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Experiencing high BP, panic attack. Prescribed with prozac, amlodipine. Normal EKG. Side effect?

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Practicing since : 1998
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Good day,
I would like to give a fair amount (sorry) of background before I ask my questions:

A lot of this probably seems psychological in nature but my cardio health is what I am concerned about here:

I've always been borderline hypertensive - BP hovering between 120/80 to 130/90. This was discovered at a specialist for nerves as I had damaged my Ulner never (irrelevant). However this doctor for some reason asked if I was depressed and when I realised I was, he prescribed Prozac for me (2008 – I was 20. I tried this for about a month but I was having difficulty concentrating after taking it.

After seeing another doctor and describing the problem and wanting his advice on if I should discontinue the drug or if there was possibly something similar he could help me with. To my surprise he offered Ritalin, something I thought was only for kids with ADD.

After taking the Ritalin I realised how obvious the changes it makes are - I could focus on something - a lot better than before I started taking the Prozac. On top of that it actually sort of helped motivate me to do my chores and homework. I've always never been able to finish doing something but on Ritalin it was easy. (I still think this is a character flaw which was just run over by the methylphenidate).
The fact here was that I was studying engineering and being able to focus as well as everyone else was a huge necessity. From then on I felt no depression and didn't see the need for the Prozac so I stopped taking it (was on it for a total of about 3 months).

Beginning of 2011 (I would be 23) I had what I later found to be a Panic Attack. Like many who experience it for the first time I assumed I was having a heart attack. At the time of this however I was also taking Ritalin which to be effective for me needed to be a somewhat high dose of 40mg split up through the day. That particular day I was pushing it a bit hard and took and extra 10mg pill in the evening to try stay clear headed while making a presentation. Then it hit me, a wave of adrenaline and a heart which was racing faster than mercialago. I was convinced it was going to beat "overload" and that would be it. I think mine was worse, as the Ritalin allowed to to focus hard on the panic attack and also giving thoughts like "It's the ritalin which has done this".

Eventually after an EKG (normal) and waiting for my BP to drop, the panic attack subsided. I was monitored in the ER for a while before I was let go.
During that panic attack episode my blood pressure was as high as 190/100 so the doctor gave me something to bring the blood pressure down. And before he released me put me on 5mg of amlodipine.

After such a fright and suddenly being put on high BP meds, I made an appointment with a cardiologist. The cardiologist said that the amlodipine would give me low blood pressure if I didn’t need it so kept me on it (My BP was then 130/80). He did a few blood test including cholesterol and whatever you analyse urine for indicating that they were all fine.

I also went for an echo which indicated my heart itself was also fine. He was particularly obsessed with the idea that I had a pheochromocytoma and checked my ephedrine as well as norephedrine in my urine. When that came back normal he had me on a CT machine with an Iodine solution to rule it out completely.
After that he declared my problem essential hypertension with panic attacks.
Since then I have been taking the 5mg amlodipine once a day and was still suffering from occasional panic attacks.

I eventually had a doctor prescribe a benzo (Ativan) to take during the attacks as they were debilitating (especially when flying). This worked relatively well as I could just take a couple of them when the attack happened (say once a month) (Is this not better than SSRI? I can't get addicted to the stuff which is what I understand is the concern as he only needs to give me 4 a month or somethign)
My doctor then decided (2012) that I should give an SSRI a shot to manage my anxiety rather than relying on the Ativan. I took his advice and began on 10mg Lexamil (escitalopram). I was on this up until recently where I decided that I need to deal with the attacks without medication, so tapered down and eventually stopped. This decision was based on wanting to stop taking unnecessary medication as well as the side effects of apathy and sexual dysfunction.
The withdrawal here has been tough with now having no libido and a fair number of brain zaps. I’m also having trouble staying awake. (Any tips for the brain zaps??)
Before stopping the SSRI my blood pressure was averaging 145/80 which I still wasn’t happy with but my doctor insisted was fine. After stopping the SSRI I have had a few panic attacks and my blood pressure is creeping up to a 160/90. After having a few chest pains I went to my doctor and asked him to check my BP and add another medication which he did so – 4mg Prexum (which is an ACE inhibitor).
This seems to be doing a gradual job of returning my blood pressure to the ideal range (every time it’s taken the result is better – its still not perfect). I have notice that it increased my resting heart rate however.
When I was taking no medication my resting heart rate was ~70. Once I started taking amlodipine it dropped to 60. The ACE inhibitor seems to have increased it to ~ 80 to 90 – is this normal?
I’d like to also mention that before all this happened I was relatively fit and weight approximately 90kg at 6’3”. Over time (but especially after the first panic attack and the following year) I put on and extra 30kg and now weigh (120kg) which I understand makes me very overweight. I have tried to lost this weight through diet and light exercise (my doctors aren’t keen on my doing anything that gets my heart going to wild) with no success.
So finally my questions are as follows: Was the procedure correct in determining I definitely have essential hypertension (which if I didn’t have then has definitely set in now) my doctor seemed so dead set that it was a pheochromocytoma that I’m sure he ignored a lot of other possible causes – for instance would an underactive thyroid not cause my weight gain as well as explain the hypertension?
What tests (other than having my BP taken regularly) should I possibly undergo (eg, should I be having my kidneys checked annually or anything like that)? The reason I ask is because although my medical aid has those benefits outlined in my “care programme” I am never requested to do them.
My waist size is 42” now (used to be 36”), could all the fat I’m carrying cause an insulin resistance making it harder for me to lose weight? Is it reasonable that the doctors won’t let me go to gym and really get my heart going? (I’m sure this would have the most benefit. Walking my dog for half an hour a day may be good for the mind and soul but I can’t see it making my heart that much stronger…)
Lastly, with regards to the Ritalin which helped me so much to concentrate is this drug a “no no” for me? (I did stop taking it after the panic attack for fear of another panic attack)
I have told you a lot and asked a lot of questions, my main question however is really: Should I go to another specialist to reassess my situation rather than accepting the hypertension has no root cause – was adequate medical reasoning done?
Last question out of interest: why would I not have been put straight onto a beta blocker since this can also help with anxiety? Also, why would a calcium channel inhib be first choice over diuretic or ACE inhibitor?

