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Clinical Clues to the Diagnosis of RAS

 
 
 
 
 
 
 
 
 
Determine if one or more of the following is present:
❑ Onset of hypertension before the age of 30 years or severe hypertension after the age of 55
❑ Accelerated, resistant, or malignant hypertension
❑ Development of new azotemia or worsening renal function after administration of an ACE inhibitor or ARB agent
❑ Unexplained atrophic kidney or size discrepancy between kidneys >1.5 cm
❑ Sudden, unexplained pulmonary edema
❑ Unexplained renal dysfunction, including individuals starting renal replacement therapy
❑ Multi-vessel CAD
❑ Unexplained CHF
❑ Refractory angina
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If no, proceed with non-invasive imaging
 
 
 
 
 
 
 
If yes, proceed with invasive renal arteriography
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Is patient allergic to contrast
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If yes proceed with US
 
If no check for:

❑ Implanted devices:

  • Pacemakers
  • Defibrillators
  • Cochlear implants
  • Spinal cord stimulators
❑ Claustrophobic patient
 
 
 
 
 
Abdominal aortography to assess the renal arteries during coronary and peripheralangiography
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If none of the above proceed with MRA
 
If yes to any of the above, proceed with CT
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Negative noninvasive test but with high clinical suspicion
 
Evidence of RAS
 
 
 
 
Evidence of RAS
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Go to invasive imaging
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Confirmed RAS:

❑Proceed to medical therapy

❑Consider revascularization