Pickering et al. (27) first reported bilateral RAS as a cause of congestive cardiac failure in 1988. It is thought to be due to a severe excess of angiotensin II and aldosterone, leading to hypertension, sodium retention, and fluid overload. Frequent associated left ventricular dysfunction from hypertension and coronary disease does not help matters. The association has been validated by the dramatic response to renal angioplasty. MacDowall et al. (28) looked at outpatients with New York Heart Association grade II-IV heart failure and found a 34% prevalence of RAS. Although there has been no study on the effect of revascularization in these patients on survival, it should in theory be beneficial because it would allow the use of ACE inhibitors.
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