How is renovascular hypertension (RVHT) treated?

Updated: Dec 01, 2020
  • Author: Rebecca J Schmidt, DO, FACP, FASN; Chief Editor: Vecihi Batuman, MD, FASN  more...
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Antihypertensive drug therapy is indicated. Optimal blood pressure control plays an essential role in the therapeutic management of renovascular hypertension (RVHT); however, aggressive control of other risk factors for atherosclerosis is also crucial. Cessation of smoking is important for its positive impact on the cardiovascular risk profile in patients with hypertension. Similarly, antidyslipidemic therapy for those patients with hyperlipidemia likely provides benefit in atherosclerotic RVHT.

Progression of atherosclerotic stenosis may occur in as many as one third of patients, and the sequelae of ongoing ischemia to the stenotic kidney are a theoretical concern. Furthermore, normalization of blood pressure may be associated with reduced renal perfusion pressures, and renal function may deteriorate despite good blood pressure control.

Definitive therapy for the underlying cause must be considered in order to avoid the development of ischemic nephropathy. [10] Intervention to treat hemodynamically significant stenoses has been presumed to offer clinical benefit; however, trials comparing renal artery revascularization with medical management do not unequivocally favor surgical over medical intervention, suggesting the need for research to identify patients most likely to benefit from intervention. [17, 35] Currently, the following are considered indications for revascularization [36] :

  • Progressive worsening of renal function
  • Recurrent 'flash pulmonary edema'
  • Rapid increase in antihypertensive requirement in patients with previously well-controlled hypertension

The invasive and surgical options for treatment of renovascular hypertension include the following:

  • Percutaneous transluminal angioplasty (PTA)
  • Surgical revascularization
  • Nephrectomy

Catheter-based radiofrequency denervation of the renal arteries has entered clinical use in many countries as a treatment for resistant hypertension. The SYMPLICITY HTN-3 trial randomized 535 patients with severe resistant hypertension and found that catheter-based radiofrequency denervation of the renal arteries was safe but did not result in a significant reduction of systolic blood pressure 6 months post-procedure, as compared with a sham control. [37] Subsequent reviews, however, have shown that renal denervation was not effectively or consistently achieved in the trial. [38]

The patient should be transferred to a tertiary care medical facility whenever the need for invasive or surgical treatments has been established and the current treating facility is not equipped for such procedures.

Inpatient care usually is necessary for the management of hypertensive urgencies or emergencies associated with RVHT. Timely diagnosis of RVHT and early intervention are required to prevent further ischemic end-organ damage to the kidney and other organs.

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