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Resistance to antihypertensive medication as predictor of renal artery stenosis: comparison of two drug regimens

Journal of Human Hypertension volume 15, pages 669–676 (2001)Cite this article

Abstract

Background: Renal artery stenosis is among the most common curable causes of hypertension. The definitive diagnosis is made by renal angiography, an invasive and costly procedure. The prevalence of renal artery stenosis is less than 1% in non-selected hypertensive patients but is higher when hypertension is resistant to drugs.

Objective: To study the usefulness of standardised two-drug regimens for identifying drug-resistant hypertension as a predictor of renal artery stenosis.

Design and setting: Prospective cohort study carried out in 26 hospitals in The Netherlands.

Patients: Patients had been referred for analysis of possible secondary hypertension or because hypertension was difficult to treat. Patients ⩽40 years of age were assigned to either amlodipine 10 mg or enalapril 20 mg, and patients >40 years to either amlodipine 10 mg combined with atenolol 50 mg or to enalapril 20 mg combined with hydrochlorothiazide 25 mg. Renal angiography was performed: (1) if hypertension was drug-resistant, ie if diastolic pressure remained ⩾95 mm Hg at three visits 1–3 weeks apart or an extra drug was required, and/or (2) if serum creatinine rose by ⩾20 μmol/L (⩾0.23 mg/dL) during ACE inhibitor treatment.

Results: Of the 1106 patients with complete follow-up, 1022 had been assigned to either the amlodipine- or enalapril-based regimens, 772 by randomisation. Drug-resistant hypertension, as defined above, was identified in 41% of the patients, and 20% of these had renal artery stenosis. Renal function impairment was observed in 8% of the patients on ACE inhibitor, and this was associated with a 46% prevalence of renal artery stenosis. In the randomised patients, the prevalence of renal artery stenosis did not differ between the amlodipine- and enalapril-based regimens.

Conclusions: In the diagnostic work-up for renovascular hypertension the use of standardised medication regimens of maximally two drugs, to identify patients with drug-resistant hypertension, is a rational first step to increase the a priori chance of renal artery stenosis. Amlodipine- or enalapril-based regimens are equally effective for this purpose.

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Acknowledgements

The study was supported by a grant from the Dutch Health Insurance Executive Board.

We are indebted to Prof Dr WH Birkenhäger for valuable comments on the design of the study. We are also indebted to the following investigators and institutions for their participation in the DRASTIC study listed in descending order of the number of patients enrolled: FME Hoekstra, AJ Man in ’t Veld, AH van den Meiracker (University Hospital Rotterdam, Rotterdam); AKM Bartelink, SJ Eelkman Rooda and CAMJ. Gaillard (Eemland Hospital, Amersfoort); A Dees (Ikazia Hospital, Rotterdam); JWM Lenders and Th Thien (University Hospital St Radboud, Nijmegen); JACA van Geelen (Medical Center, Alkmaar); CJ Doorenbos (Deventer Hospitals, Deventer); J van der Meulen and P Smak Gregoor (Merwede Hospital, Dordrecht); PW de Leeuw, PN van Es, MME Krekels and AA Kroon (University Hospital Maastricht, Maastricht); F van Berkum and R Lieverse (Ruwaard van Putten Hospital, Spijkenisse); P Chang, A Cohen and AAMJ Hollander (Department of Nephrology, University Hospital Leiden, Leiden); G Schrijver (Rode Kruis Hospital, Beverwijk); PJ Wismans (Havenziekenhuis, Rotterdam); F de Heer, FLG Erdkamp (Maasland Hospital, Sittard); RM Brouwer and WAH Koning (Medisch Spectrum Twente, Enschede); PPNM Diderich (St Franciscus Gasthuis, Rotterdam); GA van Montfrans (University Medical Center, Amsterdam); W Hart (Reinier de Graaf Gasthuis, Delft); EJ Buurke (Westeinde Hospital, Den Haag); JH Bolk (Department of Internal Medicine, University Hospital Leiden, Leiden); HH Vincent (St Antonius Hospital, Nieuwegein); FL Waltman (Oosterschelde Hospital, Goes); TLJM van der Loos and FJM Klessens-Godfroy (Oogziekenhuis, Rotterdam); G Kolsters (Hospital De Weezenlanden, Zwolle); J Silberbusch and KJ Parlevliet (Onze Lieve Vrouwe Gasthuis, Amsterdam); S Lobatto (Hospital Hilversum).

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Authors and Affiliations

  1. Departments of Internal Medicine, University Hospital Rotterdam, The Netherlands

    BC van Jaarsveld, FHM Derkx, J Deinum & MADH Schalekamp

  2. Twenteborg Hospital, Almelo, The Netherlands

    AJJ Woittiez

  3. University Hospital Nijmegen, The Netherlands

    CT Postma

  4. Department of Public Health, Center for Clinical Decision Sciences, Erasmus University Rotterdam, The Netherlands

    P Krijnen

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  1. BC van Jaarsveld
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  2. P Krijnen
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  3. FHM Derkx
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  6. CT Postma
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  7. MADH Schalekamp
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for the Dutch Renal Artery Stenosis Intervention Cooperative (DRASTIC) Investigators Group

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Correspondence to BC van Jaarsveld.

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Members of the DRASTIC Investigators Group are listed in ‘Acknowledgements’.

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van Jaarsveld, B., Krijnen, P., Derkx, F. et al. Resistance to antihypertensive medication as predictor of renal artery stenosis: comparison of two drug regimens. J Hum Hypertens 15, 669–676 (2001). https://doi.org/10.1038/sj.jhh.1001258

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  • DOI: https://doi.org/10.1038/sj.jhh.1001258

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