Most had their patients sit on the edge of the examination table. A right open adrenalectomy was performed on November 5, 2014. 9.1 White Coat Hypertension. I have seen about 15 to 20 patients with pheochromocytomas over the years. In my experience with a few such huge pheochromocytomas, we tended to α-block until the patient could not stand because we worried so much about unstable BP intraoperatively. Dr Bursztyn: What is the nature of his chronic pain? 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. 57(5):898-902. . 1-800-242-8721 Medication consisted of α-blockade with doxazosin 8 mg at night with titration in 2-mg increments according to orthostatic vitals and β-blockade with metoprolol. Case of Episodic and Positional Hypertension. 2012;380:2224-2260. Although pathological examination did not identify a malignant pheochromocytoma, one cannot judge malignancy by simply observing the histology. The effect of crossing legs on blood pressure: a randomized single-blind cross-over study. Musculoskeletal: back and joint pain, muscular pain, and leg cramps at night. The external surface is inked black. Dr Carey: There were no episodes of hypotension accompanying or associated with these episodes? They should not be on narcotics. Ambulatory blood pressure monitoring in Australia: 2011 consensus position statement. I suggest that perhaps some anatomic structure compressed the tumor when the patient was in a certain position. Dr Basile: I would refer everyone to the New England Journal of Medicine review article by Neumann et al3 that just came out on paraganglioma and pheochromocytoma because it talks extensively about the importance of a genetic workup. Although a 24-hour BP is not necessary for the diagnosis of hypertension in this patient, I would like to know what his pressures are when he is having positional hypertension and when he is in a different position. The findings are most consistent with pheochromocytoma with possible malignant transformation given the presence of the thrombus within the right adrenal vein. J Hum Hypertens. Between episodes, his mean systolic BP was usually 140 to 150 mm Hg and his diastolic BP was 75 to 80 mm Hg. He was referred to a pain clinic and tried several options, but maybe it was psychological, maybe it was chronic pain syndrome. Noncompliance with the position guideline resulted in misclassification of 15 patients (7.4%) as prehypertensive, when, in fact, they were normotensive. MDedge: Keeping You Informed. Specifically, he had less cramping and fewer attacks. Actually, we did not manage that because we wanted to get everything else done fairly quickly and enrolled him in our charity program, so that we could do everything in September, before he actually turned 60. Lim SS, Vos T, Flaxman AD, et al. Dr Dudenbostel: To answer question 1, he reported that he first had symptoms in 2000. Dr Carey: What was the total duration of the pain and these episodes? 18. Dr Bursztyn: Were the opiates helping him? The patient did not regularly attend follow-up at the UAB Hypertension Clinic, and his episodic hypertensive episodes remained unresolved. The 2007 Canadian Hypertension Education Program recommendations for the management of hypertension: part 1- blood pressure measurement, diagnosis and assessment of risk. Some patients may exhibit postural hypotension, especially with certain antihypertensive drugs. The positron emission tomography scan showed a hypermetabolic right adrenal mass containing necrotic areas corresponding to pheochromocytoma with no additional suspicious hypermetabolic lesions elsewhere (Figure 1B). In the abdomen? New Engl J Med. He has palpitations. I would be concerned that he actually behaved as if he had a pseudopheochromocytoma presentation after removal of the pheochromocytoma. 2003;289:1027-1030. We did review his chart in an effort to determine the nature of his pain, but we could not. MDedge Daily News: Can androgen therapy improve male frailty? Dr Luther: I agree with Dr Carey and many of Dr Basile’s comments. Dr Egan: Brent Egan, Greenville, South Carolina, and I agree with what my colleagues Dr Carey and Dr Basile have said. Figure 3 shows the BP and HR trajectories before and after surgery, demonstrating fluctuations in BP before surgery with a period of stabilization after surgery and a postoperative onset of BP fluctuations after 1 year. 7. Dallas, TX 75231 Proper technique is particularly important with the aneroid sphygmomanometer to obtain consistent and accurate results.5 Good training and an ability to hear the Korotkoff sounds are crucial. A repeat 24-hour urine collection showed normal levels of catecholamines and fractionated metanephrines, and repeat urine drug screening results were negative. An 8.5×8.2×8.0-cm