Hypertension?

[is_something_wrong]

Hello,

I believe I suffer from white coat hypertension.

Earlier (until a year ago), when I didn't care about my blood pressure, I always had excellent results when my doctor measured it (115-120/60-70).

After I started worrying about my heart (not so much anymore, I usually try my best to help people on the heart rhythm community) my BP readings are higher. I feel my muscles get tense and my heart starts pounding when the cuff inflates, and blood pressure is 140-155/80-95.

At home, I get similar symptoms on the first measuring, but it resolves and gradually slows to 120/70 after some tries. I measured it one weekend after a good night of sleep and it was 105/55. I was completely relaxed, for once, at that time.

What is quite strange, is that I imagine this started when I started using propranolol (20 mg) for PACs and sinus tachycardia. After this, my heart didn't race when I got scared, but beat harder instead. When I was really scared, I actually had bradycardia, but I got a strange sensation that my blood vessels were constricted (may be imagination..)

I got my beta blocker changed to metoprolol (25 mg) and I feel my anxiety getting a bit stronger. But now my heart races a bit more in response to anxiety.

Can propranolol actually contribute to higher blood pressure with stress?
Are my assumptions correct that propranolol works better on anxiety due to the non-selective effect?
Is my BP really normal?

My heart is otherwise fine with normal chambers, wall dimensions and excellent contractility (EF 78%). I have some PACs but I'm otherwise healthy, exercise 3 times/week and normal weight.

Thanks in advance!

[is_something_wrong]

Thanks a lot. I think that was the last piece in the puzzle to accept that my blood pressure is fine and that my heart is healthy!

By the way, that's the first time I see a cardiologist using smileys! Most of them in my country are grumpy old men! Awesome, thanks again :)

[CCF HeartMD-1]

Hey there,

These readings looks great! I would not treat you with those readings :)  Amazing what stress can do though, but how exercise can definitely improve hypertension!!

Good job!

[is_something_wrong]

Hello.

I was considering making a new post, but I hope for a quick reply to this:

I measured my BP two days ago, with results as follows:

Supine: 108/60 mmHg - HR 57
Sitting: 106/65 mmHg - HR 62
Standing: 104/75 mmHg - HR 73

This is probably because 1) I'm not so scared of BP measuring anymore, and 2) my exercise condition has improved. I can tolerate exercise up to 14-15 METs. And my dads aortic surgery was successful.

Will this, in combination with your last post, change your opinion concerning medical treatment?

[is_something_wrong]

Thanks for a detailed follow up answer.

I will discuss it with my primary care physician when I make an appointment later this year, but as my cardiologist told me to forget my blood pressure, and my primary care physician gave me a strict order to sell my blood pressure monitor, I really do not expect to get this treated, but I can bring your answer.

I have consulted 4 cardiologists + one specialist in internal medicine the last year and a half, with completely normal test results. Stress test revealed normal chronotopic response to exercise and normal blood pressure increase (120/80 to 210/90) with max heart rate 210 (sinus tachycardia). At that time, I was somewhat unfit due to health anxiety and immobilization. Holter revealed rare atrial ectopics and that was about it. Echo results (2 weeks ago) from a cardiologist assumed to be one of the best in our country:

LVPWd 10 mm
LVISd 10 mm
LVIDd 51 mm
LVIDs 31 mm
Fraction shortening: 40%
LVEF: 78%
RV function: Normal
LA dimensions and function: Normal
RA dimensions and function: Normal
Slim, well functioning valves with no sign of dysfunction and regurgitation
Aortic outflow velocity: 1,2 m/s
PA pressure: Normal

Impression: Normal echo study. Structurally normal heart with excellent function / contractility.

The cardiologist told me: This had to be the best heart he had seen in a while.

