He Needed Elective Surgery: Just Not a Knee Replacement
High Blood Pressure is Not a Disease: It is a Measurement
A 61-year-old physically active construction foreman with chronic arthritis of the knee was scheduled for knee replacement. He had not seen a doctor in twenty years. He did not smoke and only had 4 or 5 drinks a week. His blood pressure on his visit before admission was 178/92. By all appearances he was healthy, and he was given a fluid pill (HCTZ) which lowered his blood pressure to 140/82. He was admitted, and his knee was replaced. His pressure just prior to anesthesia was 168/92.
On the first day after surgery, the patient was working with a physical therapist and his blood pressure was noted to be 216/99 mm Hg with a heart rate of 141 beats per minute, a respiratory rate of 20 breaths per minute. He was going into congestive heart failure. The patient was admitted to the intensive care unit. On the second day after surgery, he had a cardiac arrest and developed progressive organ failure. He died on the fifth day after surgery.
His heart failure was the type that is seen in patients who experience severe emotional or physical distress. 90% of the reported cases are in women. Severe emotional and physical stress cause excess production of the fight or flight hormone adrenalin. That raises the pulse and blood pressure acutely to prepare us to deal with the threat. It is that excess adrenalin that causes this type of heart failure. This patient had a tumor of his adrenal gland that weighed about half a pound. It made an excess adrenalin type substance that raised his pressure, pulse, and ultimately caused his death. These patients, unlike many with high blood pressure, frequently have symptoms and they are the ones you would expect-racing pulse, feelings of panic, pounding heart. These symptoms may be constant, or they may wax and wane. Fortunately, these tumors are rare and only occur in about one in 100,000 adults.
The point is this. Most high blood pressure treatment is easy. A nurse practitioner with a protocol and the authority to change treatment as part of a chronic disease team does a spectacular job with most patients, but there are these exceptions. That is where focus, experience, and additional training are essential. I ran into a patient like this myself. She was a middle-aged woman who had episodes where she had stress symptoms and her pressure would go very high. She had her tumor removed at a university medical center and she was cured. The patient we are discussing here in this piece did not need to rush to knee replacement. There was no hurry. It is unlikely that he was totally without symptoms. More time with a primary care team focused on chronic diseases might have revealed this deadly problem before surgery.
This case may be the most dramatic demonstration of a key fact in cardiovascular chronic disease management. High blood pressure is not a disease, it is a measurement that reflects abnormalities that are already present in the arteries and heart. In this case, high blood pressure was due to excess production of an adrenalin-like substance from a tumor. In most people, it is caused by excess abdominal weight which increases production of other substances that cause inflammation, scarring, and thickening in the arteries. The point is, lowering the blood pressure is just part of the problem. The best treatments address the underlying cause of high blood pressure. That is why a focus on chronic disease and optimal medical treatment is so important. If you find this information helpful, please enroll free to receive the latest on cardiovascular and related chronic diseases.