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European Heart Journal Advance Access published online on May 26, 2005
European Heart Journal, doi:10.1093/eurheartj/ehi304
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European Heart Journal © The European Society of Cardiology 2005; All rights reserved
Received July 9, 2004
Revised January 10, 2005
Accepted March 31, 2005

Review

Atherosclerotic renovascular disease in chronic heart failure: should we intervene?

Ramesh de Silva 1*, Nikolay P. Nikitin 2, Sunil Bhandari 3, Anthony Nicholson 4, Andrew L. Clark 2, and John G.F. Cleland 2

1 Academic Cardiology, University of Hull, Castle Hill Hospital, Castle Road, Cottingham, East Yorkshire, HU16 5JQ, UK
2 Academic Cardiology, University of Hull, Castle Hill Hospital, Castle Road, Cottingham, East Yorkshire, HU16 5JQ, UK
3 Department of Nephrology, Hull Royal Infirmary, Hull, East Yorkshire, HU3 2JZ, UK
4 Department of Vascular Radiology, Leeds General Infirmary, Leeds, West Yorkshire, LS1 3EX, UK

* To whom correspondence should be addressed.
Ramesh de Silva, E-mail: ramesh{at}desilva84.freeserve.co.uk


  Abstract

Renal artery stenosis (RAS) is most commonly caused by atherosclerosis, which is also the most common cause of chronic heart failure (CHF). One-third of patients with CHF are reported to have significant renovascular disease. The presence of RAS confers a worse outcome in studies of hypertension and coronary disease, though data are lacking for patients with CHF. As the kidney is intricately involved in the fluid retention that occurs in CHF, an adverse effect of RAS on outcome would be expected. Presentations of RAS in CHF include flash pulmonary oedema, hypertension, worsening of CHF, and worsening renal function. RAS commonly progresses and may cause worsening of renal function in patients with CHF and previously stable renal function. A variety of investigations that can safely and accurately identify RAS in CHF are available, although none is recommended in current guidelines for the management of CHF. Treatment for RAS, whether for hypertension, for renal dysfunction, or for pulmonary oedema, is at the discretion of the physician due to the lack of adequate randomized controlled trials demonstrating the efficacy and safety of intervention. As it is not clear how RAS should be managed in CHF, screening cannot be advocated. Currently, a multicentre randomized outcome trial, which includes a cohort of patients with RAS and CHF, is in progress to provide answers in this area of uncertainty.

Keywords: Heart failure; Renovascular disease; Intervention.
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