Paroxysmal Hypertension Associated With Presyncope.

Presentation of the Patient A 62-year-old woman with a history of well-controlled hypertension was urgently referred to the Vanderbilt Hypertension Clinic for evaluation of worsening hypertension with increasing blood pressure lability. The referral was initiated by her primary physician after measuring her in-office systolic blood pressure to be >300 mm Hg, despite treatment with amlodipine 5 mg, losartan 100 mg, and hydrochlorothiazide 12.5 mg daily. No other new medications had been recently started, and in particular, she was not taking nonsteroidal anti-inflammatory drugs. She meticulously recorded her home blood pressure and documented presyncope with hypotension in the mornings (87/66 mm Hg), which resolved with lying down. In the evening, blood pressure increased in the range systolic of 190 to 200 mm Hg. She also reported symptoms associated with hypertension, including visual difficulty, palpitations, tachycardia, a “hot feeling” in the head, and throbbing headaches. In particular, she described her visual disturbance as a “black curtain coming down over her eyes.” Her husband and other observers described her as “ashen” or “like a ghost,” but on one occasion she was described as being intensely red in the face, appearing flushed. We were fortunate in that her husband was trained as an accountant, so he came to the clinic with her blood pressures recorded in a spreadsheet, which he had frequently documented during the day. Her blood pressure increased during the day, reaching a peak in the early evening, and it was at this point that she had symptomatology such as visual disturbance (Figure 1). However, the following morning, her blood pressure would be low. This pattern repeated again the following day. She had orthostatic hypotension with symptoms on the third morning of observation. During episodes of elevated blood pressure, she had corresponding tachycardia. The heart rate correlated with systolic blood pressure up to levels of ≈160 mm Hg (Figure 1C). Her medical history included mild diabetes mellitus, which was treated by diet alone, hypothyroidism, chronic low back pain associated with muscle spasm, neck pain, and generalized anxiety. She was prescribed additional medications, including simvastatin 20 mg daily, tizanidine 4 mg three times daily, and levothyroxine 0.125 mg daily. She did not smoke tobacco, drink alcohol excessively, or use cocaine. She had no family history of early-onset hypertension or endocrine tumors. On physical exam, her systolic pressure was 186/92 mm Hg, heart rate was 84, and body mass index was 34 kg/m. Fundoscopic exam revealed some copper wiring and arteriovenous nicking, and the physical examination was otherwise normal with no radial-femoral pulse delay. ECG was normal and demonstrated no left ventricular hypertrophy and no repolarization abnormality.