Patients with unilateral renal artery stenosis who are hypertensive should receive antihypertensive therapy. The data and specific recommendations are presented elsewhere. (See "Goal blood pressure in adults with hypertension".)
●Angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs) are effective in patients with renovascular disease; additional medications are frequently required. Potential concerns with the use of medical therapy without revascularization include progression of the stenosis, impaired kidney function with angiotensin inhibition, and long-term ischemic damage of the stenotic kidney. (See 'Medical therapy' above.)
●For patients with unilateral renal artery stenosis who meet one or more of the following four criteria, we suggest revascularization rather than medical therapy alone; revascularization is usually achieved by percutaneous angioplasty with stenting (or surgical revascularization in patients with complex anatomic lesions) (see 'Revascularization versus medical therapy alone' above) (Grade 2C):
•A short duration of blood pressure elevation prior to the diagnosis of renovascular disease, since this is the strongest clinical predictor of a fall in blood pressure after renal revascularization
•Failure of optimal medical therapy to control the blood pressure
•Intolerance to optimal medical therapy
•Recurrent flash pulmonary edema and/or refractory heart failure
●For patients with unilateral renal artery stenosis who do not meet one of the four criteria just listed, we suggest not revascularizing and instead treating with medical therapy alone (Grade 2B).
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