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

  • Hypertension (WB White and AJ Peixoto, Section Editors)
  • Published:
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Abstract

Although “labile hypertension” is regularly encountered by clinicians, there is a paucity of information available to guide therapeutic decisions. This review discusses its clinical relevance, the limitations of current knowledge, and possible directions for future research and clinical management. Results of studies that assessed measures of blood pressure variability or reactivity are reviewed. The limited information about effects of antihypertensive drugs on blood pressure variability is discussed. Two different clinical presentations are differentiated: labile hypertension and paroxysmal hypertension. Labile hypertension remains a clinical impression without defined criteria or treatment guidance. Paroxysmal hypertension, also called pseudopheochromocytoma, presents as dramatic episodes of abrupt and severe blood pressure elevation. The disorder can be disabling. Although it regularly raises suspicion of a pheochromocytoma, such a tumor is found in <2 % of patients. The cause, which involves both emotional factors and the sympathetic nervous system, and treatment approaches, are presented.

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References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Mann SJ. The clinical spectrum of labile hypertension: a management dilemma. J Clin Hypertens. 2009;11(9):491–7.

    Article  Google Scholar 

  2. Muntner P, Shimbo D, Tonelli M, Reynolds K, Arnett DK, Oparil S. The relationship between visit-to-visit variability in systolic blood pressure and all-cause mortality in the general population: findings from NHANES III, 1988 to 1994. Hypertension. 2011;57(2):160–6.

    Article  CAS  PubMed  Google Scholar 

  3. de la Sierra A, Redon J, Banegas JR, Segura J, Parati G, Gorostidi M, et al. Prevalence and factors associated with circadian blood pressure patterns in hypertensive patients. Hypertension. 2009;53(3):466–72.

    Article  PubMed  Google Scholar 

  4. Mancia G, Ferrari A, Gregorini L, Parati G, Pomidossi G, Bertinieri G, et al. Blood pressure and heart rate variabilities in normotensive and hypertensive human beings. Circ Res. 1983;53(1):96–104.

    Article  CAS  PubMed  Google Scholar 

  5. Mancia G. Blood pressure variability at normal and high blood pressure. Chest. 1983;83(2 Suppl):317–20.

    Article  CAS  PubMed  Google Scholar 

  6. Kikuya M, Hozawa A, Ohokubo T, et al. Prognostic significance of blood pressure and heart rate variabilities: the Ohasama study. Hypertension. 2000;36(5):901–6.

    Article  CAS  PubMed  Google Scholar 

  7. Conway J, Boon N, Vann Jones J, Sleight P. Mechanisms concerned with blood pressure variability throughout the day. Clin Exp Hypertens A. 1985;7(2–3):153–7.

    CAS  PubMed  Google Scholar 

  8. Pringle E, Phillips C, Thijs L, Davidson C, Staessen JA, de Leeuw PW, et al. Systolic blood pressure variability as a risk factor for stroke and cardiovascular mortality in the elderly hypertensive population. J Hypertens. 2003;21(12):2251–7.

    Article  CAS  PubMed  Google Scholar 

  9. Khattar RS, Swales JD, Banfield A, Dore C, Senior R, Lahiri A. Prediction of coronary and cerebrovascular morbidity and mortality by direct continuous ambulatory blood pressure monitoring in essential hypertension. Circulation. 1999;100(10):1071–6.

    Article  CAS  PubMed  Google Scholar 

  10. Madden JM, O’Flynn AM, Dolan E, Fitzgerald AP, Kearney PM. Short-term blood pressure variability over 24 h and target organ damage in middle-aged men and women. J Hum Hypertens. 2015.

  11. Rothwell PM, Howard SC, Dolan E, O’Brien E, Dobson JE, Dahlöf B, et al. Prognostic significance of visit-to-visit variability, maximum systolic blood pressure, and episodic hypertension. Lancet. 2010;375(9718):895–905. This is the most widely cited study supporting the relationship between visit-to-visit blood pressure variability and cardiovascular prognosis.

