Diagnostic testing includes the following ones:

• Chest x-ray.

• Electrocardiogram.

• Echocardiogram.

• Check of the lungs function.

• Fatigue Test.

• Ventilation – perfusion scintigraphy.

• Computed tomography with a high definition.

• Magnetic tomography.

• Pulmonary angiography.

• Cardiac Catheterization.

At any time during this process, these tests could reveal some abnormalities that may indicate a diagnosis other than P.H. Depending on the test results, medical team may follow a different approach for future exploratory tests.

Chest x-ray
At a chest x-ray central arteries are enlarged with abrupt discontinuation, as a pollard. At a very high pulmonary pressure, pulses of the pulmonary artery may be tangible and a valve failure occurs causing early diastolic murmur pulmonary valve insufficiency.

Electrocardiography may show signs of “right ventricular hypertrophy” (thickening) or “right ventricular strain” (which means that the right side of the heart works harder than normal), common findings for P.H.

Echocardiography checks:
• Various structural abnormalities (for example, heart valves, to see if there is a leak from valves when closed and if blood flows smoothly in these).
• Some congenital heart defects, such as the “hole in the heart”.
• The mass of blood pumped by the heart with each heartbeat.
It is possible to estimate the blood pressure within the blood vessels. This test is very useful in P.H. The echocardiogram gives images moving and stationary, from which they can measure heart size and thickness of the heart muscle.

Control of pulmonary function
The pulmonary function tests include a series of tests that provide information about the amount of air a person’s lungs can fit and how effectively they work. Patients with P.H. often have normal air ducts (airway) and usually exhibit mild to no limitation but even clogging lungs. Comparing the results of patients with the results of healthy people of the same age and the same height, the doctor may conclude whether the patient’s airways are narrower or less efficient than normal.

Distress tests
There are several different types of fatigue tests that may be requested by the doctor. These tests can help detect if there is a reduced exercise tolerance (fatigue), and sometimes they provide information about the cause of the patient’s symptoms. In P.H. distress tests are often used as a measure of “exercise ability” of a person. From some patients, doctors ask to walk on an exercise treadmill wearing a special mask which takes measurements. This way doctors are able to quantify how efficiently the patient uses oxygen and how “hard” the heart and lungs work. The distress test can also help detect the presence and indicate the severity of coronary disease or other disorders of the heart.
The 6-minute walking test or accelerated walking up and down is not really specific diagnostic test. However, in combination with a complete history and physical examination, it can help to identify the exercise ability (fatigue) and the functional status of the individual.
In the distress test, such as “6 minute walk test”, the patient should just cover the greatest possible distance walking on a treadmill within 6 minutes. The “test accelerated walking up-down” is similar, but requires the patient to walk up and down a 10-meter course with increasing speed until gasping so much that he cannot continue anymore.
During these tests, it is often required for the patient to wear a monitoring device on the finger or on the earlobe to measure the amount of oxygen in their blood. At patients suffering from P.H., oxygen levels may fall below normal without even the gasping part.
These tests give doctors an insight into the severity of the disease and they can be a good way to measure how effective the pharmaceutical treatments are for each patient.

Ventilation- perfusion scintigraphy
The ventilation – perfusion scintigraphy is used most often to detect the presence of blood clots in the lungs (which, sometimes, doctors refer to as pulmonary plugs). Chronic blood clots in the lungs may be the cause of P.H. Although the presence of blood clots is not an established diagnose for P.H., it can play a big role in making decisions about future examinations and treatment. Overall, the results are interpreted as low, middle or high probability of pulmonary embolism (clots in the lungs). One of the most common type of P.H. occurs in people who have developed recurrent blood clots in their lungs during a long period.

High -resolution computed tomography
The radiologist looks for any abnormalities in the lung tissue. If used contrast, consider also any abnormal filling of the pulmonary vessels, which may also indicate the presence of blood clots within the lungs.

Magnetic tomography
Investigation of P.H. through magnetic tomography has the ability to display both heart and large blood vessels in the surrounding tissue. Thus, it is possible to detect cardiac abnormalities since birth (such as holes in the heart). With magnetic tomography it is possible to take pictures from more angles and specific details in comparison to a CT. Also, the difference between normal and abnormal tissue is often sharper in the magnetic than at the computed tomography.

Pulmonary angiography
Many patients are not subjected under pulmonary angiography, but this test may be used in adults when the results of ventilation – perfusion scintigraphy do not lead to any definitive conclusions. It is the best test for the diagnosis of possible blood clots, and therefore it is used to confirm or exclude the presence of blood clots in the lungs.
The patient is connected to an electrocardiograph while he lies on a bed (as in an x-ray) and a catheter is inserted into the body through a needle placed in the groin. While the operator monitors by a monitor device, the catheter is driven through the cavities of the heart and into the pulmonary artery. Then, the injected dye (contrast) gets into the arteries of the lung through the catheter and receives a series of film (X-ray). The dye allows the arteries to be better visible. With the help of this dye, the x-ray gives a pulmonary angiography extremely detailed radiographic images (known as ” angiograms”) of the pulmonary artery and the smaller sectors. The radiologist then examines angiograms to see if there are problems, for example if there are signs of blood clots or other pulmonary problems.
A small minority of patients who undergo the examination of pulmonary angiography is allergic to the liquid dye because of the iodine it contains. Anyone who has previously experienced such allergic reactions should report it to the doctor. Pregnant women need to request information about whether the examination with X-rays is a risk of harm to the baby. The risk of harm to a patient from the x-rays is very small, and modern radiographic equipment is designed to take high quality images using minimal radiation dose.

Cardiac catheterization
As in pulmonary angiography, here the patient lies on a bed while a catheter is inserted into the body through a needle placed in the groin. The cardiac catheterization study focuses on the right (abdomen) side of the heart. It provides important information about the pressure in the various cavities of the heart and the flow of blood through the heart and the pulmonary artery. To do this test it may be needed to be hospitalized for one day. It provides the ability to ensure an accurate measurement of blood pressure in the heart and pulmonary artery. Occasionally, it is required to catheterize the left heart in addition to the right heart (at the discretion of the doctor).

It should be noted that due to the nature of the non-standard symptoms, the majority of patients are diagnosed at an advanced stage (Functional Stage III or IV) and only 24 % of patients into the Functional Stage II. Currently, Doppler echocardiography is the most effective method for the diagnosis, but to ensure a definitive diagnosis it should be performed a right heart catheterization. Indeed, international guidelines recommend annual diagnostic testing of high risk groups with Doppler echocardiography.