Hypertension/Panic Disorder

[Shane__0]

Posted by Shane on July 17, 1999 at 12:28:56
First of All, thank you to all responsible for providing a service such as this one.  I understand not to rely on this information, but only to use it to direct me to the appropriate medical professional whom I can see in person within the context of a professional relationship.
I am 26 year-old caucasion male.  I have a history of early MI and sudden death among the males in my family (father's side).  I am currently finishing my 3rd year of law school at Baylor University.  I was diagnosed with mild to moderate bi-polar disorder when I was 18, treated very successfully with Lithium Bicarbonate (it is now a non-factor in my day-to-day affairs, and has been for the past 6-7 years).  In the fall of 1998, at age 25, I was diagnosed with a severe Panic/Anxiety disorder, which has, for the most part been vitiated via Celexa and/or Paxil, with Xanax on an as-need basis (I consume perhaps one to two Xanax per week).  Before acquiring treatment for the panic disorder I experienced the classic symptoms at a very acute level (i.e., constant fear of death; certainty of MI, feelings of isolation; fear to do ANYTHING, etc.).  For the past 2-3 years, I have been experiencing rather severe hypertension for a man in his early to mid-twenties.  I am currently on three different anti-hypertensive medications; Norvasc (10 mg.); Hyzaar (50-12.5); and Propranolol (80 mg.).  This regimen keeps my BP around 130/74 on the average, with a pulse rate of 70-75 (except for when I take exams or appear in a trial, at which point my BP becomes unmanageable--period).  Without this regimen, I average 170/100, with a pulse rate of 90-110.  During my first panic attack in October of 1998, I arrived at the ER (certain that I was dying of a heart attack) with a BP of 200/120 and a pulse of 165.  These extremes are now rare to non-existent. I am 5'6" and weigh about 170 (about 15 lbs overwehight).  I am very muscular (track star in high school, etc. . .), broad chested and shouldered, immaculately lean from the waist down, but carry a nice little gut.  My Father had his first heart attack at age 31, and has had three subsequently, as well as three bypass procedures.  His father had his first heart attack at age 35 and died of a massive one at age 42 (I never met him).  Grandpa's brother died of a first heart attack at age 29.  All were very overwheight and smokers.  I am slightly overwheight and do not smoke, but do use smokeless tobacco as the typical nicotine addict might (snuff).  I also drink; no more or less than your typical 3rd year law student.  Never hard liquor--I prefer Euroupean beer.  Recently, an Internal Medicine specialist suggested that I explore three avenues never before suggested by either my cardiologist or my psychiatrist; that being the following:  1)  Pheochromocytoma; 2) Renal Arterystenosis; 3) Hyperthyroidism.  What are your thoughts?  Can Pheochromocytoma by malignant?  If so, it sounds like a death sentence--but then, so does 170/110.  What can I do?  Certainly I have picked the wrong profession for a person with Panic and Hypertension!  However, if I were sitting in one of your offices, what would you tell me face to face (besides don't drink, lose the gut, and stop chewing snuff)?
Sorry for the length of this inquiry, and once agan, thank you for this generous service which you provide.
Kenneth S. Service,
J.D. Candidate,
Baylor University,
TX
07/17/99

Posted by CCF CARDIO MD JMF on July 19, 1999 at 08:01:44
Dear Kenneth,
Thank you for your very complete medical history.  I would consider a further work up of your hypertension.  While it is unusual to have pheo, your symptoms of paroxysmal increases in BP may suggest this diagnosis.  More common is hyperthyroidism and renal artery stenosis.  
these are in general easily ruled out.  Given your family history, I would manage aws many risk factors as possible and would suggest a full lipid panel, screening glucose and if you do smoke, please stop.
Further down the road i might consider a stress test to monitor both BP and ECG response to rule out significant CAD.
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