Flat Blood Pressure on Treadmill Test

[ateyah]

I have been having uncontrolled hypotension (80/40-50) and tachycardia for over a month now with no explanation.  This comes with SOB, dizziness, nausea, and obviously some fatigue.  My face is white as a ghost as my coworkers comment.  My echo, ekg, basic labs (cbc) have been normal; however the treadmill stress test showed a flatline blood pressure.  My beginning bp was 110/70 - and it never changed.  It did go down to 100/70 during recovery.  I have not been able to find any information on flatline blood pressure and its significance.

My hypotension is worst in the morning - and improves with eating...but is constant throughout the day.  It does not matter if I am standing or sitting - but obviously is worse when I stand for a long period of time.

My cardiologist is sending me for a ACTH stress test or something.  

This has been a very stressful month as no medication combination has worked - we've tried a half dozen.  Beta blockers for tachycardia - 2 different ones.  Florinef and Midodrine for Bp - do not work well for bp at least at the doses we've tried in combo with the beta blocker.

Comments - suggestions for direction greatly appreciated.  My cardiologist admits he is lost and is sending me to a colleague for a second opinion on the 17th.

Thank you.

[CCF-M.D.-MJM]

Hello,

I am sorry to hear about your frustrations.  As a physician we see cases like this sometimes and we scratch our heads.

It is important to rule out things like adrenal insufficiency.  One problem is that hypotension and tachycardia can be symptoms caused by many organ systems -- this makes it tough to narrow down a diagnosis.  

Cases like this often take time and resources to figure out and often are made as diagnosis of exclusion rather than a single test proving you have a certain diagnosis.  There is an entity that will may read about called inappropriate sinus tachycardia (IST) and another called POTS (postural orthostatic tachycardia syndrome).  These are difficult diagnosis to make and difficult things to treat.  There is recent data to suggest that IST may be causes by auto antibodies to the beta receptor that stimulate incessant tachycardia.  It can follow a period of viral illness like symtpoms.  

I do not have enough information to diagnose you with these conditions but want to let you know that these are two conditions that can present as  you describe.

I hope this is helpful and wish you well.

[hbp702]

Get an endocrinologist to do a complete check of hormone levels.

[anacyde]

"There is recent data to suggest that IST may be causes by auto antibodies to the beta receptor that stimulate incessant tachycardia. It can follow a period of viral illness like symtpoms."

I'd love to read the research on this.  Since viruses and autoimmune processes are suspected in the development of PPCM (and other cardiac issues), I have a keen interest in how things like this come about.

[jan]

I have inappropriate sinus tachycardia and when I started treatment my bp improved.  Now it can be as low as my previous 90/60 and sometimes a high normal, but usually is something around 110/70.  I take atenolol and verapamil ER.

[ateyah]

I appreciate all the comments - very helpful and interesting.  It is looking as though I do have adrenal insufficiency of some sort as my ACTH stimulation test came back abnormal.  It was not conclusive, but still abnormal.  They want to do even more specific adrenal tests now.

Maybe one day I'll have an answer.  In the meantime they're keeping my bp up artificially as best as they can.