What is the initial treatment approach for renovascular hypertension?

Initial Treatment Approach for Renovascular Hypertension

Medical treatment is the preferred initial approach for renovascular hypertension, consisting of intense lifestyle modifications, low-dose aspirin, statin, and multiple antihypertensive drugs including a thiazide diuretic at appropriate doses and a calcium antagonist with possible addition of a renin-angiotensin blocker (except in bilateral renal artery stenosis). 1

Medical Therapy Components

Antihypertensive Medications

• Thiazide diuretics at appropriate doses serve as a cornerstone of therapy 1
• Calcium channel blockers are effective and well-tolerated in renovascular hypertension 1
• Renin-angiotensin system blockers (ACE inhibitors or ARBs) can be added in unilateral renal artery stenosis but must be used with caution 1, 2
• Multiple antihypertensive medications are typically required to achieve blood pressure control 1

Caution with Renin-Angiotensin System Blockers

• ACE inhibitors and ARBs should be avoided in bilateral renal artery stenosis due to risk of acute renal function deterioration 1
• When used in unilateral stenosis, monitor for increased serum creatinine, which typically reverts when treatment is withdrawn 1
• 10-20% of patients may develop unacceptable rise in serum creatinine, particularly with volume depletion 1

Additional Medical Management

• Low-dose aspirin for cardiovascular protection 1
• Statin therapy to address atherosclerotic disease progression 1, 3
• Intense lifestyle modifications including sodium restriction 1, 4

When to Consider Revascularization

Revascularization (angioplasty or surgery) should be considered in specific scenarios:

• Refractory hypertension (elevated BP despite ≥3 drugs including a diuretic at adequate doses) 1
• Progressive decline in renal function 1
• Recurrent flash pulmonary edema 1
• Fibromuscular dysplasia, where angioplasty alone is the treatment of choice with high success rates 1

Revascularization Methods

• Angioplasty is progressively replacing surgical revascularization for most cases 1
• Angioplasty alone is the preferred treatment for fibromuscular dysplasia 1
• For atherosclerotic disease, angioplasty with stenting is typically performed 1
• Success of revascularization depends heavily on physician skill and experience 1

Monitoring and Follow-up

• Monitor renal function (serum creatinine) and potassium levels when using ACE inhibitors or ARBs 1
• Assess for signs of disease progression including worsening hypertension or declining renal function 1
• The best predictor of effective BP reduction after revascularization is a short duration of hypertension 1

Special Considerations

• Medical therapy is particularly preferred when renal function is preserved, blood pressure control can be achieved, renal artery stenosis is not tight, or there is a long history of hypertension (>10 years) 1
• Patients with atherosclerotic renovascular disease should be treated as having a coronary artery disease equivalent, with focus on comprehensive cardiovascular risk reduction 3, 5