Variable blood pressure

[peaceisin]

I'm a 67 year old female...have had lifetime labile and episodic hypertension since my 20's...and by now terrible white coat hypertension.  I usually did not require meds when younger as I developed a very healthy lifestyle, vegetarian and ;lots of exercise, yoga, meditation etc. But now I can have 115/75 at home and see a BP cuff in a medical setting an hour later and get a 230/120 reading.  This is really interfering with my ability to have needed procedures like cataract surgery, to have a treadmill test, etc. I had a bout of extreme high BP and ended up on 5 meds about 5 years ago...but still raised the BP to 200 etc. when in the Dr's office. Finally had to not allow my BP to be taken...except at home and worked my way down to one med with medical supervision.  BP has been good generally...but am in a very stressful situation now and it's starting to spike.  But I now have an extremely conditoned response to BP readings at the Dr.'s office.  Would like to see about adding a med...but I understand now there is more information about which meds actually raise BP for people with my problem and which are more likely to help? So I need to decondition myself somehow and not add on a med that's will send things in the wrong direction.  I did have facial swelling with Hyzar and got a pericadial effusiton and a lupis type reaction with Procardia (the procardia was  about 15 years ago... eyes swelled almost shut also.) I feel like I need to find a way to tackle this issue...an approach to take...maybe I should go to a center for help?

[peaceisin]

Appreciate your post. Thanks for the link to the Pubmed article. I do believe that I primarily have sympathetic nervous system mediated BP issues. It sounds like you have remarkable white coat hypertension but not what I call my " blood pressure storms" with very elevated BP for prolonged periods? Then returns to normal ..may be even for years at a time. I do empathize with you in having to convince your physician that your pressure is indeed different on an on going basis at home. I finally have an internist who never takes my pressure.  She trusts me to monitor it. I've just come to using very low dose valium...like 1mg 3 times a day, then 0.5mg 3 x a day ( similar to what your article suggests).  But just use it to break up one of these spike cycles. I am a person who quite reliably can feel when my pressure is high. I use all the stress reducing and life style tools in my tool kit...so use the valium very short term since it can  have dependence issues. But it has no impact on the pressures I get if a doctor takes it.  And because I respond differently than expected to BP meds in general, there's the question of how to get certain kinds of medical procedures done and safely. In addtion the evidence coming out now seems to be supporting the findings that these variable BP problems lead to substantially higher stroke risk. So I ramble on. But do thank you for your reply. If it's of interest to you or would be helpful I have a couple article printed up that address these issues...don't have the links right now but would be glad to post for you.  One is a 2009 from the Journal of Clincal Hypertension: The Clinical Spectrum of Labile Hypertension: A Managemant Dilemma and  another helpful one 2011.  Both help validate things people with this issue have found out by trall and error. Explains why certain meds make BP worse, not better in these instances.  Anyway hope you are well and glad your Cardiologist can appreciate your situation. I had hoped that someone at the Clevland Clinic or elsewhere could addsome experience to this discusiion from the pyhsician's perspective.Thanks again.

[achillea]

I notice you haven't received an answer.  Perhaps the subject just isn't glamorous or dangerous enough to get attention, but for years I have had pressure fluctuations like yours--normal at home, high at the Dr's office when the nurse checked me, and REALLY high when the cardiologist--a likeable, easygoing guy--took them a while later (he always seems so disappointed).  Last year, I brought him three months of daily BPs I had taken at home, usually twice a day, morning and evening, to demonstrate that on the whole, I really was fairly normal outside his office.  He peered at this sheaf of papers and said that although people talked about 'white coat hypertension,' you rarely actually saw it.  I, he said, seemed to be a genuine case.

I have tried low doses of many different types of BP meds and had bad reactions to most of them, so that question is unanswered for me, as it is for you.

However, you might find this little paper interesting.  It is about labile hypertension in the elderly, with an unusual choice in medication, related to stress:

http://www.ncbi.nlm.nih.gov/pubmed/11417185?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_SingleItemSupl.Pubmed_Discovery_RA&linkpos=1&log$=relatedarticles&logdbfrom=pubmed

[achillea]

Good luck to you in  your search.  I wish you the best.

