Labile Hypertension: Concept and Approach

Hypertension is an important problem in modern society. There is a considerable increase in the number of cases of hypertension particularly of primary (essential) hypertension. Plenty of academic materials on hypertension are available in books and journals of both modern medicine and homeopathy apart from internet sources.

Hypertension has been described as a condition of elevated blood pressure, meaning elevated systemic arterial blood pressure. Various attempts were made to fix a numerical value for a cut-off between normotension and hypertension. Later on, it was understood that rather than fixing a value, hypertention should be defined as being a value of systolic blood pressure above the ‘limit’ appropriate for the age (and gender) of a person. Generally it is taken as systolic blood pressure more than or equal to 140 mm Hg and diastolic blood pressure more than or equal to 90 mm Hg. Now a days, taking antihypertensive medicines is sometimes considered as a criteria for labeling a person as a patient of hypertension.

The value of blood pressure for the purpose of definition and classification has changed from time to time. At present the keyword in the definition is ‘sustained’ elevation. This would mean that the blood pressure values must continue to be above normal to declare a person suffering from hypertension.

Traditionally, there was an entity called ‘labile hypertension’; the idea was that the patient was hypertensive at times because the blood pressure had a tendency to rise to abnormally high values from time to time. Included under the causes were two sets of conditions:

In modern times, the term ‘sustained’ has become a compulsory part of the criteria of hypertension. This means that the group of stress / tension / anxiety induced bouts of elevation of blood pressure but normal blood pressure at other times – the group of early hypertensives with hypertension at times and not at other times gets excluded from hypertension. Among the cases of phaeochromocytoma (group (ii) above), the patients who do not have an elevated blood pressure in between the paroxysms would also get excluded. Only those cases, who have blood pressure above the permissible upper limit even in between the paroxysms, would qualify as hypertensives. The fluctuation over a wide range of values would make them true cases of labile hypertension.

In homeopathic literature, the term ‘labile’ is still used in a broad sense. It is mentioned that the term ‘labile’ can be applied to an initial phase in the development of hypertension. Explanation is given in terms of hyperactivity of the vasculature and/or a hyperactive sympathetic nervous system. Hyperactivity is usually designated as a classical psoric manifestation. Basically, the persons of psoric background suffer from labile hypertension which is often caused by anxiety, grief, apprehension, irritability etc. If these emotional factors gradually pass away, the blood pressure often comes at a normal level. These patients produce many symptoms often complaining of palpitation, chest discomfort, breathlessness, vertigo etc. The symptoms are usually relieved during absolute rest. Peculiar stitching type of chest pain, a sensation of surging of blood to the head and chest, an empty feeling or heaviness of the chest and weakness are common complaints. Apprehension and anxiety are often associated with cardiac discomfort. It is also evident that the majority of the symptoms are modified by emotional disturbances.

Phaeochromocytoma is a tumour of sympathochromaffin cells which are normally responsible for the production of catecholamines in the body. The maximum collection of these cells is in the adrenal medulla and hence the tumour is most common in the adrenal medulla. 80% of the cases involve unilateral adrenal medulla, 10% have bilateral adrenal involvement and the remaining 10% are extra-adrenal in origin (including sites inside the organs like pancreas, bladder). There are reports of cases running in the family as a part of ‘Multiple Endocrine Neoplasia’ (MEN) syndromes (particularly MEN IIB where there may be phaeochromocytoma along with medullary carcinoma of thyroid and mucocutaneous ganglioneuroma). In case of children, the adrenal tumours are bilateral in more than 20% of the cases and are found in both the adrenal and extra-adrenal areas or only in the extra-adrenal areas in about 30 – 40% of children.

Clinically, the paroxysm produces an episode of severe hypertension. There is palpitation, tachycardia, sweating and apprehension. Patients may have either flushing or pallor depending on the balance between vasodilatory and vasoconstrictive bio-amines released by the tumour. Gastrointestinal manifestations such as nausea and vomiting may occur. Metabolic effects of catecholamines produce hyperglycaemia. Rarer manifestations include mental torpor, tremor, unconsciousness etc.

Diagnosis is usually clinical and the differential diagnosis includes hypoglycaemia and panic attacks. The latter (panic attack) is often a difficult differential diagnosis because the paroxysm of phaeochromocytoma can have a prominent degree of apprehension.

Investigations include an estimation of catecholamines in plasma and urine. Practically speaking, the estimation of vanillylmandelic acid (VMA) in urine is the most helpful. VMA is a breakdown product from catecholamines and an amount exceeding 7.0 mg in 24 hours urine indicates phaeochromocytoma. Imaging (USG / CT) is also required to identify the site of the tumour which could be extra-adrenal too. In sophisticated laboratories, High Performance Liquid Chromatography with Electro Chemical Detection (HPLC-ECD) may be available for testing catecholamines and their breakdown products. Conversely, the old test which depends on the fact that ‘Phentolamine injection during the attack produces a sudden fall of blood pressure’ is no longer used.

Modern medicine management involves the use of both alpha and beta adrenergic blockers to be followed by the surgical removal of the tumour. There is obviously a scope for homeopathic management for the cases of phaeochromocytoma. This is particularly true for the patients who do not undergo surgical removal of the tumour and the relief of symptoms can be considered a great achievement.

Several medicines have been found in the Homeopathic Materia Medica as well as in the Repertory, where the description of symptomatology fits with the clinical picture of phaeochromocytoma:

The entity of labile hypertension used either in the narrow sense for ‘selected cases of phaeochromocytoma’ or in the broad sense of ‘both phaeochromocytoma and early hypertensives with stress-induced bouts of hypertension’, all are expected to show good response to homeopathic management through properly selected remedies. Labile Hypertension should therefore, receive adequate attention in homeopathic academic circles and homeopathic clinical practice.