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