Revascularization of atherosclerotic renal artery stenosis for chronic heart failure versus acute pulmonary oedema.

AIM: The aim of the study is to determine whether the apparent benefit of revascularization of renal artery stenosis for 'flash' pulmonary oedema extends to heart failure patients without a history of prior acute pulmonary oedema. METHODS: A prospective study of patients with renal artery stenosis and heart failure at a single centre between 1 January 1995 and 31 December 2010. Patients were divided into those with and without previous acute pulmonary oedema/decompensation. Survival analysis compared revascularization versus medical therapy in each group using Cox regression adjusted for age, estimated glomerular filtration rate, blood pressure and co-morbidities. RESULTS: There were 152 patients: 59% male, 36% diabetic, age 70 ± 9 years, estimated glomerular filtration rate 29 ± 17 mL/min per 1.73 m2 ; 52 had experienced previous acute pulmonary oedema (34%), whereas 100 had no previous acute pulmonary oedema (66%). The revascularization rate was 31% in both groups. For heart failure without previous acute pulmonary oedema, the hazard ratio for death after revascularization compared with medical therapy was 0.76 (0.58-0.99, P = 0.04). In heart failure with previous acute pulmonary enema, the hazard ratio was 0.73 (0.44-1.21, P = 0.22). For those without previous acute pulmonary oedema, the hazard ratio for heart failure hospitalization after revascularization compared with medical therapy was 1.00 (0.17-6.05, P = 1.00). In those with previous acute pulmonary oedema, it was 0.51 (0.08-3.30, P = 0.48). CONCLUSION: The benefit of revascularization in heart failure may extend beyond the current indication of acute pulmonary oedema. However, findings derive from an observational study.

Abordagem percutânea das doenças da artéria renal / Percutaneous approach to renal artery disease

A estenose da artéria renal (EAR) é uma importante causa de hipertensão arterial sistêmica (HAS) secundária e disfunção renal. O principal mecanismo é por doença aterosclerótica unilateral ou bilateral. O diagnóstico precoce é importante para se evitar falência renal terminal e graves complicações cardiovasculares. O início de HAS precoce ou tardia, sopros abdominais, déficit renal sem causa aparente e HAS resistente são achados clínicos para se suspeitar de EAR, sendo necessários exames complementares como o Doppler colorido, angiotomografia ou ressonância nuclear magnética das artérias renais. A arteriografia renal é o padrão ouro para confirmação diagnóstica. O tratamento medicamentoso está indicado para os pacientes assintomáticos ou que mantêm controle clínico satisfatórios. A intervenção percutânea da artéria renal com uso de stents tem sido motivo de controvérsia, ficando restrita aos pacientes com perda progressiva da função renal e estenose bilateral, hipertensão arterial resistente ao tratamento medicamentoso, edema agudo de pulmão hipertensivo de repetição e disfunção de enxerto renal no caso de pacientes submetidos ao transplante renal

Renal artery stenosis (RAS) is an important cause of secondary systemic hypertension and renal dysfunction. The main mechanism is unilateral or bilateral atherosclerotic disease. Early diagnosis is important to avoid terminal renal failure and severe cardiovascular complications. The onset of early or late secondary systemic hypertension, abdominal murmurs, renal failure without apparent cause, and resistant secondary systemic hypertension are clinical findings to suspect RAS, and complementary exams such as color Doppler, angiotomography or magnetic nuclear magnetic resonance imaging of the renal arteries are necessary. Renal arteriography is the gold standard for diagnostic confirmation. Drug treatment is indicated for patients who are asymptomatic or who maintain satisfactory clinical control. Percutaneous renal artery intervention with stents has been controversial, being restricted to patients with progressive renal function loss and bilateral stenosis, drug-resistant hypertension, acute repetitive hypertensive pulmonary edema and renal graft dysfunction in patients submitted to kidney transplant