A 76-year-old male patient with a history of hypertension, no insulin dependent diabetes, and peripheral arterial disease s/p recent superficial femoral artery stent, presents with continued high systolic blood pressure in the office. He is otherwise asymptomatic.
He is currently on aspirin 81 mg daily, metoprolol succinate 50 mg daily, lisinopril 40 mg daily, metformin 500 mg twice daily, and rivaroxaban 2.5 mg twice daily (added after his intervention). Vital signs in the office are: 97.6° F, 60 BPM, 168/78 BP, RR 15, and 100% RA. Physical exam is otherwise unremarkable. Laboratory testing thus far shows: CBC within normal limits, BMP within normal limits specifically a Cr of 0.87 GFR 60, glucose 90. The patient has been told to come for renal denervation evaluation.
The correct answer is: C. Direct plasma Renin/aldosterone ratio to rule out hyperaldosteronism.
While proceeding forward with renal denervation may be in line with the FDA's broad verbiage in the approval for this technology, the question relates to work up for secondary causes to be ruled out first. This would include ruling out diagnoses such as hyperaldosteronism, renal artery stenosis (particularly in a patient that already has a history of peripheral arterial disease) with a CT angiogram, obstructive sleep apnea, and plasma metanepherines, which would usually suffice to rule out pheochromocytoma (rather than committing to renal vein sampling). The patient should also have a thorough medication reconciliation to ensure that he is correctly taking, acquiring, and affording his medications.
This patient case quiz is part of the larger Overcoming Challenges in Hypertension Management grant. Educational grant support is provided by Medtronic. To visit the Overcoming Challenges in Hypertension Management grant page and access additional educational activities on this topic, click here.
References
- Kandzari DE, Townsend RR, Kario K, et al. Safety and Efficacy of Renal Denervation in Patients Taking Antihypertensive Medications. J Am Coll Cardiol. 2023;82(19):1809-1823. doi: 10.1016/j.jacc.2023.08.045.
- Kirtane AJ, Sharp ASP, Mahfoud F, et al.
- Swaminathan RV, East CA, Feldman DN, et al. SCAI Position Statement on Renal Denervation for Hypertension: Patient Selection, Operator Competence, Training and Techniques, and Organizational Recommendations. JSCAI. 2023;2(6):101121. doi: https://doi.org/10.1016/j.jscai.2023.101121.
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