Risk of morbidity from renovascular disease in elderly patients with congestive cardiac failure

Renovasular disease commonly affects elderly people. Elderly patients with heart failure are routinely treated with angiotensin-converting-enzyme (ACE) inhibitors, which may increase risk of renal dysfunction. We investigated the frequency of renovascular disease among elderly people with heart failure.

From the local population of Salford, UK, we recruited 86 patients with heart failure with a mean age of 77.5 (SD 5.6) years, who were admitted as acute emergencies or who attended general medical clinics. We selected patients by intention to treat with ACE inhibitors. We used captopril renography to screen for renovascular disease. All patients with abnormal renograms underwent magnetic-resonance angiography of the renal arteries as well as 40% of patients with normal renograms as negative controls.

Magnetic-resonance angiography showed severe renovascular disease (>50% renal-artery stenosis or occlusion) in 29 (34%) patients. Captopril renography had an estimated sensitivity of 78.8% (95% CI 72.7-97.8) and specificity of 94.3% (67.6-97.3) for detection of renovascular disease. The estimated positive predictive value of captopril renography was 89.7% and the negative predictive value was 87.5%. Patients with renovascular disease had worse renal function (mean creatinine 201 [SD 56] vs 136 [40] pmol/L, p<0.001), were older (mean age 80.7 [5.6] vs 76.8 [5.3] years, p<0.01), and were more likely than patients without renovascular disease to have peripheral arterial disease.

Some elderly patients with occult renovascular disease on ACE inhibitors will be at risk of developing uraemia. Renal function should be closely monitored to detect any deterioration early.