encapsulated mass was examined. Dr Dudenbostel: He had a kind of chronic pain syndrome possibly related to osteoarthritis. I have followed patients with pseudopheochromocytoma. I just wonder if it is possible to know whether that contributed to his complications. Copyright  © 2021 Frontline Medical Communications Inc., Parsippany, NJ, USA. The following case was presented on September 7, 2019, as part of the Clinical-Pathological Conference chaired by Anna F. Dominiczak and Rhian Touyz at the Hypertension 2019 Scientific Sessions in New Orleans, LA. Dr Basile: Jan Basile from Charleston. A sitting position with knees flexed straightens the rectum, enhances the use of abdominal muscles, and facilitates defecation. Dr Dudenbostel: I am not sure we had to rely basically on the patient’s self-report. Then, when he is around 45, when he stopped drinking, he received medical care. This was the first question. However, this patient had a unique symptom that cannot be neglected. Lungs: clear with no crackles or wheezes. Standard deviation for systolic BP was 3.6 mm Hg; for diastolic it was 3.8 mm Hg. Euthanasia is the administration of a lethal agent by another person to a patient for the purpose of relieving the patient’s intolerable and incurable suffering. Genitourinary: erectile dysfunction, change in sexual desire. The patient had 3 siblings with no medical problems. Patients may also have PAH in the setting of systemic sclerosis (or other connective tissue disease), human immunodeficiency virus (HIV), portopulmonary hypertension, and congenital heart disease due to uncorrected shunt.14 Schistosomiasis is the most common cause of PAH worldwide, although encountered rarely in industrialized nations. Implement a standardized hypertension treatment protocol. Does the fit change when he turns to his side? Dr Carey: Just a quick comment, I was equally concerned about using doxazosin alone in a patient like this. You are not seeing an increase in HR; you can actually see a reduction in HR with pure norepinephrine tumors. 7.1 Beneficial effects of blood-pressure-lowering therapy in hypertension. Numerous capillaries filled with red cells are visible. Actually, a friend of his supervises a sleep clinic and observed that he stopped breathing at night and said, “I think you may have OSA.” He underwent a sleep study and subsequently received a CPAP machine. The American Heart Association is qualified 501(c)(3) tax-exempt The patient also reported better BP control using hydrocodone/acetaminophen. In addition, β-blockers precipitated the episodes—a typical finding in pheochromocytoma. He had perspiration, pain, and headache. Although office BP measurement is less than ideal, it is used most often to diagnose and monitor hypertension. The patient was a former smoker from 17 years of age to 2012; he had quit smoking using nicotine patches 2 years before his initial visit to the UAB Hypertension Clinic. The abdominal and pelvic computed tomographic scan showed a large (8.4 cm) heterogeneous mass with areas of central necrosis and calcification seen arising off the right adrenal gland with possible extension into the inferior aspect of the right hepatic lobe. The systolic BP was 120 to 170 mm Hg, and diastolic BP was 70 to 110 mm Hg. The purpose of our study was to compare BP measurement in 2 positions: the standard position described above, and the examination table position in which the patient is seated on the edge of the table with back, arms, and feet unsupported. Psychiatry: difficulty focusing on specific issues, normal mood, no depression. Hypertension (defined as a blood pressure ≥140/90 mmHg) is an extremely common comorbid condition in diabetes, affecting ∼20–60% of patients with diabetes, depending on obesity, ethnicity, and age. J Clin Hypertens. His father had no medical problems. Hoboken, NJ: John Wiley & Sons; 2013. Because he knew he would then have insurance. Relationship of 24-hour blood pressure mean and variability to severity of target-organ damage in hypertension. In addition, there is a significant issue with supine to standing measurements in which there are wild variations. If a patient is placed in Trendelenburg position, shoulder braces should not be used as the risk of compressive injury to the brachial plexus is significant. Hypertension is a highly prevalent cardiovascular disease, which affects over 1 billion people worldwide [].Although more than 70% of hypertensive patients are aware of the disease, only 23–49% are treated, and fewer (20%) achieving control [2, 4, 5].Hypertension prevalence varies by … Elevating the head of the bed lessens the risk of supine hypertension, and blood pressure should be measured in this position. Figure 3. Hypertension Canada’s 2016 