Diagnostic imaging evaluation of renovascular hypertension

Over 50 million people in the United States are hypertensive. Renovascular disease accounts for 3-5% of these hypertensive patients. Because renovascular hypertension is potentially curable, much effort has been devoted to detecting and treating renal artery stenosis. Conventional angiography has been traditionally used to diagnose renal artery stenosis. However, because of its invasiveness and cost, conventional angiography cannot be utilized as a screening test in all patients who may have renal artery stenosis. Several noninvasive studies have been advocated for screening in hypertensive patients who may have renovascular disease. However, the accuracy of these noninvasive studies is widely variable, and appropriate use of these noninvasive studies needs to be better defined. Appropriate use of diagnostic imaging examinations for hypertensive patients depends on the index of suspicion for renovascular disease and on the patient's renal function. If certain clinical findings suggest the possibility of renovascular disease, then conventional angiography/intraarterial digital subtraction angiography should be performed. Captopril renography or duplex Doppler sonography could also be utilized if angiography is not desired or is contraindicated because of impaired renal function or a contrast allergy. Magnetic resonance angiography appears to be most helpful in a small, select group of patients who are likely to have proximal renal artery stenosis.