My resting EKG is normal too, with normal PR, QRS and QTc durations (145, 98 and 370 msec, respectively). Normal st-t segment, and normal r-wave progression. and  My total cholesterol levels are about 4,5 mmol/l with HDL 1,3 mmol/l. I eat healthy (salads, oats, fish, chicken) I'm not smoking and I'm rarely drinking alcohol, never more than 1-2 times a month. I take 2-3 g of Omega-3 daily. I've never ever used illegal drugs and I never will. I try to avoid sugar and I don't drink coffee. My BMI is within normal limits. I have a girlfriend who I love, and I live a basically normal life with a good, but occationally stressful job. I'm soon turning 30 years old (where have the days gone..)

I exercise 3 times a week (20 minutes jogging on threadmill with heart rate 160 (with one increase to 180 to push my oxygen uptake), 20 minutes walking at 5,5 km/h with 10 degrees incline (8-9 METs), also at heart rate 160-170, 30 minutes of weightlifting), and the days I don't exercise I make sure I'm taking a 4-5 km walk at about 6-7 km/h to get rid of today's stress at work.

I just try to accept that my heart is healthy. I guess the fact that my father (who I really care about) just got diagnosed with AAA (due to hypertension and smoking) has affected my stress levels. I'll see my therapist in a week and try to solve this mental issue.

Thanks again, dear cardiologist. I will bring your recommendations to my PCP next time I see him. Maybe he will reconsider his statements.

[CCF HeartMD-1]

The guidelines here in the US for blood pressure are < 140/90 or if you have diabetes or chronic kidney disease < 130/80.  I go with the literature suggesting white coat hypertension can lead to true hypertension and I think if it is a person who consistently struggles with anxiety, stress, panic attacks, I would treat them.  People have heart attacks during stress (as Cardiologists we have all seen it, classic case of a man or woman coming in with a full blown heart attach after having a huge argument with someone).  I am only telling you this because the physiology of stress and anxiety is much different than exercise and rather than dilating your vessels during exercise, you actually constrict or narrow your arteries/vessels with stress/anxiety.  

Propanlol and metoprolol are not great for blood pressure management.  They are excellent for heart rate control and with a resting heart rate of 50, you do not need any more beta-blockade! Guidelines would suggest hydrochlorothiazide (low dose) as a 1st line agent for blood pressure or if you have diabetes or chronic kidney disease, Lisinopril (low-dose) for blood pressure management.

[is_something_wrong]

Thank you for your reply.

It is quite amazing what differences there are between US and Norwegian healthcare guidelines for hypertension. I have been told that it is the average blood pressure <135 / 85 that matters, and it is common and benign that a doctor sees blood pressure up to 200 systolic in the setting of stress and anxiety. White coat hypertension is not treated here, though I have read some studies that prove some correlation between WCH and further development of "true" hypertension.

The paradox is in my opinion, if we all get a high systolic blood pressure during exercise (which I assume is a sign of a well functioning heart muscle, my systolic BP x heart rate at peak exercise is almost 40.000 mmhg/min, approx. 200 x 200) would it not be expected a similar effect in the setting of anxiety or panic attacks?

I am already treated with a low dose metoprolol (25 mg) which I assume would lower the blood pressure to some degree. And when I am really stressed I add 5-10 mg or propranolol. My cardiologist gave me both, and he did not care which one of them I used, as long as I did not take more than 100 mg of metoprolol or 160 mg of propranolol. But I tend to get bradycardia if I take more than 25 + 10 mg and it triggers more PACs so I try to be careful. My resting heart rate is 50.

Anyway, thank you for your reply, I do not expect an answer to this follow up from a MD, I just wanted to share some thoughts. Everyone is free to reply if they would like.

[CCF HeartMD-1]

Propranolol does not contribute to higher blood pressure with stress.  In fact, we use propanolol sometimes for patients with anxiety who also have palpitations.  So, yes, you are correct that propanolol works better for anxiety due to the nonselective effect.  In terms of your white coat hypertension, we do know that having white coat hypertension is not something to ignore and I actually recommend treating people even with white coat hypertension because getting blood pressures in the 150's at any time are not good.  If they were < 140/90 consistently that would be ok but if they are higher than that even in the setting of white coat I would treat you with a low-dose anti-hypertensive.  

Hope this helps.