cardiovascular disorders
Renovascular Hypertension
Treatment of Renovascular Hypertension
Aggressive medical management of hypertension, atherosclerosis, and related disorders For fibromuscular dysplasia, sometimes angioplasty with or without stent placement Rarely bypass grafting Without treatment, the prognosis is similar to that for patients with Prognosis . All patients should have aggressive Treatment . For patients with atherosclerotic renal artery stenosis, angioplasty with stent placement was previously considered beneficial for many patients. However, data from a large, randomized trial (the cardiovascular outcomes in renal atherosclerotic lesions [CORAL] trial) showed that stent placement did not improve outcomes compared to medical management alone ( Treatment references ). Although stent placement did provide a small (-2 mm Hg), statistically significant decrease in systolic blood pressure, there was no significant clinical benefit for prevention of stroke, myocardial infarction, heart failure, death due to cardiovascular or renal disease, or progression of kidney disease (including the need for renal replacement therapy). Importantly, all patients in the CORAL study received aggressive medical management of their hypertension and any diabetes, along with antiplatelet drugs and a statin to manage atherosclerosis. Thus, the decision to eschew angioplasty must be accompanied by strict adherence to current medical management guidelines. If serum creatinine increases by > 50% with optimal medical treatment for blood pressure, renal artery stenting may help preserve kidney function ( Treatment references ). For patients unable to strictly adhere to medical management guidelines and with a > 70% renal artery stenosis, stent placement may still be considered. 1% ( Treatment references ). Medical treatment is always preferable to nephrectomy in young patients whose kidneys cannot be revascularized for technical reasons. 1.Cooper CJ, Murphy TP, Cutlip DE, et al: Stenting and medical therapy for atherosclerotic renal-artery stenosis.N Engl J Med370:13–22, 2014. doi: 10.1056/NEJMoa1310753 2.Bhalla V, Textor SC, Beckman JA, et al. Revascularization for Renovascular Disease: A Scientific Statement From the American Heart Association.Hypertension2022;79(8):e128-e143. doi:10.1161/HYP.0000000000000217 3.Modrall JG, Rosero EB, Smith ST, et al. Operative mortality for renal artery bypass in the United States: Results from the National Inpatient Sample.J Vasc Surg48(2):317-322, 2008. doi:10.1016/j.jvs.2008.03.014 