michigan hypertension core curriculum - State of Michigan

the goals of minimizing injury to the renal artery and kidney (Table 7, Figure 8). All patients should be
evaluated for post-procedural nephropathy (Table 9), and should have regular follow-up. Nevertheless,
the benefits of revascularization have not been definitively proven, thus the need for a large,
randomized, adequately powered clinical trial such as CORAL.
Approach to hypertensive patients without vital organ injury. For asymptomatic patients < 30 years
old with controlled or resistant hypertension, CTA is reasonable to diagnose FMD. Recommendations
for revascularization are influenced by patient age, FMD location and distribution, hemodynamic
significance of stenosis, and tolerance of antihypertensive medication. In the majority, angioplasty is
appropriate to control (and likely cure) hypertension.
In older patients with new or refractory hypertension, imaging studies are reasonable to detect
ARAS, but revascularization is controversial in the absence of renal ischemia or cardiovascular
injury. These patients should first undergo a thorough evaluation for occult nephropathy (Table 5) and
renal ischemia using nuclear renal blood flow or invasive assessment (Table 6). For patients with no
nephropathy and normal renal blood flow (Type 1A), we would intensify the antihypertensive regimen
and follow patients clinically for the development of vital organ injury. For patients with unilateral or
bilateral ARAS, no nephropathy, and abnormal perfusion we would “reclassify” such patients as having
renal ischemia (Type 1B).
Approach to hypertensive patients with vital organ injury. Hypertensive patients with
manifestations of vital organ injury (Table 3) should undergo an imaging study to detect RAS. Patients
with renal FMD should undergo renal angioplasty, if possible. Patients with ARAS should undergo
clinical evaluation to identify nephropathy (Table 5) and renal ischemia (Table 6). The best candidates
for revascularization are those with minimal or no nephropathy and renal ischemia (Type 1B). The worst
candidates are those with advanced nephropathy (Type 2), especially if renal ischemia is absent (Type
2A). If performed, renal revascularization should include the technical considerations to minimize renal
injury (Table 7).
Approach to renal FMD. Since 25 % of patients with renal FMD have carotid FMD, carotid duplex
ultrasound is recommended if renal FMD is identified. In addition, patients with carotid FMD may
have berry aneurysms of the circle of Willis, so intracranial MRA or CTA is advisable, too. Decisions
about revascularization of renal FMD are simpler than ARAS, because of the high (> 80 %) cure
rate and durability (90 % patency at 10 years) after angioplasty. Since hypertensive FMD patients
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