History and exam

Key diagnostic factors

common

onset of hypertension age >55 years

Suggestive of atherosclerotic RAS.[7][16]

history of accelerated, malignant, or resistant hypertension

Patients with RAS can present with severe, progressive, and/or difficult-to-control hypertension, sometimes causing end-organ damage.[7][16]

history of unexplained kidney dysfunction

Due to progressive stenosis or hypertension-related end-organ damage.[7][16]

history of multivessel coronary artery disease

Favors atherosclerotic RAS.[16][19]

history of other peripheral vascular disease

Favors atherosclerotic RAS.[2][19]

abdominal bruit

The finding of an abdominal bruit should raise the suspicion of the presence of RAS.[2][7]

sudden or unexplained recurrent pulmonary edema

Suggestive of RAS.[7][16]

uncommon

onset of hypertension age <30 years

Suggestive of fibromuscular dysplasia.[7][16]

Other diagnostic factors

common

absence of family history of hypertension

Suggestive of RAS.[2][13]

other bruits

Bruits in other vessels are frequent due to the common pathophysiology and high prevalence of coexistent PVD.[13]

uncommon

history of acute kidney injury after administration of ACE inhibitor or angiotensin II receptor antagonist

This can be seen in some patients with bilateral RAS or RAS of a single functioning kidney, after starting an ACE inhibitor or angiotensin receptor blocker.

Despite common belief that this class of medications is contraindicated in this population, renin-angiotensin blockade is a proven therapeutic modality.[7][16]

history of unexplained congestive heart failure

Favors atherosclerotic RAS.[16][19]

refractory angina

Favors atherosclerotic RAS.[16]

history of hypokalemia

Due to activation of the renin-angiotensin system.[7]

Risk factors

strong

dyslipidemia

Cholesterol deposition in the vessel walls, followed by inflammation and progression of the cholesterol plaque.[1][15]

smoking

Favors endothelial inflammation and dysfunction.[1]

Associated with both atherosclerotic and fibromuscular dysplasia (FMD).[14]

diabetes

Causes endothelial dysfunction; major cardiovascular risk factor.[1]

weak

female sex

Fibromuscular dysplasia (FMD) more frequent in women than in males. Also, atherosclerotic RAS more likely to progress in this population.[1][2][14]

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