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Labile Hypertension

Coat Hypertension White

Labile hypertension is roughly defined as a transient but significant increase in blood pressure, primarily as a result of anxiety and emotional distress, with sympathetic stimulation of adrenergic receptors being the most probable cause. Headaches, flushing, and palpitations may appear as blood pressure increases. At this moment, diagnostic and therapeutic guidelines do not exist and an individualized approach is necessary.


Presentation

Sudden elevation in the blood pressure may be asymptomatic, but individuals can report headaches, palpitations, and flushing that are provoked by an emotional distress [1]. These findings are important distinguishing criteria from paroxysmal hypertension, in which symptoms cannot be linked to a specific trigger [1].

Camping
Intravenous Administration
  • administration of 2L normal saline over four hours, and volume contraction with a 10 mEq Na diet and 120 mg oral furosemide.[ncbi.nlm.nih.gov]
Pelvic Mass
  • Magnetic resonance imaging (MRI) of the pelvis showed a pelvic mass that was surgically resected (histology-proven paraganglioma), with post-operative normalization of blood pressure and both urine and plasma metanephrines.[ndt.oxfordjournals.org]
Hypertension
  • So far, advanced age is defined as a significant risk factor for labile hypertension and the term labile hypertension in elderly (LHE) was proposed as a distinct clinical entity.[symptoma.com]
  • UNaV and FENa during the saline load was greater in labile hypertensives than in the other groups. While FENa was inversely related to PRA in both normals and fixed hypertensives, no such relationship was found in subjects with labile hypertension.[ncbi.nlm.nih.gov]
  • Abstract A labile hypertensive black man analyzes his own personal history of hypertension.[ncbi.nlm.nih.gov]
  • An increase in heart rate and a reduction in carotid pulse upstroke time (Ut) in labile hypertensives differentiated this group from chronic hypertensives and normal subjects.[ncbi.nlm.nih.gov]
  • Higher pressures were more labile than low ones, so that "fixed hypertensives" actually had more labile pressures than did so-called labile hypertensives. Lability, also increased with age.[ncbi.nlm.nih.gov]
Quickening
  • Their attenuated heart rate responses were sharply abnormal, demonstrating an excessively rapid rate throughout but without quickening on inspiration nor slowing with expiration.[ncbi.nlm.nih.gov]
Flushing
  • Sudden elevation in the blood pressure may be asymptomatic, but individuals can report headaches, palpitations, and flushing that are provoked by an emotional distress.[symptoma.com]
  • In these cases, beta-blockers are not used to lower blood pressure, but rather to reduce the symptoms associated with these conditions such as flushing, palpitations, or headaches. They’re often used in combination with anti-anxiety treatments.[healthline.com]
  • Since then, I have daily flushing of cheeks, nose, under chin, anorexia, feeling hot, heavy perspiring, periods of extreme thirst and frequent urination, slight nose bleeds.[doctorslounge.com]
  • Hypertensive episodes were accompanied by severe physical symptoms, such as headache, chest pain, dizziness, nausea, palpitations, flushing, and diaphoresis.[jamanetwork.com]
Dysautonomia
  • DESIGN/METHODS: Afferent baroreflex failure occurs in patients with the genetic disorder familial dysautonomia (FD, Riley-Day syndrome or hereditary sensory and autonomic neuropathy type 3) and in patients with acquired lesions of the afferent baroreflex[n.neurology.org]

Workup

Defined diagnostic criteria do not exist at this moment [5], but continuous monitoring of patients and their blood pressure is useful in assessing the onset and possible triggers of blood pressure elevations.

Treatment

Therapeutic guidelines are yet to be defined [1] [5]. For patients who do experience repeated bouts of increased BP prior to basic medical or surgical procedures, anxiolytic agents (lorazepam, alprazolam) and alpha or beta blockers (doxazosin, labetalol, clonidine) may be recommended as a short-term solution [1].

Prognosis

The effects of labile hypertension on the cardiovascular system are unclear [1], but studies have proposed that marked impairment in the quality of life may be present in the elderly [3]. More importantly, labile hypertension may be a significant challenge in patients who suffer from anxiety when visiting a doctor or prior to medical or surgical procedures, which necessitates prophylactic antihypertensive drug use [1].

Etiology

Anxiety and emotional distress are by far the most common cause of labile hypertension [1], but numerous conditions have been mentioned as potential causes [2]:

Epidemiology

The exact incidence rates of labile hypertension in the population are unknown, but it is estimated that more than 40 million adults have uncontrolled blood pressure in the United states and roughly 1% of those individuals will suffer a hypertensive crisis during their lifetime [6]. So far, advanced age is defined as a significant risk factor for labile hypertension and the term labile hypertension in elderly (LHE) was proposed as a distinct clinical entity [3] [4].

