A 34‐year‐old woman with no medical history presented with complaints of severe, intermittent headaches and dizziness of 3 months’ duration. Her primary care physician had diagnosed her with “malignant hypertension” and initiated treatment with clonidine 0.1 mg 3 times a day and atenolol 50 mg daily. Despite treatment, her symptoms persisted in tandem with home blood pressure (BP) readings of 180–200 mmHg systolic/ 100–120 mm Hg diastolic. On arrival, the patient was in mild distress from her headache. Vital signs revealed a blood pressure of 226/128 mm Hg. In the emergency department (ED), her clinical exam was reportedly without any anomaly. Her BP failed to respond to multiple oral treatments in the ED, necessitating intravenous labetalol. Baseline labs did not show any anomalies, and head CT was negative. Urinalysis was negative for blood. She was admitted to the medical service for further management of hypertensive urgency. A careful secondary clinical exam revealed a bruit in the epigastrium. Duplex ultrasound of the complete abdomen showed no abnormal findings. In view of her age, severe hypertension, and abdominal bruit, a diagnosis of renal artery stenosis (RAS) was favored. Angiography to evaluate for this condition was performed given the strong clinical suspicion of this diagnosis. Images confirmed the presence of right renal artery stenosis, likely from fibromuscular dyplasia (Fig. 1). She underwent percutaneous balloon angioplasty, with improvement in blood pressure readings and de‐escalation of therapy prior to discharge. She is now off all treatment with normal blood pressure readings.
FIGURE 1. Angiographic imaging revealing irregular middistal stenosis of the right renal artery. The beaded appearance is classical, with fibromuscular dysplasia of the media and intima of the vessel.
A careful clinical exam in our patient revealed an epigastric bruit likely transmitted from turbulent flow in the renal artery, prompting definitive workup despite negative Doppler findings. Failure to miss this important clinical clue may have led to reliance on Doppler results, missing the diagnosis. Hypertension due to RAS is only partially controlled by drug treatment and would have led to poor outcomes in this young patient. Although renal artery stenosis accounts only for 5% of all hypertension, it is the most common form of surgically correctable hypertension and accounts for a disproportionate fraction of hypertension in children and young adults.
Severe, difficult‐to‐control hypertension in young patients mandates a careful clinical examination directed toward detecting stigmata of secondary causes of hypertension. RAS from fibromuscular dysplasia is 3 times more common in women than men and (when detected) is easily treated by percutaneous (not drug) therapy.
V. Chopra ‐ University of Michigan Health System, employment
To cite this abstract:Chopra V. Hypertension … and a Bruit?. Abstract published at Hospital Medicine 2011, May 10-13, Dallas, Texas. Abstract 252. Journal of Hospital Medicine. 2011; 6 (suppl 2). https://www.shmabstracts.com/abstract/hypertension-and-a-bruit/. Accessed May 22, 2019.