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HIGH BLOOD PRESSURE: THE DIAGNOSTIC PROGRAM

If you are found to have high blood pressure your doctor will schedule a series of additional examinations. You may question his advice but after you read the section on the possible complications of hypertension you will understand his reasons. These tests and examinations serve several purposes:

To determine the extent of the hypertensive disease,

To find its cause,

To search for additional risk factors.

Determining the Extent of the Disease

The first objective of the diagnostic program is to deter mine exactly how far the disease has progressed, whether the hypertension is malignant or not, whether the arteries and internal organs have been affected, etc. Your doctor has to know all this before he can draw up your treatment program. The section on the general check-up tells you how your doctor proceeds.

Isolating the Cause

The second objective of the diagnostic program is to isolate the specific cause. We already know that high blood pressure can be caused by a variety of factors. Its diagnosis is a matter of elimination. That is to elimination say, your doctor, before making a diagnosis of essential or primary hypertension, will dismiss the possibility of secondary hypertension only after checking you for all the organic diseases known to cause high blood pressure. Some of these hypertensive conditions such as unilateral atrophic kidney disease, renal artery stenosis, coarctation of the aorta, adrenal tumors, etc., can be cured by surgery. They are very rare, accounting for no more than about 4-5% of the total known cases of hypertension, but their early detection can make the difference between a normal life and premature death. A somewhat larger number, about 10%, is caused by kidney infections that respond to antibacterial or other drug therapy. An elevated blood pressure level frequently is the only indication of a kidney disease which, if left untreated, could result in kidney failure and death. Its detection is of immense importance not only for the treatment of hypertension but for the treatment of a potentially fatal kidney disease.

The Search for Additional Risk Factors

Another vitally important aspect of the examination, the search for additional risk factors, should not be neglected, unless you have recently had a complete physical check-up.

The Basic Examination

Once the physician has diagnosed high blood pressure he will suggest a series of tests to guide him in setting up your treatment plan. General practitioners, cardiologists, radiologists, and researchers have been debating the best and most promising approach to such a broad-spectrum examination, one that will isolate all possible causes of secondary hypertension and check all possible organ damage. Still, the scope of this examination should not exceed the capability of your local doctor nor should it be too costly.

What do you expect your doctor to do in a complete physical examination? The doctor will inquire into the incidence of high blood pressure, heart attacks, stroke, diabetes, obesity, gout, kidney disease in your family, ask you about diseases you have had, about medication you are taking, about stress in your work and life situation. Your answers can furnish important diagnostic clues. If you have specific complaints and pains try to describe them as precisely as you can: the type and site of the pain, its frequency, what foods or weather conditions seem to trigger it, etc. All such information may prove to be important. Tell your doctor about your general physical and mental state, your diminished capabilities, if any, your difficulties in concentration, and memory lapses, if any. To evaluate your past history your doctor must know something about your personal life. That is why he will ask questions about your eating, smoking and drinking habits, your work situation, your marriage and family life, the physical activity you engage in, and how you spend your leisure.

The physical examination begins with a thorough check of your cardiovascular system. He listens for the frequency and regularity of the heart beat (60-80 beats per minutes are the norm) and for cardiac murmurs that might indicate defects of the heart valves and he looks for arrhythmias and premature beats symptomatic of a damaged heart muscle. He auscultates the lungs for signs of congestion related to the heart. In checking this he may of course discover other pulmonary or bronchial disorders like a chronic smoker's bronchitis or emphysema which put an extra burden on the heart. Finally he palpates the big arteries at the neck, wrist, groin, and feet to test whether a pulse can be felt and whether it is strong or weak. A faint or nonexistent pulse at any of these sites is a warning sign of a developing arteriosclerotic obstruction. Pain in the kidney region may point to a kidney disease which in the absence of any other symptoms might have gone undetected.