    Article  PubMed  Google Scholar 

  12. Mancia G, Facchetti R, Parati G, Zanchetti A. Visit-to-visit blood pressure variability, carotid atherosclerosis, and cardiovascular events in the European Lacidipine Study on Atherosclerosis. Circulation. 2012;126(5):569–78. This widely cited study concluded that there was no relationship between visit-to-visit blood pressure variability and cardiovascular prognosis.

    Article  PubMed  Google Scholar 

  13. Parati G, Ochoa JE, Lombardi C, Bilo G. Blood pressure variability: assessment, predictive value, and potential as a therapeutic target. Curr Hypertens Rep. 2015;17(4):537. This recent review summarizes findings as to whether visit-to-visit blood pressure variability predicts cardiovascular outcome.

    Article  PubMed  Google Scholar 

  14. Kario K, Pickering TG, Umeda Y, Hoshide S, Hoshide Y, Morinari M, et al. Morning surge in blood pressure as a predictor of silent and clinical cerebrovascular disease in elderly hypertensives: a prospective study. Circulation. 2003;107(10):1401–6.

    Article  PubMed  Google Scholar 

  15. Kario K. Prognosis in relation to blood pressure variability: pro side of the argument. Hypertension. 2015;65(6):1163–9.

    Article  CAS  PubMed  Google Scholar 

  16. Asayama K, Wei F-F, Hara A, Hansen TW, Li Y, Staessen JA. Prognosis in relation to blood pressure variability: con side of the argument. Hypertension. 2015;65(6):1170–9. This recent review examines the relationship between different measures of blood pressure variability and cardiovascular prognosis.

    Article  CAS  PubMed  Google Scholar 

  17. Levy J, Mann SJ, Gerber LM. Non-adherence to recommendations for blood pressure measurement technique in the physician’s office and at home. J Am Soc Hypertens. 2014; e57.

  18. McKay DW, Campbell NR, Parab LS, Chockalingam A, Fodor JG. Clinical assessment of blood pressure. J Hum Hypertens. 1990;4(6):639–45.

    CAS  PubMed  Google Scholar 

  19. Leary AC, Donnan PT, MacDonald TM, Murphy MB. The influence of physical activity on the variability of ambulatory blood pressure. Am J Hypertens. 2000;13(10):1067–73.

    Article  CAS  PubMed  Google Scholar 

  20. Grassi G. Evaluating sympathetic and haemodynamic responses to mental stressors: hankering or achievement? J Hypertens. 1996;14(10):1155–7.

    Article  CAS  PubMed  Google Scholar 

  21. Parati G, Pomidossi G, Casadei R, Ravogli A, Groppelli A, Cesana B, et al. Comparison of the cardiovascular effects of different laboratory stressors and their relationship with blood pressure variability. J Hypertens. 1988;6:481–8.

    Article  CAS  PubMed  Google Scholar 

  22. Krantz DS, Manuck SB. Acute psychophysiologic reactivity and risk of cardiovascular disease: a review and methodologic critique. Psychol Bull. 1984;96:435–64.

    Article  CAS  PubMed  Google Scholar 

  23. Light KC. Cardiovascular responses to effortful active coping: implications for the role of stress in hypertension development. Psychophysiology. 1981;18:216–25.

    Article  CAS  PubMed  Google Scholar 

  24. Fauvel JP, M’Pio I, Quelin P, Rigaud JP, Laville M, Ducher M. Neither perceived job stress nor individual cardiovascular reactivity predict high blood pressure. Hypertension. 2003;42:1112–6.

    Article  CAS  PubMed  Google Scholar 

  25. Mann SJ. The mind/body link in essential hypertension: time for a new paradigm. Altern Ther Health Med. 2000;6(2):39–45.

    CAS  PubMed  Google Scholar 

  26. Jorgensen RS, Johnson BT, Kolodziej ME, Schreer GE. Elevated blood pressure and personality: a meta-analytic review. Psychol Bull. 1996;120:293–320.

    Article  CAS  PubMed  Google Scholar 

  27. Weder AB, Julius S. Behavior, blood pressure variability, and hypertension. Psychosom Med. 1985;47(5):406–14.

    Article  CAS  PubMed  Google Scholar 

  28. Mann SJ, Pickering TG, Alderman MH, Laragh JH. Assessment of the effects of alpha- and beta-blockade in hypertensive patients who smoke cigarettes. Am J Med. 1989;86(1B):79–81.