Thank you in advance!
Posted Fri, 17 May 2013 in Hypertension and Heart Disease
Answered by Dr. Sukhvinder Singh 1 hour later
Dear Sir
Thanks for writing to us.

I would take your queries one by one.

1. Our Blood pressure (BP) is continuously changing and is effected by increase in physical and mental activity. Hence it will be higher with increased stress (mental/physical) and less in periods of calmness/ sleep/relaxation. A diagnosis of hypertension should ideally be based on > 3 readings of more than 140/90 mmHg over a period of weeks with patient in totally relaxed state. Only if a patients land with very high BP and there is an evidence of end organ damage, we would label it as hypertension straight away. I hope it clears if the diagnosis was correctly made or not in the first instance. (To label it as "essential hypertension" all the causes for secondary hypertension must be ruled out, as per indications.) Even now we can use the same criteria to see if you are adequately controlled or not & if you can reduce the medication or not?

2. Yes you may go for exercise/gym if your stress test (TMT/stress ECHO) shows that you have good exercise capacity (without any symptoms and abnormal ECG/ECHO changes) which would be ~10.5-12 METs for you.

3. Definitely a thyroid profile will help us to rule out hypothyroidism as a cause of weight gain and hypertension. Renal diseases, coarctation of aorta, reno-vascular diseases, hyperaldosteronism, cushing's syndrome and sleep apnea are other common causes of secondary hypertension beside thyroid and pheochromocytoma and we work them up as per initial assessment and indicators.

4. Beta-blockers do not decrease anxiety but a few of its manifestations and they have lost their place as preferred drugs for hypertension alone in last 8-10 years.

So I agree with a combination of amlodipine and perindopril. A calcium channel blocker preferred over a diuretic or ACE inhibitor is just a matter of individual preference and scientifically all three can be used as first line.

5. I think your case should be handled by a cardiologist and a psychologist/ psychiatrist together, so that you are on minimum drugs with optimal control of BP and with least stress/anxiety/depression.

6. I would not make a comment on psychological issues/drugs as I am not an expert for same.

Hope it gives you some insight. Feel free to discuss further.
Sukhvinder XXXXXXX
Above answer was peer-reviewed by
Follow-up: Experiencing high BP, panic attack. Prescribed with prozac, amlodipine. Normal EKG. Side effect? 8 hours later
Thank you very much for your response, you have indeed given much insight.

I'm sure that patients looking up their problems on the internet is a doctors worste nightmare so I do apologize, but I feel that a patient has the right to know if they are being looked after correctly as well as be educated on their condition and medication they are taking.

I think the initial amlodipine I was put on was because I was not in my home area and the doctor felt awkward letting me leave with a high blood pressure. After visiting my cardiologist he said I should just stay on the amlodipine because my blood pressure was now normal while on the drugs. I think this might have been a bit aggressive on the diagnosis but at the end of the day it is pretty clear cut these few years later that it was a good call (I do trust the professionals - it's just always nice to get second opinions...)

My concern is that all secondary causes haven't necessarily been ruled out. You mentioned the following may be causes

Please comment if any of the following may need more investigation -

Renal diseases - ruled out via blood tests.

