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A 40-year-old woman with long-standing, resistant hypertension on multiple medications, recent acute kidney injury after ACE inhibitor use, and a history of episodic symptoms such as chest tightness and a right-sided abdominal bruit, presents for further evaluation. What clinical features in this scenario help you identify the most likely underlying cause of her hypertension and prioritize your next diagnostic steps?

VIDEO INFO
Category: Screening and Risk Assessment for Renovascular Hypertension, Renovascular Hypertension and Kidney Artery Disorders, Hypertension
Difficulty: Hard - Advanced level - Challenges experienced practitioners
Question Type: Epidemiology
Case Type: Typical Presentation

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QUESTION
A 40-year-old woman is referred for evaluation of persistently elevated blood pressure first documented 18 months ago, when home readings reached 185/110 mm Hg. Current antihypertensive therapy is amlodipine 10 mg daily, hydrochlorothiazide 25 mg daily, and labetalol 200 mg twice daily; the latter was started 10 months ago because of frequent symptomatic tachycardia....

OPTIONS
A. Presence of a high-pitched systolic-diastolic abdominal bruit just to the right of the umbilicus
B. Onset of hypertension in a woman younger than 50 years of age
C. Rise in serum creatinine after initiation of an angiotensin-converting enzyme inhibitor
D. History of fibromyalgia with chronic widespread pain and associated psychosocial stress-related symptoms

CORRECT ANSWER
A. Presence of a high-pitched systolic-diastolic abdominal bruit just to the right of the umbilicus

EXPLANATION
The main teaching point in this hard epidemiology question is that an abdominal bruit, especially one that is high-pitched and extends into diastole, is a particularly strong clinical clue to renovascular hypertension due to fibromuscular dysplasia in a relatively young woman. Large registry data and the American Heart Association fibromuscular dysplasia statement show that abdominal bruits and pulsatile tinnitus are common physical findings in FMD, reflecting turbulent flow through stenotic, irregular renal arteries. In this patient, the focal, high-pitched systolic-diastolic bruit just to the right of the umbilicus is therefore the single feature that most sharply raises the pre-test probability of FMD-related renovascular disease.

The other options represent weaker or non-specific associations. Onset of hypertension before age 50 in a woman is consistent with secondary hypertension and should prompt evaluation for renovascular causes, but many younger patients have essential hypertension and never develop FMD. A rise in creatinine after starting an ACE inhibitor can occur in bilateral renal artery stenosis or advanced chronic kidney disease and is not specific to fibromuscular dysplasia. Fibromyalgia with chronic widespread pain and psychosocial stress is common and has no established epidemiologic or pathophysiologic link to fibromuscular dysplasia in registry or guideline data. Distinguishing truly disease-enriched features (like an abdominal bruit or pulsatile tinnitus) from more generic or unrelated findings is critical at this level.


Further reading:

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