Elsevier

The Lancet

Volume 352, Issue 9121, 4 July 1998, Pages 13-16
The Lancet

Articles
Risk of morbidity from renovascular disease in elderly patients with congestive cardiac failure

https://doi.org/10.1016/S0140-6736(97)11060-1Get rights and content

Summary

Background

Renovasular disease commonly affects elderly people. Elderly patients with heart failure are routinely treated with angiotensin-converting-enzyme (ACE) inhibitors, which may increase risk of renal dysfunction. We investigated the frequency of renovascular disease among elderly people with heart failure.

Methods

From the local population of Salford, UK, we recruited 86 patients with heart failure with a mean age of 77.5 (SD 5.6) years, who were admitted as acute emergencies or who attended general medical clinics. We selected patients by intention to treat with ACE inhibitors. We used captopril renography to screen for renovascular disease. All patients with abnormal renograms underwent magnetic-resonance angiography of the renal arteries as well as 40% of patients with normal renograms as negative controls.

Findings

Magnetic-resonance angiography showed severe renovascular disease (>50% renal-artery stenosis or occlusion) in 29 (34%) patients. Captopril renography had an estimated sensitivity of 78·8% (95% CI 72.7–97.8) and specificity of 94·3% (67.6–97.3) for detection of renovascular disease. The estimated positive predictive value of captopril renography was 89·7% and the negative predictive value was 87·5%. Patients with renovascular disease had worse renal function (mean creatinine 201 [SD 56] vs 136 [40] μmol/L, p<0.001), were older (mean age 80.7 [5.6] vs 76.8 [5.3] years, p<0.01), and were more likely than patients without renovascular disease to have peripheral arterial disease.

Interpretation

Some elderly patients with occult renovascular disease on ACE inhibitors will be at risk of developing uraemia. Renal function should be closely monitored to detect any deterioration early.

Introduction

Atheromatous renovascular disease is an important cause of hypertension and progressive renal impairment. Suggestive clinical markers generally appear,1 but many cases remain undetected until serious complications occur. Elderly people are mainly affected.2 Several studies have shown comorbid symptomatic peripheral vascular disease,3 aortic atheroma or aneurysm, and ischaemic heart disease.4 The rate of renovascular disease in patients with congestive cardiac failure has not been reported. The rate is probably high, since severe heart failure may be an important predictor of underlying renovascular disease, and flash pulmonary oedema is associated with severe renovascular disease.

Inhibitors of angiotensin-converting enzyme (ACE) decrease morbidity and mortality in patients with heart failure,6 but their use may be associated with renal impairment.7 We have shown that ACE inhibitors used in the general population to treat hypertension were causally implicated in 4% of all acute uraemic emergencies in our unit over 6 years.8 Widespread use of ACE inhibitors to treat elderly patients with cardiac failure9 further increases the risk for uraemic complications.

Several non-invasive screening tests have been developed to detect renovascular disease, including captopril renography, doppler scanning of the renal vasculature, and magnetic-resonance angiography. Direct intra-arterial renal angiography remains the gold-standard investigation, but is invasive and can be harmful.10 Magnetic-resonance angiography is non-invasive and is gaining acceptance for renal-vascular imaging; it has been shown to have a high sensitivity (100%) and specificity (89%) for the detection of renal-artery stenosis.11

We investigated the rate of renovascular disease among elderly people with congestive cardiac failure who had not previously taken ACE inhibitors. We used captopril renography as the basic screening test, and magnetic-resonance angiography for non-invasive renal vascular imaging of renovascular disease.

Section snippets

Patients

Patients aged older than 70 years who presented with cardiac failure (New York Heart Association class II-IV) to the medical unit of Salford Royal Hospitals NHS Trust, Salford, UK, were eligible for entry into our study. We recruited patients after acute admission via the emergency department or attendance at the general medical clinics. We selected patients for referral to the study by intention to treat with ACE inhibitors. The study was approved by the local ethics committee. We recruited

Results

184 patients were referred for possible enrolment, of whom 86 were included. 98 patients were excluded because of previous therapy with ACE inhibitors (48), refusal or inability to give informed consent (19), inability to tolerate investigation (21), or other reasons (ten).

68 recruited patients had been admitted via the emergency department, and 18 were entered after visits to outpatient clinics (44 men, 42 women). The mean age was 77·5 (SD 5·6) years (table 1). Cardiac failure was judged from

Discussion

Our results confirm that increasing age is an important risk factor for occult renovascular disease. The rate of undetected severe renovascular disease was 33·7% (estimated to be 38·4% by extrapolation), which has major implications for the use of ACE inhibitors in elderly people. Exclusion of patients already on ACE inhibitors might have led to an overestimated rate of renovascular disease, but this selection bias is offset by exclusion of patients with advanced chronic renal failure, who are

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