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Chapter 41: Secondary Hypertension

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A 74-year-old white man with history of severe peripheral vascular disease and severe uncontrolled hypertension and has a renal Doppler study and is found to have a unilateral 80% stenosis of the right renal artery and 40% stenosis of the left renal artery. BP is uncontrolled on amlodipine 5 mg bid, losartan 50 mg bid, and metoprolol tartrate 50 mg bid. BP is 166/98 mm Hg, heart rate is 78 beats/min. Serum creatinine is 2.8 mg/dL with eGFR of 22 cc/min. What is the most appropriate next step in management of his BP?

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A. CT angiogram with IV contrast

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B. MR angiogram with gadolinium

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C. Add furosemide 40 mg bid and a statin

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D. Renal angiogram with percutaneous angioplasty and stent of the right renal artery

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E. Renal angiogram with percutaneous angioplasty and stent of the right and left renal arteries.

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The answer is C. This patient is a vasculopath with stage 4 chronic kidney disease and is at high risk for contrast nephropathy with IV contrast and nephrogenic systemic fibrosis form gadolinium so further imaging should be avoided if possible. There are multiple studies showing no definite benefit of percutaneous intervention as opposed to aggressive medical therapy with statin, RAAS blockade and aspirin. Only the lesion on the right would be considered significant and one would prefer not to intervene on this high risk patient. BP should improve with an addition of a diuretic.

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A 34-year-old white woman presents with sudden onset hypertension. No family history of hypertension. No other past medical history. She was started on amlodipine 10 mg daily and Lisinopril 20 mg daily and BP has remained elevated. BP is 152/92 mm Hg. Heart rate is 88 per minute. She has 1+ pedal edema present. Rest of examination is normal. She feels well but complains of lower extremity edema which is attributed to the amlodipine. CT angiogram is ordered and reveals beaded appearance of both renal arteries distally. What is the most appropriate next step in BP management for this patient?

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A. Add HCTZ 25 mg daily

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B. Add metoprolol succinate 50 mg daily

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C. Renal angiogram with angioplasty and stenting of both renal arteries

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D. Renal angiogram and angioplasty of both renal arteries

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The answer is D. This patient has radiologic features of fibromuscular dysplasia and should undergo renal angiogram and possible angioplasty of both renal arteries. There lesions usually do not require stenting as restenosis rate is very ...

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