    Article  CAS  PubMed  Google Scholar 

  29. Andrén L, Hansson L. Circulatory effects of stress in essential hypertension. Acta Med Scand Suppl. 1981;646:69–72.

    PubMed  Google Scholar 

  30. Munakata M, Hiraizumi T, Tomiie T, Saito Y, Ichii S, Nunokawa T, et al. Psychobehavioral factors involved in the isolated office hypertension: comparison with stress-induced hypertension. J Hypertens. 1998;16(4):419–22.

    Article  CAS  PubMed  Google Scholar 

  31. Verdecchia P, Angeli F, Gattobigio R, Borgioni C, Castellani C, Sardone M, et al. The clinical significance of white-coat and masked hypertension. Blood Press Monit. 2007;12(6):387–9.

    Article  PubMed  Google Scholar 

  32. Verdecchia P, Reboldi GP, Angeli F, Schillaci G, Schwartz JE, Pickering TG, et al. Short- and long-term incidence of stroke in white-coat hypertension. Hypertension. 2005;45(2):203–8.

    Article  CAS  PubMed  Google Scholar 

  33. Palatini P, Mormino P, Santonastaso M, Mos L, Dal Follo M, Zanata G, et al. Target-organ damage in stage I hypertensive subjects with white coat and sustained hypertension: results from the HARVEST study. Hypertension. 1998;31(1):57–63.

    Article  CAS  PubMed  Google Scholar 

  34. Ugajin TMS, Hozawa AMDP, Ohkubo TMDP, Asayama KMD, Kikuya MMDP, Obara TMS, et al. White-coat hypertension as a risk factor for the development of home hypertension: the Ohasama study. Arch Intern Med. 2005;165(13):1541–6.

    Article  PubMed  Google Scholar 

  35. Webb AJS, Fischer U, Mehta Z, Rothwell PM. Effects of antihypertensive-drug class on interindividual variation in blood pressure and risk of stroke: a systematic review and meta-analysis. Lancet. 2010;375(9718):906–15.

    Article  CAS  PubMed  Google Scholar 

  36. Rothwell PM, Howard SC, Dolan E, O’Brien E, Dobson JE, Dahlöf B, et al. Effects of beta blockers and calcium-channel blockers on within-individual variability in blood pressure and risk of stroke. Lancet Neurol. 2010;9(5):469–80.

    Article  CAS  PubMed  Google Scholar 

  37. Mancia G, Facchetti R, Parati G, Zanchetti A. Visit-to-visit blood pressure variability in the European Lacidipine Study on Atherosclerosis: methodological aspects and effects of antihypertensive treatment. J Hypertens. 2012;30(6):1241–51. This study offers evidence opposing the findings of Asayama, and concludes that visit-to-visit blood pressure variability is not related to cardiovascular outcome.

    Article  CAS  PubMed  Google Scholar 

  38. Mills PJ, Dimsdale JE. Cardiovascular reactivity to psychosocial stressors. A review of the effects of beta-blockade. Psychosomatics. 1991;32(2):209–20.

    Article  CAS  PubMed  Google Scholar 

  39. Maconochie JG, Richards DA, Woodings EP. Modification of pressor responses induced by ‘cold’ [proceedings]. Br J Clin Pharmacol. 1977;4(3):389.

    Article  Google Scholar 

  40. Dimsdale JE, Mills P, Ziegler M, Leitz K, Nelesen R. Converting enzyme inhibition and blood pressure reactivity to psychological stressors. Hypertension. 1992;20(2):210–3.

    Article  CAS  PubMed  Google Scholar 

  41. Shapiro AP. Pressor responses to noxious stimuli in hypertensive patients. Effects of reserpine and chlorothiazide. Circulation. 1962;26:242–50.

    Article  CAS  PubMed  Google Scholar 

  42. Niarchos AP, Pickering TG, Morganti A, Laragh JH. Plasma catecholamines and cardiovascular responses during converting enzyme inhibition in normotensive and hypertensive man. Clin Exp Hypertens A. 1982;4(4–5):761–89.

