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Thursday, October 23, 2014
High Blood Pressure
25 yrs+ HTN last 3mo going down
My husband HTN 25 + years. Two yrs ago changed to healthy diet and quit smoking for 4th/last time lost weight and b/p slowly improved meds beta blocker gradually reduced. April after swimming and walking looked like he was `zoned out`. I thought he was having CVA and took bp to find it 92/6? gave him qt of water and started watching water and bp daily. BP which had been nice 108-115/68-75 last year now going lower and pulse still going low on less beta blocker (mid 50`s). May came off beta all together and still on 10mg Nifepin 2x 10mg Enalapril 2x 12.5 HCTZ 1x. Found substernal goiter by accident (dry cough sob; chest x-ray then CT)May was having muscle weakness in hip/thigh and knees would sometimes buckle and ver tired. June that was getting worse. End of June leg weakness frequent had TSH, T3, T4 and TSH .23L (.34-4.82N), T3 48L (72-170N) T4 9.5N (4.5-12.1N)He was in P/T because a problem that turned out to be `very severe foraminal stenosis L4-5` where he was laid up Jan-Mar of 05 caused him to decondition and he was Dx w ataxia in 1990 and he lost his balance ability. It took months for him to regain core and leg strength and balance. O5 he had 6 SI injections and 5 epidurals. 2006 he had 6 SI injections and 2 epidurals. 2007 he had P/T and 2 SI injections and 1 interforaminal. In early May Physical Therapist thought he`d be able to be walking without assistance independantly soon. (He walked 50-125 feet a day without assistance indoors where he could walk barefoot or in stocking feet and had better balance this year) I only digressed to that because since July 1st he can`t stand more than 2or 3 minutes unassisted or walk more than 3 or 4 feet without his knees buckling since July 1st. Since July 1st his b/p kept trending down with less and less medication (high of 167/91. On 7/9 he had his first episode of tachicardia; 102/62 HR 100 and was put on beta blocker as needed when symptomatic (diaphorisis). He stopped HCTZ early July and Nifedipin around the 14th. On 27th saw endocrinologist who thought that bp from 82/54 - 167/90`s was too big a change to be thyroiditis. The Dx is mulitnodular goiter, hypothyroid, thyroiditis. Endo did not start thyroid replacement and said it was a self-limiting condition. Did more labs to see what `phase` he`s in. Went to cardiologist that day and she cut Enalapril from 10 2x to 5 mg 2 x with beta blocker still for episodes of tachiacardia. Did EKG (brady; one in June tach) BP and HR of every possible combination. ie High systolic low diastolic ie 148/78 pulse 58, 121/101 HR 74 and 25 minutes after that, after I had him flat on couch 92/47 HR 67. I was hypothyroid 5 years ago and Dx at about 90/70 started synthroid and before meds kicked in got down to 62/28 HR 44. I was bed ridden but didn`t decondition and didn`t have worry of loosing my balance skills or of compromised brain not being able to tolerate low BP, HR/ reduced blood flow like I worry about with my husband. Question: what can be done (in absence of him already being on thyroid medicine)to keep his blood pressure over 100 and heart rate over 60? Echocardogram in 05 didn`t show any serious problems according to MD it showed changes to heart related to history of HTN. (thickening and loss of elasticity?) When husbands bp goes low I can get systolic up with a glass of tomato juice (probably could give him a 1/4 teaspoon of salt for same effect)20pts systolic; but that doesn`t last more than a short time. How low would systolic, diastolic or heart rate have to go to cause permanent damage to brain with diffuse white matter atrophy? He is not alert and oriented when systolic in mid to low 90`s or lower. Do you think it`s something more than thyroid ( I don`t remember my bp going anywhere but down when I was hypothyroid and all the factors moved in sync)(Ruled out Shy Dragger syndrome with Catecholamines, Frac and Total labs 6/26; all comfortably in normal range) He had a new Dx; heart murmur, is that related to bp hr problem? What other tests do you think should be done? (at home pulse OX? Holter? new CBC`s?...?)
It is always difficult to make specific recommendations in an individual case without having the full clinical picture. However, a few points can be made:
It appears that your husband has symptomatic hypotension. He also has hypothyroidism and a history of muscle weakness. The following diseases (and tests) will have to be considered:
- Adrenal insufficiency, which can be diagnosed with a blood test (ACTH stimulation test)
- Amyloidosis, which requires a blood test and possibly other tests for diagnosis
- Peripheral neuropathy, which will require a neurological exam
Other (rare) causes for chronic low blood pressure include malignancies, malnutrition, deconditioning and certain medications. Make sure you discuss this with his doctor.
Max C Reif, MD
Professor of Medicine
Director of Hypertension Section
College of Medicine
University of Cincinnati