Sex distribution
Age distribution

Pathophysiology

Stimulation of adrenergic receptors by emotional stress and anxiety is thought to be the main pathophysiologic event [1]. Fluctuations in blood pressure occur during various physiological and pathological states, however, most common examples being physical activity, sleep deprivation, alcohol intake and numerous cardiovascular and endocrine diseases [1]. For this reason, a clear definition of the term remains to be solidified.

Prevention

Various strategies exist for preventing essential hypertension (avoidance of cigarette smoking and consumption of high amounts of alcohol, regular exercise, healthy dietary habits, etc), but how labile hypertension can be prevented is still unclear, having in mind the fact that both physiological and pathological events can induce this condition [1].

Summary

Labile hypertension is a term that describes sudden, transient blood pressure (BP) elevations, most likely in the setting of emotional distress and anxiety [1], but a myriad of diseases (hyperthyroidism, seizures, migraine attacks, alcohol withdrawal, etc.) may induce this clinical phenomenon as well [2]. Labile hypertension was initially described as a category between normotension and hypertension [1], but BP elevations may be induced by various factors, such as physical activity, intake of salt and alcohol, sleep deprivation and many other, which is why a clear definition of this term is yet to be made [1]. Age is considered to be the most significant risk factor and the term labile hypertension in elderly (LHE) was coined to emphasize its role in the quality of life and overall prognosis in this age group [3] [4]. The pathogenesis is thought to involve stimulation of adrenergic alpha and beta receptors by the sympathetic nervous system in stressful situations and this response may be followed by headaches, palpitations, and flushing, but it is not uncommon for labile hypertension to be asymptomatic [1]. Marked BP elevations frequently occur before medical procedures and physician visits, but the diagnosis may be difficult to attain, as there are no clear diagnostic criteria for the condition, nor do treatment guidelines exist at this moment [1] [5]. Repetitive and frequent BP measurement under carefully planned circumstances may be of use, however, but both diagnosis and management rely on the attending physician [1].

Patient Information

Labile hypertension is a term used to describe transient but a sudden increase in blood pressure, most frequently triggered by emotional stress and anxiety. A range of conditions is thought to induce blood pressure elevations as well, including hyperthyroidism, seizures, migraine headaches and several other, but also physiological conditions such as physical activity. For this reason, clear diagnostic criteria are yet to be defined and so far, the only known risk factor is advanced age. In fact, the term labile hypertension in elderly (LNE) is considered as a separate clinical entity. The clinical presentation may be asymptomatic, but headaches, palpitations, and flushing may be reported by patients immediately after some form of psychological distress. The diagnosis can be suspected through long-term blood pressure monitoring, but it may be difficult to obtain an objective result, as hypertension can occur when visiting a hospital (white coat hypertension) or even during measurement at home. For this reason, therapeutic guidelines do not exist and therapy is only indicated when patients are unable to go through a medical or surgical procedure. At this moments, anxiolytics and alpha or beta blockers are used in these patients. It is still unknown whether this form of hypertension is a risk factor for other cardiovascular diseases and the quality of life in general, but this clinical entity is known to be harmful in the elderly, which is why early recognition may be helpful.

References

Article

  1. Mann SJ. The clinical spectrum of labile hypertension: a management dilemma. J Clin Hypertens (Greenwich). 2009;11(9):491-497.
  2. Ma RCW, Yiu KH, Wong EHC, et al. A Man with Labile Blood Pressure. PLoS Med. 2007;4(4):e111.
  3. Nedostup AV, Fedorova VI, Dmitriev KV. Labile hypertension in elderly: clinical features, autonomic regulation of circulation, approaches to treatment. Klin Med (Mosk). 2000;78(7):27-32.
  4. Elliott MR, Soto Soto JM, Haley WE, Fitzpatrick PM, Dwyer JP. Labile hypertension: characteristics of a referred cohort. Clin Exp Hypertens. 2013;35(3):207-212.
  5. Mann SJ. Labile and Paroxysmal Hypertension: Common Clinical Dilemmas in Need of Treatment Studies. Curr Cardiol Rep. 2015;17(11):99.
  6. Varon J. Diagnosis and management of labile blood pressure during acute cerebrovascular accidents and other hypertensive crises. Am J Emerg Med. 2007;25(8):949-959.

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Last updated: 2019-07-11 21:16