The laboratory tests are designed to help detect the cause of hypertension. A high albumin (protein) and/or red blood cell content in the urine point to kidney infection. A high creatinine blood level (creatinine is a metabolic waste excreted in the urine) points to impaired kidney function. A low potassium level may be due to medication, but it may also point to adrenal-caused hypertension.

If your blood pressure remains high, particularly if you are no longer young, and the diastolic level stays above 100, your doctor is certain to order further tests.

Few people really know how the electrocardiogram (EKG) works. To put it simply, the EKG is a continuous recording of the bioelectrical impulses that stimulate and regulate heart activity. Deviations from the curve plotted by the highly sensitive apparatus can indicate either arrhythmias, changes in the heart muscle due to high pressure, impaired blood flow through the coronary vessels, or other irregularities and defects.

The chest X-ray (the amount of radiation involved is minimal and hence, harmless) yields additional information about the heart and lungs; whether the heart is enlarged or the lungs congested or whether the aorta shows signs of arteriosclerotic deterioration.

The kidney X-ray (pyelogram), which also takes in the renal pelvis and ureter, can detect chronic infections, kidney stones, atrophied kidneys, or other defects which even though asymptomatic may still be the cause of hypertension.

Don't be surprised if your doctor examines your eyes o refers you to an opthalmologist, for the condition of the retina (eyeground) and its small arteries are important diagnostic indicators. The eye more than any other single organ can show whether hypertension is becoming malignant. If so he may recommend hospitalization, additional diagnostic tests and initiate prompt treatment.

Special Tests

If secondary hypertension is suspected, all the possible causes must be checked out. For example, a sudden rise blood pressure may be a sign of pheochromocytoma, or an abnormally low potassium level may point to a tumor of the adrenal cortex. Further tests are needed to find out whether excessive amounts of their specific hormones are being excreted in the urine or have been accumulated in the blood. Once this has been established the site of the tumor can be explored. A special X-ray technique (angiography) involving the injection of a dye is used to visualize the network of the aorta, the renal and adrenal arteries. Angiography may also be used where renal artery stenosis, an atrophied kidney or some other operable cause of hypertension is suspected.

Additional examinations may be needed to evaluate the extent of the hypertensive damage discovered in the course of the general check-up. Angiography can show dangerous arteriosclerotic obstructions of the carotid, coronary, pelvic and leg arteries and indicate the advisability of surgery. Or neurological examinations may be needed to determine the extent of arterial brain damage. Testing the sensory and peripheral nerves with an electroencephalography (EEG)—something like the EKG—as well as ultrasonic examinations and similar sophisticated techniques give surprisingly accurate pictures of the condition of various parts of the brain.

These secondary forms of hypertension are very rare, so the chances that one of them is the cause of your high blood pressure are minimal. Yet, if it were so, you could consider yourself quite lucky because they are operable. Likewise, if the examination reveals that you have an unsuspected kidney disease this can be successfully treated. In all these cases early detection and correct diagnosis are prerequisites for successful treatment and cure.

In case you are concerned about the safety of diagnostic techniques like X-ray or kidney tests involving radioactive substances, let me point out: all of them are tested, safe, routine procedures, and most of them need be done only once. The minor pain or discomfort caused by the insertion of the angiogram needle can be avoided with a local anesthetic.

The Doctor-Patient Talk

What are the expectations of the doctor and of the patient?

The patient wants to learn the results, to understand them, and to be told clearly what the treatment involves.

The doctor wants the patient to be interested and cooperative.

Whether their expectations are fulfilled depends largely on their talk following the test results. Doctors attach, great importance to this conference.

You must learn to overcome your reluctance to ask questions, and you must keep on asking until you understand the findings and their consequences. That may not be as easy as it sounds. Don't be afraid of wasting your doctor's valuable time or that he may think you are slow if you don't understand a complicated medical problem right away. That would be wrong. Doctors know how difficult it is for laymen to understand medical terms or problems and they want to help.

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Cardio & Blood