Assessment for Renovascular Hypertension

  1. Patients presenting two or more of the clinical clues listed below, suggesting renovascular hypertension, should be investigated (Grade D).
    1. Sudden onset or worsening of hypertension and age greater than 55 or less than 30 years;
    2. Presence of an abdominal bruit;
    3. Hypertension resistant to three or more drugs;
    4. Increase in serum creatinine level of ≥30% associated with use of an angiotensin-converting enzyme inhibitor or angiotensin II receptor antagonist;
    5. Other atherosclerotic vascular disease, particularly in patients who smoke or have dyslipidemia;
    6. Recurrent pulmonary edema associated with hypertensive surges.
  2. When available, the following tests are recommended to aid in the usual screening for renal vascular disease: captopril-enhanced radioisotope renal scan, Doppler sonography, magnetic resonance angiography and CT- angiography (for those with normal renal function) (Grade B). Captopril-enhanced radioisotope renal scan is not recommended for those with CKD (GFR <60 mL/min/1.73 m2) (Grade D).
  3. Patients with hypertension and presenting with at least one of the following clinical clues should be investigated for fibromuscular dysplasia (FMD)- related renal artery stenosis (Grade D: new guideline):
    1. Age less than 30 years, especially in non-obese women;
    2. Hypertension resistant to three or more drugs;
    3. Significant (>1.5 cm), unexplained asymmetry in kidney size;
    4. Abdominal bruit without apparent atherosclerosis;
    5. FMD in another vascular territory;
    6. Positive family history for FMD.
  4. In patients with confirmed renal FMD (Grade D; new guideline):
    1. Screening for cervicocephalic lesions and intracranial aneurysm is recommended;
    2. Screening for FMD in other vascular beds in the presence of suggestive symptoms is recommended.
  5. The following tests are recommended to screen for renal FMD (both with similar sensitivity and specificity) (Grade D; new guideline): magnetic resonance angiography and computed tomography angiography.