A change in previously controlled hypertension (HTN) should prompt consideration of a secondary workup. An 81–year–old obese female, with history of HTN, hyperlipidemia, and anxiety, presented with refractory HTN. Her blood pressure (BP) had been well controlled with lorsartan and amlodipine for more than 15 years until she developed angioedema. Her HTN was subsequently controlled with amlodipine, hydrochlorothiazide and metoprolol for 5 years. A month ago, she developed dizziness. Physical examination was unremarkable except for BP of 231/95. She was admitted to the hospital for HTN urgency/refractory HTN. Despite the maximal dose of five different classes of anti–HTN medications, including a diuretic, the patient’s BP was persistently elevated. Her clinical course was further complicated by the development of fresh pulmonary edema (FPE) and NSTEMI. In view of her refractory HTN, a secondary HTN work–up was initiated. Urinalysis showed no protein/ blood and renal function was normal. Blood tests revealed normal serum catecholamines, TSH and spot random cortisol level. An overnight oximetry revealed no sleep apnea spells. She was found to have renin level of 20 (normal 2.9–10.8 ng/mL/hr) and aldosterone level of 25 (normal <20 ng/dL), but normal aldosterone/renin ratio. CTA of chest was performed to exclude pulmonary embolism, and revealed an incidental finding of 80% stenosis of the right renal artery, and a possible stenosis of the left renal artery. She subsequently underwent bilateral renal artery angiogram which confirmed the diagnosis of bilateral renal artery stenosis (RAS). Re–vascularization and stent placement was performed successfully, which resulted in relieving of her cardio–pulmonary symptoms, successful BP control, and preserved renal function in the following 4 months.
50% of elderly patients with known CAD or HTN carry a diagnosis of atherosclerotic RAS. RAS may lead to hypertension and cardiac morbidity through elevated renin–angiotensin and aldosterone effects. Medical management and revascularization are the two major treatment options. Several randomized multi–center clinical studies failed to demonstrate superiority of interventional revascularization in comparison of medical management. However, certain subgroups of RAS patients may benefit more from revascularization, for instance, patients with bilateral RAS. Pickering syndrome (occurrence of FPE in patients with RAS, mostly bilateral) should be considered in the differential and may be a subgroup to benefit from intervention.
Here, we report a case of Pickering Syndrome of an elderly woman, who was managed successfully by renal artery revascularization and stent placement.