[peaceisin]

Good suggestion.  Thanks you so much for sharing your experience with hypnosis.  I actually haven't known anybody who has used it. I do use the self hypnoisis tapes produced by Steven Gurgevich but that isn't directed specifically for me and my issues. He'a well known medical hypnotist - teaches at the School of Integrative Medicine at U of Arizona Medical School and does  workshops,etc.  with Dr. Weil.....don't know if you know of Weil but he founded the school there and was the first to start training MD's in Integrative care...of which I am a  big advocate. During my last major BP storm I actually scheduled an appointment with Gurgevich in Arizona had my tickets, etc.  and a family emergency came up and I wasn't able to go. I hadn't thought of looking for someone here...kept thinking someday I'd get down there. Well now is good time to do this.  Maybe he'll recommend someone he knows here or I'll just go this time because I know he's good and has been around this block before with others I'm sure, and I would trust him. I could see a good Integrative care Dr. too for ideas from that direction. Finding a good Situational Anxiety Specialist is an excellent idea though for starters actually..  Good resources of this kind arent's as available here but Seattle probably has some. Appreciate your thoughfulness and concern and this gives me a very hopeful and realistic direction.  

[achillea]

Peace, this is going to sound nutty, but have you ever tried hypnosis?  For a nervous problem some years ago, my GP ( a very straight arrow guy) sent me to a hypnotherapist he respected for some work on autosuggestion when a particular situation came up.  Of course I was candid with the therapist about my skepticism that I was even hypnotiseable (is that a word?), but she told me that those who had the best success with it were intelligent (even skeptical) people who were good with words and imagery.

These sessions were really kind of remarkable, nothing like the cliché notion of being 'under' or in a trance.  It is a state of relaxed hyperawareness, hard to imagine or describe, in which you make yourself open to suggestion about your responses to certain cues.  I can tell you that after each session, I was incredibly relaxed and content for about six hours, so much so that even driving on a hectic California freeway didn't disturb me.  For years, I used a tape the therapist gave me to re-create the mood when the old problem came up (it eventually went away).

Frankly, your conditioned BP response is so severe that I don't think you have much to lose by seeing a specialist who deals with situational anxiety, with whom you might bring up the possibility of hypnosis.

[peaceisin]

Thanks for the reply. It does help to know others have similiar issues.  I have done that... no real effect at the docs' though.  The period when I was on 5 meds for BP my presssure still spiked up to the 200's when in a medical setting.  The response seems to have gotten so strongly conditioned.  I am determined to confront this somehow because it's too much of an impediment.  Not sure how yet...but working on my belief that I can and will ...sort of bringing myself back to that belief that this does not have to stay this way...but in a relaxed kind of way, not putting pressure on myself about it. It is great to work with a Dr. who understands your dilemma and will support you in that way!

[Carey01]

I can totally relate.  I have the same issue.  Cant go to the dentist, chiropractor -- nothing because my BP goes insane the second the BP cuff comes out.  I had to get a written permission slip from my Dr to get a root canal done because they were afraid Id have a stroke. Have you tried taking 1/2 a Xanax about 1/2 hr before your appointemnts?  If you a re like me you dont like to take medicine either but this does help!

[peaceisin]

Yeah...a long time ago I decided that exercise and diet and some kind of relaxation techique aren't optional for me.  It's just the way it is.  I really have to take this into my own hands. This is definitely  familial on my Dad's side.  My brother ended up with a major brain anerysm in his early 50's and is hemiplegic...similar to two Uncles and my Dad had similar BP stuff but died earlier from a different cause.  So It certainly motivating for me to do the best I can. And all of us errant BP folks are not made of one cloth.  So it is complicated for the Docs for sure.  I do get excited to see the beginnings of what someday may become very informed personalized and preventative medicine though.

You bring up some very pertinent points. I have had the adrenal checked various times.  Did do biofeedback formally in my very early 20's and it was effective in the lab...but did not generalize well for me.  I do meditate daily and do a self hypnosis tape for mind body healing.  Breathing techniques are very helpful to me..With the tranquilizing meds...can work either way for me..Must depend on the state of my bod...can have a pardoxical reaction and be made agitated. I did have to go to the ER several times during my last BP storm for hypertensive crisis...the best they ever did with the mix of stuff was to send me home when my BP hit like 100/170 or so. But is was reassuring to heaar that you made it thro catarct surgery well.  So we shall see. As my yoga teadh says.." we do things in our own lovely way"  gotta go..that's where im heading...to yoga.  have a good day.

