A 62-year-old woman with resistant hypertension (BP 168/94 mmHg on three drugs including a diuretic) is started on ramipril. Two weeks later creatinine has risen from 1.1 to 1.8 mg/dL. She reports two prior episodes of abrupt nocturnal dyspnoea requiring emergency admission with normal ejection fraction on echo. Which investigation will most likely establish the diagnosis?

• A 24-hour ambulatory blood pressure monitoring
• B Kidney biopsy
• C Micturating cystourethrogram
• D Renal artery Doppler ultrasonography ✓

Explanation

Refractory hypertension, a rise in creatinine exceeding 30 percent after starting an ACE inhibitor, and recurrent flash pulmonary oedema form the classic triad of bilateral renovascular disease, usually atherosclerotic renal artery stenosis in this age group. ACE inhibitors reduce efferent arteriolar tone and drop filtration pressure in stenosed kidneys. Duplex Doppler ultrasonography is the appropriate first-line non-invasive test to demonstrate the stenosis. Biopsy would show nonspecific ischaemic changes and ABPM adds nothing diagnostic here.

Reference: Bailey and Love's Short Practice of Surgery, 27th ed.

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Written and medically reviewed by the StethoPrep medical team.