Coarctation of aorta - I assume this was ruled out through an ultrasound

reno-vascular diseases - I think this was ruled out with a CT scan to verify the diameter of the arteries going to my kidneys

Hyperaldosteronism - This was never checked, only the ephedrine and norephedrine levels in my urine

Cushing's syndrome - This was never tested for.
Considering the following, is it necessary to be tested for this:
Symptoms I have: Extreme weight gain, mood issues, hypertension, sleep disturbance (I never sleep through the night without waking up at least a couple of times)

Symptoms I do not have: baldness, hypercholesterolemia, muscle/bone weakness, osteoporosis, glucose intolerance (at least that I am aware of, I should probably do this test as my blood sugar normally sits at 6 regardless of if I've eaten or not)

Sleep apnoea: This one was interesting as I've never known it was linked to hypertension and may be something I need to check into as I do snore and cannot sleep through the night, my dad also has this. Maybe I will film myself sleep tonight...

I was also never tested for hypothyroidism which again, considering the following is it necessary to have it tested?
Symptoms I may have: Weight Gain, Baracardia (my heart rate was normally 60 - 70 before amlodipine, on amlodipine it normally remained ~60. After starting the ACE Inhib. it's not quite high), Fatigue, Dry itchy skin, it is arguable if I have depression or not as I generally feel quite happy but some of the symptoms do fit (although I would say clinically I do not at present but have been depressed before), decreased libido, impaired cognitive function (definitely noticeable after I finished school in terms of concentration), I may have gynecomastia to some extend but most likely just fat, fatigue
Symptoms I do not have: and intolerance to cold, constipation, bradycardia, decreased sweating, thin brittle nails, Rapid thoughts, Depression (also see above), poor muscle tone, I do not have fat strips on my collar bone, mood swings

Is there anything else that they should check like hormones? (I still don’t grow much facial hair at almost 26) and is there any benefit for going for another CT scan for my kidney’s arteries now that it’s 2 years later as well as another echo on my heart?

I probably sound like a massive hypochondriac, but I’m just trying to make sure that there is no secondary cause to my hypertension as I am still relatively young.

I dream of the day I can stop taking medication and once all secondary causes are ruled out, I am going to make the life change to do that.
Lastly, is it within my right as a patient to demand a stress test so I can exercise without worry? I used to do a lot of exercise but haven’t been able to since the cardiologist stopped me from doing anything but walking (and none of my other doctors really want to give the okay to do more either – which I do do, 30 minutes a day)

Thank you in advanced for any further insight you can give, and sorry I am apparently writing such long questions!

Kind Regards,

Answered by Dr. Sukhvinder Singh 2 hours later
Dear Sir
1. Aim of discussion is not to make you worried about yourself and the work-up which has been done. I am afraid that you didn't notice (in my first answer) that testing for secondary hypertension is based on clinical assessment and indicators. I wrote clearly that for each secondary cause there has to be indicators otherwise the cost of work-up will go sky high and it will waste so much time of healthcare providers. Hence do not try to look into each cause of secondary hypertension and try to rule it out yourself. For example (to make you understand), we get detailed work up of pheochromocytoma only when clinical features suggest so; not in all cases of hypertension. Similarly we think about aldosteronism when there is low potassium/ or adrenal mass on ultrasound. A normally palpable femoral artery with no radio-femoral delay with normal lower limb blood pressure on first examination itself speaks that we do not need any work-up for coarctation of aorta. In nutshell, the responsibility of ruling out secondary hypertension lies with your physician.
2. Amlodipine is not associated with decreased heart rate but it may be associated with increased heart rate and ACE inhibitors are heart rate neutral drugs.
3. When you will ask for your exercise prescription, the cardiologist will either allow you to do it to maximum (based on his assessment) or he will ask you to get a stress test done to determine your exercise capacity. So you need not worry about that.

I hope I made it simple for you sir.

Sukhvinder Singh
Above answer was peer-reviewed by
Follow-up: Experiencing high BP, panic attack. Prescribed with prozac, amlodipine. Normal EKG. Side effect? 36 minutes later
Thank you for the reply,

I didn't mean to make it sound like I was second guessing my doctor, I was just concerned about how many other options he considered other than pheochromocytoma since this is was the only thing he did tests on, even after the epinephrine/norepinephrine results in my urine came back normal he still made me go for the radioactive isomer CT.

This is why I was asking if the other two, considering my background should be tested for, I haven't seen that cardiologist in 2 years after moving state and basically want to know if I should go through the hassle of going to see another one here or just trust my GP to alter my meds as he sees fit.

The pressing concern for me really is that at the same time the blood pressure showed up, I gained weight and started struggling to concentrate which would indicate to me a secondary cause.

Kind Regards,
Answered by Dr. Sukhvinder Singh 14 minutes later
Dear Sir

As I mentioned earlier, you should seek opinion both the cardiologist (rather than GP) and psychologist/psychiatrist. I advised you so, because once you will remain mentally relaxed/ calm. A lot of problems like blood pressure/ issue of weight will come under better control, and your cardiologist will be able to know the real contribution by hypertension/ your physical problems. Right now it is an amalgamation of psychological issues and physical issues, where degree of physical issues appear more than what it is.

I hope it was of some help.

Sukhvinder Singh
Above answer was peer-reviewed by
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