Labile and Paroxysmal Hypertension: Common Clinical Dilemmas in Need of Treatment Studies

Clarifying the Cause and Treatment of Paroxysmal Hypertension (Pseudopheochromocytoma)

PURPOSE OF REVIEW

To review the clinical characteristics of paroxysmal hypertension (pseudopheochromocytoma), its previously unsuspected cause, and effective treatment approaches.

RECENT FINDINGS

Patients with paroxysmal hypertension experience recurrent, sudden, unprovoked, symptomatic, and severe elevations of blood pressure that occur independently of current stress or perceived emotional distress. Recent findings point to a previously unsuspected psychosomatic etiology, linked in most to a past history of abuse, trauma, or prolonged severe stress, often with repression of pertinent emotions, or to a repressive coping style. Consistent with this understanding, treatment with an antidepressant is thus far the only pharmacologic intervention demonstrated to be effective in preventing recurrent paroxysms, and is effective in most patients. Other treatment approaches are discussed, including medications to acutely lower blood pressure during paroxysms, and, in some cases, the possibility of emotional healing.  Recent findings indicate that paroxysmal hypertension is a psychosomatic disorder frequently linked to a past history of trauma or prolonged severe stress, usually with longstanding repression of pertinent emotions. Data strongly encourage treatment with an antidepressant in patients with recurrent or severe paroxysms. Further studies are needed.

Late side effects of radiation treatment for head and neck cancer

Patients undergoing radiation therapy for head and neck cancer (HNC) experience significant early and long-term side effects. The likelihood and severity of complications depends on a number of factors, including the total dose of radiation delivered, over what time it was delivered and what parts of the head and neck received radiation. Late side effects include: permanent loss of saliva; osteoradionecrosis; radiation recall myositis, pharyngoesophageal stenosis; dental caries; oral cavity necrosis; fibrosis; impaired wound healing; skin changes and skin cancer; lymphedema; hypothyroidism, hyperparathyroidism, lightheadedness, dizziness and headaches; secondary cancer; and eye, ear, neurological and neck structures damage. Patients who undergo radiotherapy for nasopharyngeal carcinoma tend to suffer from chronic sinusitis. These side effects present difficult challenges to the patients and their caregivers and require life-long strategies to alleviate their deleterious effect on basic life functions and on the quality of life. This review presents these side effects and their management.

Pseudopheochromocytoma

Pseudopheochromocytoma manifests as severe, symptomatic paroxysmal hypertension without significant elevation in catecholamine and metanephrine levels and lack of evidence of tumor in the adrenal gland. The clinical manifestations are similar but not identical to those in excess circulating catecholamines. The underlying symptomatic mechanism includes augmented cardiovascular responsiveness to catecholamines alongside heightened sympathetic nervous stimulation. The psychological characteristics are probably attributed to the component of repressed emotions related to a past traumatic episode or repressive coping style. Successful management can be achieved by strong collaboration between a hypertension specialist and a psychiatrist or psychologist with expertise in cognitive-behavioral panic management.

Assessment of the Validity of the Psycho-Cardiological Comorbidity Index in the Practice of a Cardiologist

Background. The feasibility of creating a screening Index for the comorbidity of mental disorders and cardiovascular diseases in the practice of the cardiologist dictates the need to validate existing algorithms.

Aim. To validate the previously proposed Index of psychocardiac comorbidity in prediction of outpatient recommendation of psycho-pharmacotherapy for cardiology patients.

Materials and methods. Medical records of 302 consecutive patients of cardiac in-patient department were retrospectively analyzed with ROC-curve to estimate the predictive value of previously proposed Index of psychocardiac comorbidity for out-patient recommendation of psycho-pharmacotherapy.

Results. The prevalence of outpatient psycho-pharmacotherapy in the examined patients was 15.2 %; this group of patients was more polymorbid and was characterized by a higher proportion of women and a higher prevalence of a labile course of arterial hypertension. The sedative antipsychotics, non-benzodiazepine tranquilizers and mood stabilizers were predominant pharmacological groups. An analysis of reproducibility of Index of psychocardiac comorbidity was provided on a cohort of cardiology in-patient department (n = 302). Index calculated by using the formula I = C + 3(6)×Q + 3×W + 8×A (C – number of Comorbid diagnoses, Q – Quake in the chest, palpitations or arrhythmia, onset before 55 (3 points) or 50 (6 points) years; W – Women; A – labile Arterial hypertension). Area under ROC-curve in validation cohort was 0.828 ± 0.035 (p < 0.001). Positive predictive value of Index was maximal for the score of ≥ 13.

Conclusion. The proposed Index of psychocardiac comorbidity is a valid tool to predict the prescription of psychopharmacotherapy in cardiology patients.

Resistant Hypertension: Detection, Evaluation, and Management: A Scientific Statement From the American Heart Association

Resistant hypertension (RH) is defined as above-goal elevated blood pressure (BP) in a patient despite the concurrent use of 3 antihypertensive drug classes, commonly including a long-acting calcium channel blocker, a blocker of the renin-angiotensin system (angiotensin-converting enzyme inhibitor or angiotensin receptor blocker), and a diuretic. The antihypertensive drugs should be administered at maximum or maximally tolerated daily doses. RH also includes patients whose BP achieves target values on ≥4 antihypertensive medications. The diagnosis of RH requires assurance of antihypertensive medication adherence and exclusion of the "white-coat effect" (office BP above goal but out-of-office BP at or below target). The importance of RH is underscored by the associated risk of adverse outcomes compared with non-RH. This article is an updated American Heart Association scientific statement on the detection, evaluation, and management of RH. Once antihypertensive medication adherence is confirmed and out-of-office BP recordings exclude a white-coat effect, evaluation includes identification of contributing lifestyle issues, detection of drugs interfering with antihypertensive medication effectiveness, screening for secondary hypertension, and assessment of target organ damage. Management of RH includes maximization of lifestyle interventions, use of long-acting thiazide-like diuretics (chlorthalidone or indapamide), addition of a mineralocorticoid receptor antagonist (spironolactone or eplerenone), and, if BP remains elevated, stepwise addition of antihypertensive drugs with complementary mechanisms of action to lower BP. If BP remains uncontrolled, referral to a hypertension specialist is advised.