Comprehensive First‐Line Magnetic Resonance Imaging in Hypertension: Experience From a Single‐Center Tertiary Referral Clinic

Abstract

European guidelines recommend that patients with hypertension be assessed for asymptomatic organ damage and secondary causes. The authors propose that a single magnetic resonance imaging (MRI) scan can provide comprehensive first-line imaging of patients assessed via a specialist hypertension clinic. A total of 200 patients (56% male, aged 51AE15 years, office BP 168AE30/96AE16 mm Hg) underwent MRI of the heart, kidneys, renal arteries, adrenals and aorta. Comparisons were made with other imaging modalities where available. A total of 61% had left ventricular hypertrophy (LVH), 14% had reduced ejection fraction, and 15 patients had myocardial infarcts. Echocardiography overdiagnosed LVH in 15% of patients and missed LVH in 14%. Secondary causes were identified in 14.5% of patients: 12 adrenal masses, 10 renal artery stenoses, seven thyroid abnormalities, one aortic coarctation, one enlarged pituitary gland, one polycystic kidney disease, and one renal coloboma syndrome. This comprehensive MRI protocol is an effective method of screening for asymptomatic organ damage and secondary causes of hypertension.

Whole‐Body Imaging Procedures in Resistant Hypertension: Evaluating for Secondary Causes or to Define End‐Organ Damages?

“…The article by Burchell and coworkers in this current issue of the Journal introduces an interesting concept on the diagnostic side of hypertension management, suggesting that a whole‐body MRI could answer most of the diagnostic questions and assist in making an etiologic diagnosis for hypertension in a single session . Such thinking is somewhat analogous to the concept of the “polypill,” as suggested by some to treat hypertension and cardiovascular risk factors with a small amount of multiple agents .…”

“…There are European countries where patients wait for months for an MRI and even in the United States, insurance preapproval may be needed. Perhaps reviewing the potential limitation of the study by Burchell and colleagues in more detail would offer us a glimpse into the future.…”

“…In summary, we are unable to agree with the authors' conclusion that “given the high prevalence of target organ damage reported… we recommend that MRI should be used as the primary imaging modality in tertiary hypertension clinics.” We would view this very interesting technology as a work in progress and belonging exclusively to the realm of clinical research at the present time. We regard this effort by the authors as a worthy undertaking for working on finding the causative diagnosis of hypertension rather than simply adding to treatment guidelines and protocols.…”

Cardiac magnetic resonance imaging provides new insight into hypertensive heart disease—a reply

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With regards to the request for correlation with office and ambulatory blood pressure readings, these data are provided in the manuscript: end-diastolic wall thickness correlated with office systolic blood pressure (R=.43, P<.01)andofficediastolicbloodpressure (R=.32, P<.005) but did not correlate with ambulatory blood pressure monitoring systolic blood pressure (R=.24, P=.12), ambulatory blood pressure monitoring diastolic blood pressure (R=.18, P=.27), or ambulatory blood pressure monitoring systolic mean arterial pressure (R=.18, P=.27).We agree that echocardiography is currently the imaging modality most frequently used to investigate patients with arterial hypertension, but cardiovascular magnetic resonance imaging has the potentialtooffera"one-stop"comprehensiveassessmentofpatientswith hypertension,bothtoscreenforsecondarycausesandidentifytarget organ damage. 2 We elected to perform cardiovascular magnetic resonance imaging rather than echocardiography because of its increased tissue contrast and because of its superior ability to image subjects with concomitant obesity consistently. We did not perform a direct comparison of echocardiographic and cardiovascular magnetic resonance imaging findings but agree it would be interesting to perform such a study in the future.We also agree that left ventricular (LV) geometry is an interesting parameter.We provide data on absolutewall thickening relative to the LV end-diastolic diameter to correct for changes in LV cavity size.

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Comment on: “Comprehensive first‐line magnetic resonance imaging in hypertension: experience from a single‐center tertiary referral clinic”

“…As the authors mentioned, these tumors may be small and therefore the diagnosis may be missed. 1,3 Computed tomography and magnetic resonance imaging lack sensitivity for detecting primary aldosteronism. In these patients, the aldosterone to renin ratio should be routinely measured to rule out aldosteronism.…”