Erratic BP may be emotional reaction

Dear Dr. Roach: I’m an 85-year-old woman. For the past four years, I have been having erratic blood pressure readings. Sometimes my blood pressure is 80/50, other times 200/90 or higher. I am treated with nadolol as needed. My cardiologist said he cannot help me. When my blood pressure is low, I have blurry eyesight and trouble walking. They tell me to eat salt when my blood pressure is low.

Anon.

Answer: Blood pressure that fluctuates that greatly over a short period of time is unusual and has a short list of potential causes.

One is a tumor that produces the substance epinephrine, also called adrenaline, or similar molecules that raise the blood pressure. This is called a pheochromocytoma and is quite rare. Rarely, other substances that raise blood pressure can be produced by the body, as in carcinoid syndrome.

Blockages in the arteries to the kidneys can cause blood pressure to go way up and way down. Some drugs can do it. We see it occasionally in a person who has had a stroke. But by far the most common reason is emotional. Often the person is not aware of any emotional distress at the time of the event. Physical symptoms, like the blurry vision and walking difficulty you mention, are universal. Common symptoms include headache, chest pain and dizziness. The blood pressure is normal apart from the symptoms, unless the patient has been put on blood pressure medication.

This condition, paroxysmal hypertension, is much more common than a pheochromocytoma, but many doctors aren’t aware of it. A very thorough evaluation is necessary before making this diagnosis, but with a correct diagnosis, treatment is generally effective.

For an acute attack, treatment may be with a short-acting blood pressure medicine, such as labetalol. Given intravenously, it starts working within a few minutes, as opposed to the nadolol you were given, which starts working three to four hours after an oral dose. Also, an anti-anxiety medicine, such as alprazolam, may be helpful. This is effective even if a person does not feel anxiety.