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Hypertension — ABIM Board MCQ

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HardHypertensionABIM Board

A 72-year-old man with coronary artery disease and peripheral artery disease is evaluated after his second hospitalization in 4 months for abrupt pulmonary edema accompanied by blood pressure of 224/118 mm Hg. Between episodes, 24-hour ambulatory blood pressure averages 168/92 mm Hg despite confirmed adherence to maximally tolerated chlorthalidone, amlodipine, carvedilol, and doxazosin. Echocardiography shows a left ventricular ejection fraction of 60% and no significant valvular disease. Six months ago, lisinopril increased his serum creatinine from 1.4 to 2.1 mg/dL within 6 days; the creatinine returned to baseline after lisinopril was discontinued. CT angiography demonstrates bilateral calcified ostial renal artery stenoses. Catheter angiography confirms 80% stenosis with a significant translesional pressure gradient in each renal artery. After treatment of the acute pulmonary edema, which of the following is the most appropriate management strategy?

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Correct answer: D — Refer for percutaneous renal artery angioplasty with stent placement

Explanation lettering: E = shown as A · D = shown as B · B = shown as C · C = shown as D · A = shown as E

This patient has a high-risk presentation of atherosclerotic renovascular disease: true resistant hypertension, recurrent flash pulmonary edema, bilateral hemodynamically significant stenoses, and a greater than 30% creatinine increase after renin-angiotensin system blockade. Although routine stenting does not improve outcomes for most patients with stable atherosclerotic renal artery stenosis, those negative trial results do not readily apply to patients with recurrent pulmonary edema or other failed medical management. Referral for percutaneous revascularization is therefore appropriate; ostial atherosclerotic lesions are generally treated with angioplasty and stenting. A is inappropriate because the prior 50% creatinine increase reflects loss of angiotensin II-dependent efferent arteriolar tone in bilateral flow-limiting disease; rechallenge does not address the recurrent pulmonary edema. B is ordinarily a strong option for resistant hypertension, but additional medication alone is insufficient after recurrent heart failure despite multidrug therapy and documented high-grade bilateral disease. D is more appropriate for renal-artery fibromuscular dysplasia, in which angioplasty without routine stenting is preferred; this older patient has calcified ostial atherosclerotic lesions. E may be considered in selected patients with uncontrolled hypertension, but it neither restores renal perfusion nor addresses the specific high-risk renovascular syndrome.

Reference: Revascularization for Renovascular Disease: A Scientific Statement From the American Heart Association (June 16, 2022) — https://pubmed.ncbi.nlm.nih.gov/35708012/ When Is Renovascular Hypertension Amenable to Revascularization (Published June 16, 2022; updated July 23, 2026) — https://professional.heart.org/en/science-news/revascularization-for-renovascular-disease/Commentary High-risk clinical presentations in atherosclerotic renovascular disease: prognosis and response to renal artery revascularization (February 2014) — https://pubmed.ncbi.nlm.nih.gov/24074824/