Guideline-Driven Management of Hypertension: An Evidence-Based Update

Patient Evaluation and Screening for Secondary Hypertension 

The 2017 ACC/AHA Guideline emphasizes the need for comprehensive evaluation in patients with suspected secondary hypertension––particularly in young individuals or those with resistant hypertension. Identifying secondary causes such as renovascular hypertension is essential, as targeted interventions may improve blood pressure (BP) control and even lead to a cure.

Renovascular Hypertension

Renovascular hypertension––often caused by atherosclerotic cardiovascular disease (ASCVD)-related renal artery stenosis or fibromuscular dysplasia (FMD)––presents diagnostic and therapeutic challenges. Randomized controlled trials (RCTs) have not demonstrated significant improvements in survival or renal function following renal artery interventions in ASCVD-related hypertension. However, a systematic review of major RCTs found that angioplasty reduced diastolic BP (DBP) and medication burden, though systolic BP (SBP) and renal function remained unchanged. The management strategies depend on the type and severity of renal artery stenosis:

Fibromuscular Dysplasia (FMD) – is more common in younger females and is associated with smoking. Diagnosis relies on computed tomography (CT) or magnetic resonance (MR) angiography and is confirmed via renal angiography. When CT and MR angiography are not available, Doppler ultrasound (US) can be opted for. Angioplasty without stenting is the preferred treatment.

Aortic Coarctation – can be suspected in patients with early-onset hypertension and lower extremity claudication. Screening involves brachial-popliteal BP measurement and CT angiography. Referral to a congenital heart disease or vascular medicine specialist is recommended. 

ASCVD – is more prevalent in older males and is often associated with atherosclerosis in multiple vascular beds, smoking, and hyperlipidemia. Screening involves Doppler US, CT, or MR angiography. Renal angiography is the indicated intervention.

Management of renovascular hypertension requires individualized treatment strategies based on the patient's risk factors, comorbidities, and stenosis severity. While medical therapy remains first-line in most cases, interventional procedures are selectively considered for high-risk patients to optimize BP control and preserve renal function.

Source: Carey RM, Wright JT Jr, Taler SJ, et al.Circ Res. 2021;128(7):827-846.