The Man with the Up and Down Blood Pressure

(A case from 2014)

Gordon Grass had fallen three times. He said he was always lightheaded.

A slender chain smoker with nicotine-stained fingertips, he didn’t go to doctors much. He was on a blood pressure pill, though, started years ago by a colleague over in Danderville.

I looked at his vital sign display in my EMR. His blood pressure had never been high in the years that I had known him. In fact, sometimes it was on the low side. His typical systolic blood pressure was 130-134, but occasionally it was in the 100-110 range.

His exam was unremarkable when I saw him a couple of weeks ago. I listened carefully for bruits in his carotid arteries, did a standard neurological and ENT exam and even took out my tuning fork to check his Weber and Rinne; everything was normal.

Sitting on my stool opposite Gordon in the drafty, north facing Room 4, its old windows rattling as a powerful nor’easter pounded on the brick walls of the former hospital, I pulled the portable blood pressure cuff stand closer and tightened it on Gordon’s right arm. Sitting, his blood pressure was 136/68, and standing, it was 122/60.

“I think we should stop your blood pressure pill and see how you do”, I said. Gordon said he was happy to get rid of them, and we agreed to check his blood pressure and his symptoms in a couple of weeks.

I knocked on the door to Room 1 and entered the sun-drenched room across the hall from where I had seen him two weeks earlier.

“Feel that solar heat”, I said as he squinted in the warm, bright yellow room. “How are you doing?”

“Better, not as lightheaded.”

I looked at his vital signs. Autumn had entered his blood pressure when she checked him in: 112/62.

“Your blood pressure is lower than last time”, I mumbled, adding “I have read that the effect of hydrochlorothiazide can last for months after you stop it.”

Instinctively, and without speaking, I pulled the wall mounted sphygmomanometer down from the concrete wall between Gordon’s chair and the exam table on his left, tightened it around his arm and pumped up the cuff. Listening carefully as I released the pressure, I, too, recorded a lower blood pressure than last time: 116/60.

“I like the cuff we used last time better, but let me check your right arm also with this cuff”, I said and stretched the tubing across to his right arm. There, his blood pressure was 132/78.

“Hmm, let me check a few things again”, I said and ran my fingers along his neck, his collarbones and in his armpits. I put my stethoscope in my ears again and listened to his carotid arteries and his lungs.

Finally, I took both his wrists and found each radial pulse with my index fingers. I took a deep breath and relaxed. Then I sat quietly as my fingertips registered his pulse, bom-boom, first in his right wrist, and, a split second later, in his left.

“This is the first time I’ve diagnosed this condition in thirty five years”, I began.

I explained Subclavian Steal Syndrome to Gordon; how a blocked artery under his left collarbone causes blood to be shunted from the right carotid artery, across the brain, and downward through the left carotid and into his circulation-deprived left arm, stealing some of the blood that was supposed to fuel his brain.

“There are two ways you can get this condition”, I said. “One is similar to any blocked artery from smoking and all the other causes of poor circulation, and the other is something constricting the artery from the outside, like a cervical rib or a tumor of the lung”.

Gordon made a silent gesture to the pack of Pall Mall cigarettes in his breast pocket.

“Yes, them, either way”, I said. “Let me order some tests…”

A few days later, the Chief of Radiology called me: Subclavian Steal, no tumor.

Next week, Gordon meets with a cardiovascular surgeon to discuss a bypass of his blocked subclavian artery, because he is still symptomatic, even without his blood pressure pill.