Renal Artery stenosis?

[diane__0__0]

  In october of last year, I went to the hospital with chest pains.
  My bp was 195/110.  they gave me three nitro glycerin tablets before it
  came down.  The blood test revealed no negative enzymes.  That was a
  sat. night and I was admitted to the hospital and put on a nitro patch.
  5 AM monday morning, the ekg showed that I had "flipped my t-waves."  Up
  to that point the ekg hadn't changed.  Tues. morning I was transferred to
  another hospital for a heart cath.  That revealed no damage but the doctor
  said that part of my heart was not beating with the rest.  I believe it
  was the anterior apical.  The diagnosis based on the above info was that
  I had a coronary artery spasm.  that there was some damage to my heart but
  they felt it was reverseable.  I was told I have prinzmetal's angina also.
  I went to cardiac rehab for 3 months and was working out 4 days a weeks
  at the gym after I finished the rehab.  A few weeks ago, I went to SLC,
  Utah.  On both planes on the way out I had chest pains and took my nitro.
  The next day I had chest pains 2 more times.  The hotel called the
  paramedics and I was taken to the er.  My bp was again 190/110.  I had
  chest pains again in the hospital and they gave me nitro and it finally
  came down and stayed down.  After 6 hours they released me.  The cardio-
  logist at the er in Utah said he thought I got cehst pains because of the
  high bp and that he wasn't convinced it was angina or that I had a CAS in
  October.  I was dizzy off and on for the week that I was there but I
  thought this was due to the altitude (I live at sea level and SLC is 4500
  ft.)  When I returned home I was still dizzy.  Went to my cardiologist and
   my bp was 200/100.  He put me on diovan and sent me for a renal scan
  with flow (nuclear).  the results of the renal scan were R>L 55>45.
  that was a couple of weeks ago.  the diovan is keeping my bp around 110/70.
  the cario. wanted me to go to our local community hospital and have a
  renal angiogram and possible angioplasty.  This hasn't been done at
  this hospital before and I don't think I want to be the first.  My
  primary physician is sending me to another cardiologist at Temple
  University in Phila. for a second opinion.  I see him on the 22nd
  of this month.  This is where I get confused.  Why a second cardiologist?
  Should I be seeing a different kind of specialist?  Sorry I forgot
  to mention that I am 48 year old female.  My father had a heart attack
  at 54 and he had high blood pressure although he was an acute alcoholic
  so I assumed the bp was from the alcohol.  I don't drink (haven't in
  19 years), stopped smoking 3 years ago.  Smoked from 18 to 26, didn't
  smoke from 26 to 36, smoked from 36 to 45.  I take cardizem cd 300mg,
  lipitor 10mg, premarin 1.25 and one aspirin daily. And now diovan 80 mg.
  From what I have read 55>45 doesn't sound definitive for blockage but
  I was told that normally the left kidney has greater flow then the right.
  I am wondering IF my renal artery is partially blocked, could this have
  been the reason for the cardiac event in October?  Could it have been
  that my bp going so high caused damage to my heart? It was more then 2
  hours before I went to the hospital and my bp was high at the hospital
  for a while before they finally got it down.
  Thank you for your time
  diane

[CCF Cardio MD-SGM]

_
Dear Diane,
The severe hypertension you describe could be either "essential hypertension" which is due to a collection of ill-defined genetic and environmental influences that don't have a simple cause, or it could be "secondary hypertension" which is operative in about 2 percent of hypertension cases.  Renal artery stenosis is a common cause of secondary hypertension.  However, as you can see by the percentages, RAS is an infrequent cause of hypertension overall.   I don't believe the renal scan was conclusive, and think you should see a nephrologist (kidney specialist) to further evaluate the renal arteries, including the consideration of an angiogram of these vessels to confirm/exclude significant stenosis.  Other causes of secondary hypertension should also be considered, including excesses in catecholamines (pheochromocytoma), and other neuroendocrine causes.  
In any case, the BP you're reporting needs to be treated aggressively.  The cardizem is a good start, especially if you have any element of coronary artery spasm (also called Prinzemetal's angina).
It sounds as if you don't have atherosclerotic coronary disease, based on the results of the catheterization.  However, in the absence of atherosclerotic disease, it's a bit more difficult to explain the antero-apical problem that you mentioned.  Perhaps this was induced by coronary artery spasm.   There are two approaches to this problem:  The first is to empirically treat potential spasm with the calcium channel blocker (diltiazem/Cardizem) that you're receiving.  The second is to perform another heart cath and do a special test to look for spasm.  
It is most likely, however, that the chest pains are a response to the very elevated blood pressure.   As such you would do best to evaluate this BP issue thoroughly before seeing more cardiologists.  Experts in hypertension management can be found in any large/academic medical center.  These include nephrologists, internal medicine physicians, and endocrinologists.  We'd be happy to see you at our hypertension center at the Cleveland Clinic,  by calling 800 CCF CARE for an appointment.
Best of luck. Information in the Heart Forum is for general purposes only.  Specific diagnoses and therapies can only be provided by your physician.