    CAS  PubMed  Google Scholar 

  43. Ulrych M. Changes of general haemodynamics during stressful mental arithmetic and non-stressing quiet conversation and modification of the latter by beta-adrenergic blockade. Clin Sci. 1969;36(3):453–61.

    CAS  PubMed  Google Scholar 

  44. Andrén L, Hansson L, Eggertsen R, Hedner T, Karlberg BE. Circulatory effects of noise. Acta Med Scand. 1983;213(1):31–5.

    Article  PubMed  Google Scholar 

  45. Julius S. The blood pressure seeking properties of the central nervous system. J Hypertens. 1988;6(3):177–85.

    Article  CAS  PubMed  Google Scholar 

  46. Pandhi P, Sharma PL, Sharma BK, Wahi PL. Comparative effect of propranolol and labetalol on isometric exercise and cold stress induced increase in arterial blood pressure. Int J Clin Pharmacol Ther Toxicol. 1986;24:249–53.

    CAS  PubMed  Google Scholar 

  47. Anand MP, Dattani KK, Datey KK. Effect of isometric exercise and mental stress on blood pressure--comparative effects of propranolol and labetalol. Indian Heart J 36(1):4–7

  48. Morgan T. Clinical pharmacokinetics and pharmacodynamics of carvedilol. Clin Pharmacokinet. 1994;26:335–46.

    Article  CAS  PubMed  Google Scholar 

  49. Richards DA, Prichard BN. Clinical pharmacology of labetalol. Br J Clin Pharmacol. 1979;8 Suppl 2:89S–93S.

    PubMed Central  CAS  PubMed  Google Scholar 

  50. Prichard BN, Richards DA. Comparison of labetalol with other anti-hypertensive drugs. Br J Clin Pharmacol. 1982;13 Suppl 1:41S–7S.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  51. Mann SJ, Gerber LM. Low-dose alpha/beta blockade in the treatment of essential hypertension. Am J Hypertens. 2001;14(6 Pt 1):553–8.

    Article  CAS  PubMed  Google Scholar 

  52. Frishman W. Clinical pharmacology of the new beta-adrenergic blocking drugs. Part 1. Pharmacodynamic and pharmacokinetic properties. Am Heart J. 1979;97:663–70.

    Article  CAS  PubMed  Google Scholar 

  53. Van Peer A, Snoek E, Woestenborghs V, Van de Velde V, Mannerns G, Meuldermans W, et al. Clinical pharmacokinetics of nebivolol. A review. Drug Investig. 1991;3 Suppl 1:25–30.

    Article  Google Scholar 

  54. Mann SJ. Severe paroxysmal hypertension (pseudopheochromocytoma)—understanding the cause and treatment. Arch Intern Med. 1999;159(7):670–4.

    Article  CAS  PubMed  Google Scholar 

  55. Mann SJ. Severe paroxysmal hypertension: an autonomic syndrome and its relationship to repressed emotions. Psychosomatics. 1996;37:444–50.

    Article  CAS  PubMed  Google Scholar 

  56. Pacak K, Linehan WM, Eisenhofer G, Walther MM, Goldstein DS. Recent advances in genetics, diagnosis, localization, and treatment of pheochromocytoma. Ann Intern Med. 2001;134(4):315–29.

    Article  CAS  PubMed  Google Scholar 

  57. Sharabi Y, Goldstein DS, Bentho O, Saleem A, Pechnik S, Geraci MF, et al. Sympathoadrenal function in patients with paroxysmal hypertension: pseudopheochromocytoma. J Hypertens. 2007;25(11):2286–95.

    Article  CAS  PubMed  Google Scholar 

  58. Mann SJ. Severe paroxysmal hypertension (pseudopheochromocytoma). Curr Hypertens Rep. 2008;10:12–8.

    Article  PubMed  Google Scholar 

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Samuel J. Mann declares that he has no conflict of interest.

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  1. Division of Nephrology and Hypertension, NY-Presbyterian Hospital—Weill Cornell Medical College, 424 East 70th St, New York, NY, 10021, USA

    Samuel J. Mann

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Mann, S.J. Labile and Paroxysmal Hypertension: Common Clinical Dilemmas in Need of Treatment Studies. Curr Cardiol Rep 17, 99 (2015). https://doi.org/10.1007/s11886-015-0646-0

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