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Thursday, July 24, 2014
High Blood Pressure
How to control unstable blood pressure
My husband had hypertension since his early 40`s. In 1999 he switched from Ziac to a combination of ACE, calcium channel, beta blocker and HCTZ. In 05 1 MD suggested stopping Atenenol his pulse was 55. He stayed on it but with better diet reduced it to chip 6.25+/- a day. B/P was 115-125 over 75-82 at MD`s office last 2 years until April. One day mid April looked like he was having TIA but BP was 90`s over 60`s. Drank water and was OK. Watched water intake carefully and it still happened again. Cut out beta blocker (6.25) early May and had EKG mid May as episodes continued. EKG OK. Episodes more frequent. He would say "I was out to sea" or "I`m coming around" after one of these. Accidentally found substernial goiter (x-ray for cough) End of June labs showed low T-3 low TSH high T4. July; 1) Episodes of hypotension more frequent and leaving residual deficits like a stroke. 2)scan showed multinodular HYPOthyroid 3)9th-16th of July cut out channel blocker, HCTZ and reduced ACE from 20 to 5 mg a day after episode in a doctor`s office and cardiac consultation 3)endocrinologist Dx "sub-acute thyroiditis" self limiting, refused thyroid replacement and advised against it. 4)b/p as low as 80/51 while sleeping (woke him and gave tomato juice). This has continued and gotten worse. Cardiologist said let bp go high since condition to be self limiting and heart OK (for 70 year man Hx hypertension). I give salt, fluids to raise it as needed. Thyroid labs improving but bp very unstable. Within wk of starting thyroid pill went to 25 mg ACE and up since to near max (40)but low resistance now and immediately prior to problem (ie UTI, yeast infection, SBO, pneumonia) bp drops like rock. Can be increasing dose slightly and doing OK then sudden drop in bp and spend day eating salty food and gatorade.After those problems titrates back on ACE. Currently on Captopril (shortest acting I`m told) max dose so far: 50mgAM 25 8 hours later. I let bp go as high as 190/98 late evening but overnight bp still wants to drop below 110/70. Also formerly healthy, active man now debilitated and can`t get into IP rehab until "medically stable" (on bp/meds)I`m up many nights feeding him tomato soup/water. Get bp up and hour later in `yellow` zone. What would be best Rx and regime to keep bp reasonable in day and not overmedicated overnight? One MD suggest (and `wrote` Enalapril 5mg 1x day in combo with Captopril for when he maxs out dose (50mg not more than 8 hours) as he now as intermitant polyuria, diuretic not good idea, beta lowers HR too much and lasts 24 hours, calcium channel too strong especially if he comes down with infection/virus and bp drops. Also A1C 5.3, lab for DI negative, Cardiologist said not cardiac condition, neurologist said not neuro, Endocrinologist said "BP not my problem". Hypotension has caused hypoxia and ischemia and MUST be avoided. Is it normal to drop 30-40% at night? Normal to drop at onset of infection? My husband not in hospital since TURP in 92 now vaso vagual August, UTI September, ER outpatient w/yeast infection October, SBO November followed by hospital acquired pneumonia (bedridden 13 out of 21 days). Last blood chemistry 12/7 all normal. CBC: anemic & low red cells (15 in May, 10.1 August and negative for intestinal bleeding, now 12)
Thank you for visiting NetWellness. On this site, we try to answer general questions about high blood pressure but cannot diagnose or recommend treatment. This is a very complicated case and your husband should be seen by a hypertension specialist. You appear to have some very, very specific questions about your husband's case, which can only be answered properly by a physician who is familiar with his history, physical exam, and test results. Your questions about the testing results you've been given or the risks, benefits, and alternatives for proposed treatments of this condition need to be directed to your treating physician(s). You should insist that they answer these questions in a way that you are able to understand before consenting to any treatment. If your physician is unable to help you understand these issues, you should get a second opinion. Take care.
Jackson T Wright, MD, PhD, FACP
Professor of Medicine
School of Medicine
Case Western Reserve University