[achillea]

Those are indeed informative articles.  Thank you for posting them.

When my doc tried me on calcium channel blockers, this type of drug was pretty ineffective at corralling the higher BPs, though I should have mentioned the absence with this one of the steep drops in pressure I got on the other meds, and which do seem to have been closely related to the fainting.  In retrospect, yeah, maybe the calcium channel blockers were associated with steadier--if not lower--pressures.

Several of my docs have agreed that there appears to be a seasonal oscillation to my pressures, but have only noted this as a curiosity.  I don't think I have ever seen a reference to anything like it in the literature anywhere, but to my amateur eyes there certainly does appear to be a temporal relationship.  My vitamin D levels have been checked, and I am dead normal.  Also, while I have not noted a change in my moods with the change of seasons, our son, as a teenager, was diagnosed with SAD, so one could postulate some kind of familial mis-wiring.  ;-)  

I certainly hope that you find a doctor or clinic who can help you stabilize your pressures, but things really don't look too hopeful right now, do they?  I cope to some extent by going to the gym and working my rear end off (I hope literally).

Just a couple more thoughts:  

1. I would assume you have been checked for the presence of the rare but real pheochromocytoma?  I have, several times, but nope, adrenals just fine.

2.  Have you noted, in surgical preparation or similar situations, that your BP goes normal once they feed a nice tranquilizer into you, even though you might have been totally freaked just a few minutes before?  I have actually heard the monitor telling me that things were normalizing while they were getting me ready for cataract surgery (which went very, very well, btw).

3.  Have you ever tried biofeedback?  One of my friends, who has subsequently been diagnosed with a lifelong anxiety disorder, told me that biofeedback training enabled her--to this day and in spite of a traumatic life--to lower her BP and heart rate at will.  Weird, but intriguing.

.

[peaceisin]

Shoot...just wrote you this long reaction to your post and as I went back for the links all my words of "wisdom" got lost.  so let me first just get you the links!
http://onlinelibrary.wiley.com/doi/10.1111/j.1751-7176.2009.00155.x/pdf
That is the Journal of Clinical Hypertension article
http://www.physorg.com/news187538292.html
Review of papers in The Lancet

As you can tell I'm not too technically astute...so if you have trouble opening let me know.  They are informative.. Bottom line in terms of current thinking is that Calcium Channel Blockers may be the drug of choice for variability...even tho in themselves not real strong at lowering BP numbers ...that may fit your situation actually since your pressures don't get too very high and other meds might have dropped it too low...thus the fainting?  Didn't notice that you had tried one. And I would add that taking an extended release anything has been helpful to me...with the variability it smooths out the meds delivery...not startling my reactive sysytem.  Other thing is the seasonal tendency you have...wonder if you are sensitive to the light changes, sort of like people with Seasonal Affective Disorder...or if it relates to your VIT D levels...have you had that measured? Well so much for my novice speculations.  I'm glad your long term pressures don't get into the scary zone...but are obviously of concern and you are trying to take good care of yourself if you only knew how to do it. I wish you the best with this. Glad to chat anytime.  Have had lots of experiences with my own stuff.  Now I focus on nutrition...particular foods that research is showing lower BP as well as overall diet which has been a long term approach for me.  We have lots to learn about that area too. Hope the info helps.

[achillea]

I think people like us are difficult for physicians, because boy, there are no quick and dirty answers.  But I *would* very much appreciate seeing the links you mention.

There are times when my BP runs higher outside the doctor's office--not dangerously high, but treatable high--for a number of months.  It was during such periods that, through my worried physician, I have been introduced to beta blockers, calcium channel blockers, ACE inhibitors, and AT2 receptor blockers.  I tended to faint on all of them, and I mean pass out in grocery stores while running errands.  Not a good thing.

Then invariably, after a couple of months, my pressures would be down again for prolonged periods, most noticeably during the summer (which lasts about six months where I live).  

It's a mystery.