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A 75-Year-Old Man Comes to the Office for Hypertension Follow-Up

question 38

Multiple Choice

A 75-year-old man comes to the office for hypertension follow-up. The patient has been taking chlorthalidone since being diagnosed with hypertension 15 years ago, and he was started on metoprolol 4 years ago after he had a non-ST elevation myocardial infarction. Over the last 2 years, his blood pressure measurements have ranged from 160/80 mm Hg to 180/100 mm Hg, and amlodipine was added to his medical regimen 6 months ago. The patient has had no chest pain, dyspnea, palpitation, headache, or subjective neurological deficits. His medical history includes hyperlipidemia and peripheral vascular disease, and other medications are aspirin and atorvastatin. The patient is a former smoker with a 30-pack-year history and does not use alcohol or illicit drugs.
Today, blood pressure is 165/86 mm Hg and pulse is 68/min. Physical examination is notable for an abdominal bruit.
Serum creatinine is 1.2 mg/dL, and duplex Doppler ultrasonography reveals >60% stenosis of bilateral renal arteries.
Which of the following is the most appropriate next step in management of this patient?

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