Canadian Hypertension Education Program Guidelines for Blood Pressure Measurement, Diagnosis, Assessment of Risk, Prevention, and Treatment of Hypertension. I wonder about drug contributions to his hypertension. Prominent areas of hemorrhage were observed throughout the tumor (Figure 2A). I will save the first question I have, a comment about etiology, for later. The second question regarding OSA. We conducted this study to describe clinical, functional, radiologic, and hemodynamic characteristics and outcome of patients with NF1-associated PH. The diabetes mellitus was managed with metformin, with a glycated hemoglobin of 7.1%. Specifically, they occurred when he was bending or pushing wood parts or pieces together. Expert consensus groups such as the American Heart Association (AHA) publish recommendations for proper technique in reliably measuring BP,6-8 and they emphasize the importance of patient positioning during BP measurement. High blood pressure (BP), or hypertension, is defined by two levels by 2017 American College of Cardiology/American Heart Association (ACC/AHA) guidelines [1, 2] : (1) elevated BP, with a systolic pressure (SBP) between 120 and 129 mm Hg and diastolic pressure (DBP) less than 80 mm Hg, and (2) stage 1 hypertension, with an SBP of 130 to 139 mm Hg or a DBP of 80 to 89 mm Hg. Very inconsistent. The postoperative medications included diltiazem ER 180 mg BID, metoprolol 50 mg BID, metformin 500 mg in the morning and 1000 mg in the afternoon, aspirin 81 mg, warfarin 5 mg, baclofen 5 mg BID, and hydrocodone/acetaminophen 7.5/325 mg daily. In addition, he has paroxysms of hypertension, which may be more common than sustained hypertension in these patients. All the work up back then focused more on cardiac etiology. Two measurements were obtained in each position for 204 patients, and we determined the difference between the average readings in the 2 positions. Room set-up and patient positioning for endoscopy. The other thing that will drive BP crazy, and I am not going to link this to position, but certainly renal artery stenosis can give you very episodic and severe elevations of BP. Campbell NR, Chockalingam A, Fodor JG, et al. Similarly, Dr Egan mentioned that a vertebral artery can be compressed in patients with obvious cervical spine osteoarthritis and cause positional hypertension. The increases in BP were also positional, that is, they occurred while he was bending or turned to the right. McKay DW, Campbell NR, Parab LS, et al. Factored into the comparison was an estimation of inherent variance of the device and observer achieved by repeated measurements on a healthy individual. Contact Us. No subjects were reclassified as hypertensive, but the study lacked statistical rigor.10 Another study found variable BP readings regardless of body position.11. The endoscope — a thin, flexible, lighted tube — is passed through the mouth and pharynx, and into the esophagus. I am certain something else is going on such as pheochromocytoma, but I just thought I would make that point. Teach patients to take their first dose at bedtime and to move slowly from a sitting to a standing position. The back? The diagnosis of hypertension is based on indirect measurement of BP using in-office, ambulatory, or home monitoring. Those who agreed were asked to read and sign an informed consent approved by a regional institutional review board for human subjects. ... You may also want to mention a class or volunteer position to highlight your commitment to professional growth. In the feet? Prominent areas of hemorrhage were observed throughout the tumor. organization. At that time, he occasionally found himself lying on his right side with a BP ≥250/160 mm Hg. We excluded patients who declined participation for any reason, who were in severe pain or distress that may have prevented them from completing the protocol, or who had limited mobility that could interfere with climbing onto the examination table. 7272 Greenville Ave. Dr Siddiqui: He could not describe the exact nature of his chronic pain. 1-800-AHA-USA-1 The study population consisted of patients presenting consecutively to a teaching family medicine center. A 59-year-old Caucasian man who worked as a carpenter was seen in September 2014 as an outpatient at the University of Alabama at Birmingham (UAB) Hypertension Clinic. We would use phenoxybenzamine—a general α-blocker—combined with metryosine to block catecholamine secretion. He reported that back then, he had palpitations, and that was the main symptom that concerned him, and he was 45. Systolic blood pressure variability as a risk factor for stroke and cardiovascular mortality in the elderly hypertensive population. 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