Acute Hypertension : hypertensive importunity and Hypertensive Emergency
Hypertension : How to Treat the Elderly
Six months after the onset of these headaches, the patient sought care from a chief doctor, who diagnosed meek high blood pressure ( blood pressure, 140/102 millimeter Hg ). Results of a 24-hour urinalysis for catecholamines and an MRI read of the headway were normal. The patient was referred to a neurologist, who reported that the neurological examen was normal and that the diagnosis was tension-type concern ; that doctor prescribed amitriptyline, 10 magnesium heat content. The patient stopped taking the medicine after a few weeks because of slope effects, however. The primary doctor thought that the high blood pressure was causing the headaches, and prescribed 50 mg/d of atenolol. Despite this therapy, the patient continued to experience daily headaches for the follow 51/2 years.
During that 51/2-year interval, the patient returned sporadically to the chief care doctor ; he besides checked his blood pressure frequently at home. Most rake imperativeness recordings were normal, but elevations american samoa high as 160/ 110 millimeter Hg occurred whenever he omitted the antihypertensive medicine for a day or two. There was no change in the pattern of the about constant headaches with these elevations of blood imperativeness. His day by day pulmonary tuberculosis of analgesics continued. Five years late, nifedipine, 30 mg/d, was added to the regimen. This agent did not change the headaches, but it did reduce the blood pressure. In previous years, the patient had infrequently experienced typical episodic tension-type headaches that might start in the afternoon ; these could be promptly terminated with 1 or 2 tablets of an OTC analgesic. He besides experienced an occasional isolate migraine without aura. The medical history was otherwise noncontributory. The patient was unaware of any elevations of blood press before his initial travel to to the primary coil doctor.
He was referred to the Vanderbilt Headache Clinic with this 6-year history of about constant headaches with superimposed migrainelike attacks for which he had used 4 to 6 analgesic tablets casual. The history was reviewed ; results of his neurological examination were normal. Blood pressure was 90/62 millimeter Hg in the right arm and 90/ 68 millimeter Hg in the left. Rebound headache was suspected.
The phenomenon of rebound concern was cautiously explained to the patient. He was told that until prove otherwise, the headaches of 6 years ’ duration were the solution of the about daily practice of pain easing medications. He was given a tilt of analgesics ( aspirin, acetaminophen, NSAIDs, opiates, ergotamine, triptans, and caffeine ) to avoid completely. He was besides told to stop the antihypertensive agents and to monitor his blood blackmail frequently at home. last, he was asked to keep a concern calendar and to return to the clinic in 4 weeks.
After the prevent pain stand-in medications were wholly omitted, the affected role ’ south headaches gradually subsided. After 3 weeks, he had the attack of 12 consecutive days of total freedom from pain. At that time, he was told to limit analgesics to 2 days per week in the future. More frequent use of analgesics might result in recurrence of the chronic day by day concern and the high blood pressure.
During the stick to 5 years, the affected role ’ s rake pressure remained normal without the antihypertensive agents, except for a single record of 148/94 mm Hg during the fifth calendar month. He had infrequent, brief, tension-type headaches, but no daily headaches and no migraines. He rarely used an analgesic during this 5-year interval.
When encountering a patient with new-onset high blood pressure, the doctor needs to obtain a accomplished history, perform a thorough examen, and order appropriate testing ground studies to try to determine the lawsuit. Often, a particular lawsuit for the blood press elevation can not be found and the patient is labeled as having essential, or primary coil, high blood pressure. He or she is then given long-run antihypertensive therapy with the hope that the pressure will become lower and its complications will be reduced or delayed.
many physicians do not realize that daily OTC analgesics—especially NSAIDs—can cause secondary hypertension.1-3 If the analgesics are not stopped, the lineage pressure may remain promote for months or years. Likewise, many physicians are not mindful that the most common campaign of chronic day by day or about day by day headaches is the daily or about daily function of medications for symptomatic relief of headache pain.4 The case history presented hera documents how the failure to recognize these possibilities resulted in a patient having 51⁄2 years of daily prolonged headaches and taking unnecessary antihypertensive medications.
Rebound headache—also called chronic refractory concern, chronic migraine, transformed migraine, and a horde of other names—typically presents as a constant, dull, tension-type concern with frequent superimposed more acute migrainelike attacks.5 The affected role uses pain relief medications casual or about daily that only dull or briefly stop the pain.
Medications to prevent concern are ineffective when a patient is in the bounce state. Some patients can recall a specific illness, operation, or wound for which they initiated the daily medications. many, however—especially those with a prolong history of headache— can not recall a specific precipitating event : these patients might describe a sudden or gradual development of daily concern.
This patient ’ s floor was distinctive for recoil headaches— a condition that can be suspected from the history and proved only by the delayed end point of the casual headaches after total omission of all pain relief medications that might cause this trouble ( namely, aspirin, acetaminophen, NSAIDs, opiates, ergotamine, triptans, and caffeine ). No testing ground test points to this diagnosis. The hurt medications must be avoided until the goal of 6 straight pain-free days is reached. Although some patients note cessation of daily headache in 1 week, the mean time for patients to experience 6 straight painfree days is 3 months.5 A few patients might not reach this finish until the 12th calendar month or late.
This patient ’ randomness high blood pressure was not identified until after he had used OTC analgesics for 6 months. There have been many other patients seen in our third concern clinic in whom high blood pressure developed after the practice of NSAIDs and in whom blood press returned to convention after daily analgesics were discontinued.
WHICH CAME FIRST: HYPERTENSION OR HEADACHE?
Physicians frequently fail to inquire or consider which came first gear, the lineage coerce elevation or the frequent headaches. In 1953, Stewart6 documented that high blood pressure alone rarely causes headaches unless the systolic pressure is over 200 mm Hg and the diastolic blackmail exceeds 120 millimeter Hg.
In the past 15 years, numerous articles have stressed that analgesics—especially NSAIDs—can cause meek elevations of blood pressure3,7-11 or affect the control of preexisting hypertension.3,8 The average elevation of systolic imperativeness is much alone 5 mm Hg9 and varies between the nonselective NSAIDs. Ibuprofen is less likely to cause elevations of pressure than piroxicam, indomethacin, naproxen, celecoxib, or rofecoxib.3 The Nurses Health Study reported that the gamble of high blood pressure was slightly greater in women who were using acetaminophen 22 or more days per month than in those using NSAIDs 22 or more days per month.10 Aspirin is occasionally cited as a cause of minimal elevations of blood blackmail. One article describes the case of an aged patient using salsalate in whom high blood pressure developed.11
In shortstop : basically all analgesics can elevate blood press in some persons. The mechanism is not amply silent.
When one looks at the chapters on high blood pressure in recent textbooks of medicine, NSAIDs are included in the lists of agents that cause junior-grade high blood pressure ; however, this cause of high blood pressure is not stressed in the accompanying text.1,2 In the most late edition of a popular textbook of syndicate exercise, NSAIDs were not included in the list of drugs causing this problem.12 It is not storm that the busy practitioner might be unaware of this trouble.
When confronted with a affected role with new-onset high blood pressure, clues that suggest secondary high blood pressure and rebound concern include a history of headaches that began before the onset of high blood pressure ; rake coerce of less than 200/120 millimeter Hg in a affected role with daily concern ; and day by day tension-type headaches with intermittent migraine attacks that start when the patient awakens or shortly thereafter and that persist most of the day.
Frequent pulmonary tuberculosis of OTC ibuprofen is a cause of high blood pressure and of chronic day by day headaches. Both can be reversed by discontinuing the drug.
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