drrabines
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You have a patient with High BP 220/120, you star ACEi he comes back with 170/90
next step?
- ACEi is not working change drug
- check renin
- captopril scan
- see for stenosis renal
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check renin
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| zaki
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evaluate for renal artery stenosis if he is refractory ot the medical treatment(if adequate antihypertensives are given)
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Maverick
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| gballarino
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Actually, you should add another drug... a diuretic would be a great option. But do not discontinue ACEi. :!:
Unfortunately that is not an option... so... Iīm asking... Where did that question came from? Are those all the possible answers... thatīs weird, just four options. :?
Given those option I would go for "check renin".
Clearly, changing drugs is of no use. JNC VI (and VII) says you should add a second drug when one drug is not working as good as you would expect. Besides.... ACEis are working!! You achieved a 50mmHg reduction in systolic blood pressure.
Captopril scan is, according to harrisonīs, the best choice to screen for renovascular hypertension. If this option were true, so would it be "seek for renal stenosis".
However, if the stem of the question gives any reason to think about secondary hypertension of renovascular origin, such as abrupt onset of severe hypertension and/or onset of hypertension of any severity before age 20 or after age 50, or abdominal bruits on PE, we should go for the captopril scan.
I am not sure what would the use be for renin level assesment in this setting. The Aldosteron:Renin ratio would be more useful if we want to rule out primary aldosteronism as a cause for secondary hypertension. But thereīs anything in the history to think about this? Hypokalemia would be a fair clue.
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Guillermo Ballarino
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| zaki
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TOTALLY AGREE WITH U
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Maverick
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| zaki
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TOTALLY AGREE WITH U , NOW MRI AND MRA IS ALSO USE FOR THE RENAL ARETERY STENOSIS.
THAT'S Y I USE EVALUTE FOR RENAL ARTERY STENOSIS
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Maverick
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| gballarino
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Zaki... Although you can actually "see" the obstruction to blood flow by using MRI and MRA, those studies cannot tell for sure that arterial stenosis is causing the high blood pressure. You can have a whole lot of false positives using those methods because atherosclerotic narrowing of renal arteries ar very prevalent. In fact, if you randomly select a bunch of healthy people you will find a lot with renal artery stenosis by MRI and MRA.
Thatīs why the only specific method to confirm the diagnosis of hypertensión secondary to renal artery stenosis is selective catheterization of both renal arteries and messure of renin levels in individual renal veins. I donīt know wether that is done much or not, but according to the literature itīs the only way to know for sure. Then you have screening methods... but you wouldnīt wanna go for vascular surgery on the grounds of a "screening" diagnose, would you?
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Guillermo Ballarino
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This is a really confusing (incomplete) question, drabbines could you please, post the answer of it.
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| zaki
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thats y its gold standard, symptomatic pt with stenosis on mra u should follow with catheterization and do angioplasty at the same time .
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Maverick
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| drrabines
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Well doctors, thanks a lot, the question is about for a patient with recent onset og High BP, 43 yo, no other physical findings, in the options it wasnt add diuretics or another drug, cannot remember more, no MRI, no CT
(my Stp 2)
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