Easily “Curable” Anxiety‐Induced Hypertension

Pickering and Clemow ¹ have nicely compared and contrasted paroxysmal hypertension related to pheochromocytoma, pseudopheochromocytoma, panic attacks, and hyperventilation. I present here a type of anxiety‐induced hypertension that is probably far more common and easily “cured” if the cause can be identified.

A case in point is that of an 85‐year‐old woman with known chronic hypertension who was initially referred following a syncopal episode in a restaurant. Detailed history revealed that her medications had been escalated both in number and dose in response to episodes of elevated office hypertension. The combination of food, alcohol, relaxation with family, and overmedication was the most obvious explanation for the syncopal episode. She was treated by gradual withdrawal and down‐titration of her medications plus reassurance and her blood pressure (BP) was then controlled.

Over the next several years she had 2 episodes of elevated office hypertension. In both instances her BP was well above her usual baseline, but there was no evidence of target organ damage or an incident secondary organic cause. A sympathetic approach and a genuine attempt to determine what was bothering her yielded the information that she was extremely upset because her exterminator had failed to come and her kitchen was overrun with bugs. A short visit focused on her BP might not have permitted the establishment of rapport and revelation of her true problem. She likely would have been given additional antihypertensive medication and sent home. What she really needed was a new exterminator. On her subsequent visit she reported that her kitchen was free of vermin and her BP was at her baseline.

The second episode required a bit more time to identify the cause. In brief, her family owned several hotels and had replaced all of the in‐room televisions in one large purchase. The family members bought more advanced television sets for themselves at a highly discounted price. Somehow, Grandmother was left out. When the error was discovered, the family asked the vendor to provide an additional set but he had no more of that model in stock. He did have a state‐of‐the‐art model that had numerous “bells and whistles” and this was delivered to her. The delivery person installed the new set, handed her the remote control, took the old set out, and left. Tears filled her eyes as she admitted that she did not know how to operate the “smitchik” (switch or remote control). It became clear that this stress was the cause of her paroxysmal hypertension. The “cure” was to have the delivery person come back and train her on the use of the remote. On the next visit her BP was at her baseline.

Not even the most sophisticated laboratory or imaging studies could have identified the cause of her paroxysmal hypertension on these 2 occasions. Sympathetic conversation and gentle probing, however, costs time—a commodity for which few are willing to pay. The result is greater cost in the form of unnecessary studies, medications, and the consequences of overmedication.

A noncompliant major arterial system is incapable of damping increased left ventricular stroke work that is, in turn, a result of anxiety‐induced increased sympathetic nervous system activity. Antihypertensive medications are generally of little value in these situations; anxiolytic agents should be used if necessary. Otherwise unexplained increases in BP above baseline in elderly patients should trigger a patient and sympathetic inquiry into nonorganic causes of the increase. If the root cause can be identified, the cure may be easy.

Not all examples pertain to the elderly. A 35‐year‐old woman who was married and had 2 children was the chief executive officer of a large company. Her job required a great deal of personal interaction. She was under high pressure but found the job stimulating and rewarding. She met and fell in love with a surgeon whose wife had died suddenly at age 40. She divorced her husband, gave him custody of the children, married the surgeon, and moved to his city. They decided to have a child together and did so. They noticed that her BP had increased to 135 to 140 mm Hg systolic from its usual 106 to 110 mm Hg and they became fixated on it. On evaluation, there was no evidence for organic secondary hypertension and no target organ damage. The question, “Are you sad?” elicited a flood of tears and the above story. Further probing revealed that she had gone from a high‐powered highly interactive executive job to mothering a 6‐month‐old baby. Her husband’s long work hours left her alone with the baby for long periods. She was indeed sad. Family counseling rather than antihypertensive medication resolved the BP problem.

Such historical exploration takes time that may not be available in a busy practice. Clinical intuition is a useful tool for selecting those patients most likely to have something that can be easily identified and cured. Physician extenders such as physicians assistants, advanced registered nurse practitioners, or even well‐trained office staff might lend a sympathetic ear and alert the physician to a potential problem.

It is certainly worth trying.