What are the ACC/AHA guidelines for renal artery stenosis (RAS) screening?

Updated: Dec 01, 2020
  • Author: Rebecca J Schmidt, DO, FACP, FASN; Chief Editor: Vecihi Batuman, MD, FASN  more...
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Answer

It is useful to determine the clinical risks for renovascular hypertension (RVHT) before embarking on an extensive workup that may not be productive or cost-effective. Patients in whom a definitive noninvasive or invasive workup is indicated are those in whom suggestive clinical features have been identified in the course of the history and physical examination (see Presentation).

At present, no sufficiently accurate, noninvasive, radiologic, or serologic screening test is available that, if negative, completely excludes the presence of renal artery stenosis (RAS). [20] Current guidelines of the American College of Cardiology (ACC) and the American Heart Association (AHA) advocate screening for RAS only for patients in whom a corrective procedure would be considered if renovascular disease were detected. [3]   Testing is not recommended in patients whose hypertension is responsive to medication and those in whom there is not a high likelihood of clinically significant renovascular disease. 

Guidelines from the ACC/AHA and the European Society of Cardiology (ESC) recommend performing diagnostic studies to identify RAS in patients with any of the following [3, 21] :

  • Onset of hypertension before the age of 30
  • Onset of severe hypertension after the age of 55
  • Accelerated hypertension (sudden and persistent worsening of previously controlled hypertension)
  • Resistant hypertension (failure of blood-pressure control despite full doses of an appropriate three-drug regimen including a diuretic)
  • Malignant hypertension (hypertension with coexistent end-organ damage;  ie, acute kidney injury, flash pulmonary edema, hypertensive left ventricular failure, aortic dissection, new visual or neurological disturbance, and/or advanced retinopathy)
  • New azotemia or worsening renal function after the administration of an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin receptor blocker (ARB)
  • Unexplained atrophic kidney or size discrepancy of greater than 1.5 cm between the kidneys
  • Unexplained renal failure thought to be a consequence of renovascular disease

The ACC/AHA guidelines also include patients with sudden, unexplained pulmonary edema in its class I recommendations. [3] The ESC recommendation include patients with hypertension and abdominal bruit as well as those with hypertension and hypokalemia in particular when receiving thiazide diuretics. [21]


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