An Acute Hypertensive Episode Triggered by an Ambulatory Blood-Pressure–Monitoring Device
http://www.100md.com
《新英格兰医药杂志》
To the Editor: Twenty-four-hour ambulatory blood-pressure monitoring is used to differentiate so-called white-coat hypertension from more prolonged and frequent hypertension.1,2 We describe a patient in whom the monitoring device itself was instrumental in triggering an acute hypertensive episode.
A 46-year-old man was referred to the hypertension clinic in Ashkelon, Israel, for ambulatory blood-pressure monitoring to rule out white-coat hypertension, because his blood pressure was high when measured in the office but normal when measured at home. His medical history was unremarkable. Shortly after the monitoring device was attached to the patient, he was arrested by the police. The wires penetrating through his shirt had caused bystanders to suspect that he was a terrorist wired to a bomb (the blood-pressure–monitoring device had a separate battery pack, partly obscured by his jacket). Police officers immediately handcuffed him, as is standard procedure for handling an armed terrorist, and released him after a brief interrogation.
While the man was being arrested, the peak blood pressure (at 9:12 a.m.) rose to 161/101 mm Hg (Figure 1). The elevated systolic blood pressure persisted for more than 90 minutes, and the elevated diastolic blood pressure for more than 45 minutes. Tachycardia, with rates up to 122 beats per minute, persisted for more than four hours. A second hypertensive episode was triggered by another police interview approximately four hours after the initial arrest.
Figure 1. Printout of Blood-Pressure and Heart-Rate Measurements Throughout the Stressful Incident, from the Ambulatory Monitor.
The arrows indicate declines in systolic blood pressure (SBP) and diastolic blood pressure (DBP), and the asterisks indicate peaks in the heart rate (HR). MAP denotes mean arterial pressure. The dotted lines show the normal limits of systolic and diastolic blood pressure.
During the entire monitoring period, the patient's average daily blood pressure was 130/71 mm Hg; 25.2 percent of systolic values were above 140 mm Hg. This level may be considered borderline for the diagnosis of hypertension, as defined by the 24-hour–monitoring criterion of 25 percent of systolic blood-pressure values above 140 mm Hg, an average daily blood pressure of 130/85 mm Hg or higher, or both.3 However, when the hour including the initial police arrest was excluded, the patient's average daily blood pressure was 122/68 mm Hg, and only 22.2 percent of the systolic blood-pressure values were above 140 mm Hg.
During the subsequent nine months, the patient's blood pressure — as measured with an ambulatory monitor and at home — has been normal, with a mean daily blood pressure of 122/81 mm Hg and a mean heart rate of 81 beats per minute. The patient has remained asymptomatic.
Stress-associated hypertension has been described after the September 11, 2001, terrorist attack4 and after an earthquake in Japan.5 In both cases, the hypertensive response was prolonged (lasting one week and four weeks, respectively).4,5 In the present case, the unusual event was the blood-pressure monitoring itself, which — by the resemblance of the monitor to an explosive device — triggered the stressful event, which in turn led to prolonged hypertension and tachycardia.
Chaim Yosefy, M.D.
Barzilai Medical Center
Ashkelon 78000, Israel
Mordehay Vaturi, M.D.
Robert A. Levine, M.D.
Massachusetts General Hospital
Boston, MA 02114
References
O'Brien E, Beevers G, Lip GYH. ABC of hypertension: blood pressure measurement. III. Automated sphygmomanometry: ambulatory blood pressure measurement. BMJ 2001;322:1110-1114.
Pickering TG, Coats A, Mallion JM, Mancia G, Verdecchia P. Blood pressure monitoring: task force V: white-coat hypertension. Blood Press Monit 1999;4:333-341.
Zachariah PK, Sheps SG, Bailey KR, Wiltgen CM, Moore AG. Age-related characteristics of ambulatory blood pressure load and mean blood pressure in normotensive subjects. JAMA 1991;265:1414-1417. [Abstract]
Lipsky SI, Pickering TG, Gerin W. World Trade Center disaster effect on blood pressure. Blood Press Monit 2002;7:249-249.
