Pkcering syndrome, flash pulmonary edema in renal artery stenosis

This patient is experiencing her second episode of flash pulmonary edema associated with severe hypertension.  She has peripheral arterial disease (intermittent claudication) and multiple risk factors (smoking, diabetes, hyperlipidemia) for diffuse atherosclerosis.  Recurrent flash pulmonary edema in patients with atherosclerotic disease should raise suspicion for renovascular hypertension due to bilateral renal artery stenosis.

Patients with bilateral renal artery stenosis can experience flash pulmonary edema (Pickering syndrome) despite normal left ventricular ejection fraction.  Other clues for renovascular hypertension include an acute rise in serum creatinine (>30%) after initiation of an ACE inhibitor or unexplained renal asymmetry on imaging studies.  Patients who have a high likelihood of renovascular disease should be evaluated with renal Doppler ultrasound or CT or MR angiography to detect renal artery stenosis.

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