Mayo Foundation for Medical Education and Research
38-Year-Old Woman With Hypertension, Headaches, and Abdominal Bruit
Mira T. Keddis, MD and Vesna D. Garovic, MD
Additional article information
A 38-year-old woman presented to her local clinic for recurrent episodes of headache of several weeks' duration. Evaluation revealed a blood pressure of 202/136 mm Hg. The patient was prescribed 37.5 mg of triamterene with 25 mg of hydrochlorothiazide (1 tablet) twice daily and 50 mg of atenolol once daily.
Her blood pressure remained elevated, and her headaches persisted. She was referred to the hypertension clinic for further management.
The patient's medical history was remarkable for preeclampsia during her second pregnancy 9 years previously. She smoked half a pack of cigarettes per day for 15 years. Her alcohol use was limited to social gatherings and consisted of 1 to 2 drinks monthly. She exercised regularly and had a balanced low-salt diet. Essential hypertension was common on her maternal side.
On physical examination, the patient's blood pressure was 172/100 mm Hg (both arms), and her heart rate was 90 beats/min. Findings on funduscopic examination were normal. Cardiac examination revealed a grade 2/6 systolic ejection murmur at the right upper sternal border. Abdominal examination was remarkable for a systolic-diastolic bruit present over the right midabdomen without palpable masses. No evidence of pitting edema was observed, and findings on lung examination were normal.
Initial work-up included the following (reference ranges shown parenthetically): hemoglobin, 14.1 g/dL (12.0-15.5 g/dL); creatinine, 0.8 mg/dL (0.7-1.2 mg/dL); sodium, 139 mEq/L (135-145 mEq/L); potassium, 4.2 mmol/L (3.6-4.8 mmol/L); bicarbonate, 29 mEq/L (22-29 mEq/L), and calcium, 9.5 mg/dL (8.9-10.1 mg/dL). Findings on electrocardiography were normal.
On the basis of this patient's clinical context, which one of the following is the most likely diagnosis?
Anxiety
Essential hypertension
Secondary renovascular hypertension due to atherosclerotic renal artery stenosis
Secondary renovascular hypertension due to fibromuscular dysplasia (FMD)
Hypertension associated with renal insufficiency
Anxiety can be associated with episodes of dramatic but temporary elevations in blood pressure. This patient's hypertension appears to be persistently elevated, which argues against this diagnosis.
Essential hypertension commonly occurs in middle-aged people who are usually asymptomatic with normal findings on physical examination.1 Secondary hypertension, defined as the presence of a specific condition known to cause hypertension, may affect up to 10% of hypertensive patients. It commonly presents as resistant hypertension, defined as an inability to control blood pressure despite the concurrent use of 3 antihypertensive agents, one of which is a diuretic.2 Our patient's severe stage 2 hypertension (defined as a systolic blood pressure ≥160 mm Hg and/or a diastolic blood pressure ≥100 mm Hg), young age, and inadequate response to blood pressure therapy argued against essential hypertension and raised suspicion for secondary causes.
Renovascular hypertension results from critical stenosis of the renal arteries. When the stenosis is sufficiently severe (ie, causing ≥75% diameter reduction), renal hypo perfusion ensues, leading to up-regulation of renin in the affected kidney. Consequent stimulation of angiotensin II and aldosterone leads to vasoconstriction and salt retention, respectively, which play a central role in the development of renovascular hypertension. Abdominal bruits, particularly those that have a diastolic component and lateralize to the renal areas, are suggestive of renal artery stenosis. Our patient's clinical presentation was highly suggestive of renal artery stenosis. Although atherosclerotic renal artery stenosis usually occurs in elderly patients with cardiovascular comorbid conditions such as hyperlipidemia and coexisting atherosclerotic vessel disease, fibromuscular dysplasia commonly affects young women with a history of smoking.3 Considering our patient's age, sex, and history of smoking, renovascular hypertension due to renal artery stenosis secondary to fibromuscular dysplasia was the most likely diagnosis. Hypertension associated with renal insufficiency was less likely given the negative findings on physical examination, normal kidney function, and absence of significant proteinuria on urinalysis.