Minami J, Kawano Y, Ishimitsu T, Yoshimi H, Takishita S. Effect of the Hanshin-Awaji earthquake on home blood pressure in patients with essential hypertension. Am J Hypertens 1997;10:222-225.
A 46-year-old man was referred to the hypertension clinic in Ashkelon, Israel, for ambulatory blood-pressure monitoring to rule out white-coat hypertension, because his blood pressure was high when measured in the office but normal when measured at home. His medical history was unremarkable. Shortly after the monitoring device was attached to the patient, he was arrested by the police. The wires penetrating through his shirt had caused bystanders to suspect that he was a terrorist wired to a bomb (the blood-pressure–monitoring device had a separate battery pack, partly obscured by his jacket). Police officers immediately handcuffed him, as is standard procedure for handling an armed terrorist, and released him after a brief interrogation.
While the man was being arrested, the peak blood pressure (at 9:12 a.m.) rose to 161/101 mm Hg (Figure 1). The elevated systolic blood pressure persisted for more than 90 minutes, and the elevated diastolic blood pressure for more than 45 minutes. Tachycardia, with rates up to 122 beats per minute, persisted for more than four hours. A second hypertensive episode was triggered by another police interview approximately four hours after the initial arrest.
Figure 1. Printout of Blood-Pressure and Heart-Rate Measurements Throughout the Stressful Incident, from the Ambulatory Monitor.
The arrows indicate declines in systolic blood pressure (SBP) and diastolic blood pressure (DBP), and the asterisks indicate peaks in the heart rate (HR). MAP denotes mean arterial pressure. The dotted lines show the normal limits of systolic and diastolic blood pressure.
During the entire monitoring period, the patient's average daily blood pressure was 130/71 mm Hg; 25.2 percent of systolic values were above 140 mm Hg. This level may be considered borderline for the diagnosis of hypertension, as defined by the 24-hour–monitoring criterion of 25 percent of systolic blood-pressure values above 140 mm Hg, an average daily blood pressure of 130/85 mm Hg or higher, or both.3 However, when the hour including the initial police arrest was excluded, the patient's average daily blood pressure was 122/68 mm Hg, and only 22.2 percent of the systolic blood-pressure values were above 140 mm Hg.
During the subsequent nine months, the patient's blood pressure — as measured with an ambulatory monitor and at home — has been normal, with a mean daily blood pressure of 122/81 mm Hg and a mean heart rate of 81 beats per minute. The patient has remained asymptomatic.
Stress-associated hypertension has been described after the September 11, 2001, terrorist attack4 and after an earthquake in Japan.5 In both cases, the hypertensive response was prolonged (lasting one week and four weeks, respectively).4,5 In the present case, the unusual event was the blood-pressure monitoring itself, which — by the resemblance of the monitor to an explosive device — triggered the stressful event, which in turn led to prolonged hypertension and tachycardia.
Chaim Yosefy, M.D.
Barzilai Medical Center
Ashkelon 78000, Israel
Mordehay Vaturi, M.D.
Robert A. Levine, M.D.
Massachusetts General Hospital
Boston, MA 02114
References
O'Brien E, Beevers G, Lip GYH. ABC of hypertension: blood pressure measurement. III. Automated sphygmomanometry: ambulatory blood pressure measurement. BMJ 2001;322:1110-1114.
Pickering TG, Coats A, Mallion JM, Mancia G, Verdecchia P. Blood pressure monitoring: task force V: white-coat hypertension. Blood Press Monit 1999;4:333-341.
Zachariah PK, Sheps SG, Bailey KR, Wiltgen CM, Moore AG. Age-related characteristics of ambulatory blood pressure load and mean blood pressure in normotensive subjects. JAMA 1991;265:1414-1417. [Abstract]
Lipsky SI, Pickering TG, Gerin W. World Trade Center disaster effect on blood pressure. Blood Press Monit 2002;7:249-249.
Minami J, Kawano Y, Ishimitsu T, Yoshimi H, Takishita S. Effect of the Hanshin-Awaji earthquake on home blood pressure in patients with essential hypertension. Am J Hypertens 1997;10:222-225.