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To Your Good Health: Blood pressure spikes could be evidence of labile hypertension

Keith Roach, M.D., syndicated columnist

DEAR DR. ROACH: I’m 85 years old and in basically good health for my age. I am an active nonsmoker, eat healthy, practice tai chi, and enjoy having many friends. I have no reason to experience extreme anxiety.

Yet, for months, I have had unexplained blood pressure spikes. The highest I had was 243/127 mm Hg, and this is when I called local EMTs, who took me to the emergency room. I was given meds to lower my blood pressure, two electrocardigorams, and an X-ray. I was discharged after three hours and was told that my heart seemed fine.

I am now taking losartan and propranolol. I tried triamterene after consulting with a cardiologist, but I couldn’t tolerate the side effects. I occasionally use lorazepam.

Today, a blood pressure reading showed 197/100 mm Hg. Just the thought of checking my blood pressure spikes the reading. How long can I go on with these blood pressure levels? Can these readings be normal for some people? — S.O.

ANSWER: No, these readings are not normal. Since you say that the blood pressure “spikes,” I think you mean that most of the time, your blood pressure is normal.

The biggest concern is a condition where the body intermittently secretes substances that raise the blood pressure. This may be caused by a tumor called a pheochromocytoma. They are exceedingly rare, but must be looked for in a case like yours, with sudden and dramatic spikes in your blood pressure. Your regular doctor or cardiologist will know how to look for a pheochromocytoma.

If you have a spike, a blood test will be dramatically elevated for epinephrine and norepinephrine. But if your blood pressure is normal at the time of the visit, a 24-hour urine test is done.

There are other rare causes, including blockages in the arteries to the kidneys and certain drug use, such as monoamine oxidase inhibitors (very rarely used for depression) in combination with some foods. Cocaine use is another cause in a person on a beta blocker, like the propranolol you are on.

Even more likely is a condition called labile hypertension, where emotional stress leads to an increase in blood pressure levels. This is more likely for you because of the last thing you said: Just the thought of checking your blood pressure may cause it to spike.

Managing labile hypertension should be done by an expert. There are experts in hypertension, who may be generalists, nephrologists or cardiologists who have expertise in managing the very unusual cases of hypertension.Your doctor may have already considered this diagnosis because lorazepam is often used for spikes, sometimes in combination with short-acting blood pressure medicines, like labetalol or clonidine.

DEAR DR. ROACH: I’m a 62-year-old woman in good health who has always been very active. When I was younger, I would hardly be sweaty after I worked out. My clothes would be dry. Now when I do a similar workout, I’m so sweaty that my clothes are wet. Why is there such a big difference? Is it hormone-related? I also have hot flashes. — M.C.

ANSWER: Yes, it’s very likely to be related to the hormonal changes of menopause. When estrogen levels go down due to the ovaries ceasing production, temperature regulation at the level of the hypothalamus in the brain is changed. The brain causes heat-losing changes, like skin flushing and sweating, much more easily.

This can happen for no particular reason, but it may be triggered by exercise. So much heat can be lost that a woman may get so cold she shivers to rebuild heat.

If it’s bothering you, try less-intense exercise, exercising in air conditioning or near a fan, or swimming.

DEAR DR. ROACH: It was less than five years ago that I had a TURP (transurethral resection of the prostate) surgery for slow urination. It is not at a critical point yet, but it feels like my urine flow is slowing down again. How often do men who’ve had a TURP surgery require a second operation?

A normal prostate is the size of a walnut. As men age, it enlarges. Does it ever stop growing at a certain point? How large can it actually get? Can it get to the size of an orange or larger? — Anon.

ANSWER: You are right that in young men, the prostate is typically the size of a walnut. In many men, the prostate enlarges, but there are different anatomical areas within the prostate, called zones. The urethra, which carries the urine from the bladder out through the penis, goes right through the transitional zone of the prostate, and it’s this zone that most often causes symptoms in older men.

Surgery is done less often now for enlarged prostates than 20 years ago, because medication is much more effective. Most men don’t need surgery, but surgery is certainly still done. In addition, there are other options, such as photoselective vaporization, microwave treatment, cold and laser treatments, and prostate artery embolization. The decision of which to offer is in the hands of the urologist, but I can give some guidance on how often a repeat surgery is necessary.

After five years, about 7% of men who had the surgery you had required a second operation. Most other treatments were similar, but some weren’t as long-lasting. Prostatic artery embolization required retreatment 24% of the time at five years, while microwave treatment required retreatment 31% of the time.

Unfortunately, the prostate tends to keep growing. You really don’t want to beat the “world record” of 4 liters, which is about the size of a small watermelon. (The person who had it didn’t have any symptoms, so treatments weren’t done.)

DEAR DR. ROACH: I received a COVID vaccine seven weeks ago. It’s the one that has been given since 2023, so it was not an updated vaccine. But the Food and Drug Administration just approved and released the updated vaccine for 2024. Can I get the most recent and updated vaccine, or must I wait? — V.C.

ANSWER: A new vaccine was approved by the FDA in August, and it’s available now, specifically for the new omicron variant, KP.2. This new vaccine closely targets the circulating viruses. You can get the vaccine if you have not had (any) COVID vaccines in the past two months, so you just need to wait another week.

There is a lot of COVID circulating right now in many areas of the country, and getting a vaccine right away may be a good choice for people, especially if they haven’t been vaccinated in a long time or if they are at a high risk due to age or medical conditions. Some people might consider waiting a couple of months for the expected winter surge. I am advising most of my patients to get the new vaccine now, but your particular situation may be different. So, talk to your doctor about the optimal timing.

EDITOR’S NOTE: Readers may email questions to ToYourGoodHealth@med.cornell.edu or request an order form of available health newsletters or mail questions to P.O. Box 536475, Orlando, FL 32853-6475.

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