Paroxysmal Hypertension: The Role of Stress and Psychological Factors

Abstract

who is studied for a pheochromocytoma with negative results. for every patient referred for a suspected pheochromocytoma, there are many more who have the symptoms but do not have a tumor. although all practicing hypertension specialists must see large numbers of patients with paroxysmal hypertension, the hypertension literature is largely silent on the issue, except for discussion of pheochromocytoma. it is likely that stress and emotion play a major role in many of these cases, but physicians who treat hypertension are often unfamiliar with the underlying problems and are poorly equipped to deal with them. there is a variety of diagnostic labels given to these patients, which include pseudopheochromocytoma, panic attacks, and hyperventilation syndrome. the purpose of this paper is to review the clinical features, pathology, diagnosis, and treatment of these syndromes.an example of a patient who fulfilled these criteria and who was recently seen in our practice is described below. CASE REPORTthe patient was an 85-year-old white woman referred for evaluation of paroxysmal hypertension. she had a history of mild hypertension and hyperlipidemia of many years, which had until recently been controlled with a thiazide diuretic and a statin. she was well until January 2007, when she was found to have hyponatremia on a blood test. she was hospitalized, and the diuretic was discontinued and replaced with a calcium channel blocker. at this time, she began to have episodes of paroxysmal hypertension, which she described as starting with epigastric pain, flushing in her face, weakness, light-headedness, and a feeling of warmth and anxiety. her blood pressure was typically high during these episodes and could R e v i e w P a p e r

Carotid baroreflex activation therapy for resistant hypertension

“…Given that paroxysms are accompanied by signs of severe sympathetic excitationsuch as dramatic hypertensive surges, tachycardia, diaphoresis, and panic-patients often undergo multiple negative evaluations for pheochromocytoma and are left incapacitated by their unexplained hypertensive disorder for which there is no viable treatment. [116][117][118] Baroreflex activation therapy would, therefore, be life changing if it could be activated as needed-ideally by BP-sensing circuitry-to abort attacks.…”

Effect of sertraline in paroxysmal hypertension

“…These findings may explain why SSRI are very effective in managing panic disorder. Given very similar clinical symptoms of panic disorder and pseu-dopheochromocytoma 11 , it is possible that increased brain serotonin turnover also plays an important role in the pathogenesis of pseudopheochromocytoma, and this may explain very good therapeutic effect of SSRI in our patients.…”

“…Although paroxysmal hypertension, in contrast to panic disorder, is not anteceded or triggered by fear or panic 7 , these two units are sometimes difficult to distinguish in clinical practice 10 . The clinical picture of panic disorder to certain extent overlaps with pseudopheochromocytoma and both may well represent different manifestations of the same disorder entity 11 .…”

“…There is no existing exact definition of paroxysmal hypertension 11 , which made the selection of patients for the study difficult. Our patients presented usually with severe elevations of blood pressure during paroxysms, which was on average by 40 mmHg higher (or, relatively, by 30% higher) than their office BP.…”

Pseudopheochromocytoma: An uncommon cause of malignant hypertension

“…[1213] Anxiety and psychological instability may play a key role in onset of severe hypertension in patients at risk. [1214] Even if our patient denied any uncommon anxiety or distress, one can suspect a link between hypertension and his emotional state. His first episode of paroxysmal hypertension eight months before diagnosis occurred after a crucial business travel and the last one was concomitant with more stress at job because of unpredictable international financial situation.…”