Review of Systems for Severe Left Renal Artery Stenosis
Focus your review of systems on identifying clinical manifestations of renovascular hypertension, cardiac destabilization syndromes, and other atherosclerotic disease that would impact management decisions.
Cardiovascular System
- Hypertension characteristics: Ask specifically about sudden onset or worsening of hypertension, particularly if the patient is older than 55 or younger than 30 years 1
- Resistant hypertension: Determine if blood pressure remains uncontrolled despite taking 3 or more antihypertensive medications, including a diuretic 1
- Flash pulmonary edema: Inquire about recurrent episodes of sudden-onset shortness of breath or pulmonary edema associated with hypertensive surges, even with preserved systolic heart function 2, 1, 2, 1
- Heart failure symptoms: Ask about recurrent heart failure episodes, orthopnea, paroxysmal nocturnal dyspnea, or intractable heart failure despite maximally tolerated medical therapy 2, 3, 2
- Unstable angina: Screen for chest pain, particularly if recurrent despite medical management 2
Renal System
- Progressive renal dysfunction: Ask about known chronic kidney disease or recent worsening of renal function 1
- Response to ACE inhibitors/ARBs: Specifically inquire if there was a serum creatinine increase of ≥30% after starting an ACE inhibitor or ARB, which suggests hemodynamically significant bilateral stenosis or stenosis in a solitary kidney 1
- Urinary symptoms: Screen for changes in urine output or color 1
Vascular System
- Atherosclerotic disease elsewhere: Ask about history of coronary artery disease, peripheral arterial disease, carotid disease, or prior stroke, as these strongly suggest atherosclerotic renal artery stenosis 1, 4, 1
- Abdominal bruit: While this is physical exam, ask if any prior provider mentioned hearing an abdominal bruit 1
- Claudication: Screen for leg pain with walking, which indicates peripheral arterial disease 4
Risk Factors and Medications
- Smoking history: Document current or past tobacco use, as smoking is strongly associated with atherosclerotic renal artery stenosis 1
- Dyslipidemia: Ask about known high cholesterol or lipid disorders 1
- Diabetes: Screen for diabetes diagnosis and control 4
- Medication use: Identify all current antihypertensive medications and doses to determine if truly resistant hypertension 1
- BP-raising substances: Ask about NSAIDs, amphetamines, immunosuppressive agents, cocaine, oral contraceptives, sympathomimetics, and corticosteroids 3, 1
Age-Specific Considerations
- Young patients (<30 years): If patient is young, specifically ask about family history of fibromuscular dysplasia, as this would completely change management toward angioplasty without stenting 2, 1, 2, 1
- Older patients (>55 years): Focus on atherosclerotic risk factors and manifestations of widespread vascular disease 1
Other Secondary Hypertension Causes
- Sleep apnea symptoms: Ask about snoring, witnessed apneas, daytime sleepiness, and non-restorative sleep 3, 4
- Primary aldosteronism symptoms: Screen for unprovoked or excessive hypokalemia, muscle weakness, or polyuria 3, 1
- Pheochromocytoma symptoms: Ask about paroxysmal headaches, palpitations, sweating, panic attacks, and pallor 1
Critical Red Flags
The presence of any of these warrants urgent consideration for revascularization rather than medical management alone 2, 1, 2, 1:
- Recurrent flash pulmonary edema
- Refractory hypertension (uncontrolled on ≥5 drugs including a diuretic)
- Rapidly progressive renal function decline
- Bilateral renal artery stenosis or stenosis in a solitary functioning kidney