Should a 37-year-old female with horseshoe kidney and hypertension undergo cardiac testing?

Cardiac Testing for a 37-Year-Old Female with Horseshoe Kidney and Hypertension

A 37-year-old female with horseshoe kidney and hypertension should undergo a 12-lead ECG as initial cardiac testing, with further cardiac evaluation guided by specific findings or risk factors. 1

Initial Cardiac Assessment

• A 12-lead ECG is recommended as part of the routine initial workup for all patients with hypertension, regardless of age or comorbidities 1
• The ECG should be specifically analyzed for left ventricular hypertrophy (LVH) and atrial fibrillation (AF), which are common cardiac manifestations of hypertension 1
• Basic laboratory tests should include serum creatinine, estimated glomerular filtration rate (eGFR), and urinary albumin-to-creatinine ratio (ACR) to assess kidney function and hypertension-mediated organ damage (HMOD) 1

Additional Cardiac Testing Based on Specific Indications

• Echocardiography is recommended if any of the following are present:

  • Abnormal ECG findings
  • Cardiac murmurs on physical examination
  • Any cardiac symptoms (e.g., dyspnea, chest pain)
  • Signs of hypertensive heart disease 1

• Echocardiography may be considered even with normal ECG if:

  • Resources and reimbursement policies allow
  • It would likely change patient management 1

Special Considerations for Horseshoe Kidney

• Renal ultrasound and Doppler examination should be performed to:
  • Assess kidney structure
  • Determine causes of potential chronic kidney disease (CKD)
  • Exclude renovascular hypertension, which is more common in patients with horseshoe kidney 1, 2
• Patients with horseshoe kidney have an increased risk of end-stage renal disease (ESRD) compared to matched controls, which may influence cardiovascular risk assessment 3
• Horseshoe kidneys often have aberrant renal vasculature (average 4.57 arteries per patient vs. 2.4 in normal kidneys), which may contribute to renovascular hypertension 4

Risk-Based Approach to Additional Testing

• For patients under 40 years (like this 37-year-old), screening for HMOD should be considered since standard cardiovascular risk calculators (SCORE2) are not validated in this age group 1
• Additional cardiac testing to consider based on risk assessment:
  • Coronary artery calcium (CAC) scoring may be considered if it would change management 1
  • High-sensitivity cardiac troponin and/or NT-proBNP to assess for subclinical cardiac damage 1
  • Carotid or femoral ultrasound to detect atherosclerotic plaque 1

Important Caveats

• Cardiac biomarkers (BNP/NT-proBNP, troponins) should be interpreted with caution in patients with reduced kidney function, as they may be elevated due to decreased renal clearance rather than cardiac damage 1
• The presence of horseshoe kidney increases the likelihood of renovascular hypertension, which may require specific imaging studies such as renal angiography in cases of difficult-to-control hypertension 2
• Hypertension in the setting of horseshoe kidney requires vigilant monitoring as these patients have higher risk of ESRD compared to the general population 3

Follow-up Recommendations

• Regular monitoring of kidney function is essential, with annual measurements of serum creatinine, eGFR, and urine ACR if moderate-to-severe CKD is diagnosed 1
• Repeat ECG if irregular pulse or cardiac symptoms develop 1
• Consider more comprehensive cardiovascular assessment if hypertension becomes difficult to control 1