Labile hypertension

Labile Hypertension
Labile Hypertension
	Graphic image that shows vasoconstricting and vasodilation of a blood vessel to show fluctuation in blood pressure
Specialty	Cardiology
Risk factors	Cardiovascular disease, stroke
Diagnostic method	Blood pressure measurements
Prevention	avoidance of smoking, limited alcohol intake, reduced intake of salt and caffeine

Last updated April 27, 2024

Labile hypertension occurs when there are unexpected changes in blood pressure. The term can be used to describe when people have blood pressure measurements that abruptly fluctuate from being abnormally high, approximately 140/90mm Hg or over and returns to its normal range.^[1]

Patients who have labile hypertension may have higher cardiac output and lower total peripheral resistance than others.^[2] Behavioural and lifestyle factors are the two main factors that causes labile hypertension to occur. Extrinsic factors such as physical activities, insomnia and intake of sodium are likely to increase the occurrence of labile hypertension. Reduced arterial compliance and baroreflex failure may contribute to trigger a response as well.^[3] Diagnosis is typically by 24 hours ambulatory blood pressure monitoring to which measurements can be taken at home without having to visit to the physician’s office.

Labile hypertension can be a primary risk factor that may contribute to stroke or cardiovascular disease (CVD). Prevention of life threatening complications involves lifestyle changes such as avoidance of smoking and reducing the amount of salt, caffeine and alcohol intake. There are no set criteria to treat labile hypertension as there are many underlying mechanisms and symptoms. Because stressors are the main cause of labile hypertension, common treatment may involve prescription medications such as anti-anxiety tablets to reduce emotional stressors, and otherwise, as well as decrease the risk of labile hypertension.

Types

There are two different types of hypertension, though, the underlying mechanisms to which the blood pressure fluctuates from being normal to abnormally high remains the same.^{[ citation needed ]}

Labile hypertension: Normally occur during emotional or social stressors and may not physically show symptoms. Currently, there are limitations of current knowledge behind the mechanisms of labile hypertension and clinicians are still finding future clinical management. ^{[ citation needed ]}
Paroxysmal hypertension: Occur randomly during the day but it is said that paroxysmal hypertension are caused by repressed distressed emotions such as intense fear due to past trauma. Some of the physical symptoms that accompany include headache, weakness and fear. Paroxysmal hypertension is different from panic disorder in which they are characterised with extreme elevation of blood pressure that is not triggered by fear. In panic disorder, elevation of blood pressure is generally mild and is normally triggered by fear or panic.^[4] There is a small percentage, approximately 2% who raises suspicion for have pheochromocytoma, a tumour in the adrenal glands. This involves the sympathetic nervous system and treatment for paroxysmal hypertension is available.^[5]

Symptoms and signs

Generally, labile hypertension does not present any physical symptoms during fluctuations of blood pressure. Elevation and decrease of blood pressure reading usually occurs without intervention. However, if the normal resting pressure remains abnormally excessive, common signs and symptoms that are present include: Headache, Heart palpitations, Flushing, Tinnitus (ringing or buzzing noise in one or both ears), Weakness of body, Dizziness and diaphoresis. Some may describe the episodes as abrupt in onset such that they were not evoked by stress. Episodes of these symptoms may range from half an hour to many hours and frequently of attacks ranged from once or twice a day to a few months.^{[ citation needed ]}

Complications

Typically, an increase in blood pressure may put strain on the heart and possibly other organs that may cause damage to the blood vessels, eyes and the heart. Uncontrollable increase in blood pressure can cause damage to the arteries that are present around kidneys, and thus restrict the blood to deliver. Due to inconsistent fluctuations in blood pressure, this can cause additional problems to people with pre-existing heart or blood vessel conditions such as angina, cerebral aneurysm or aortic aneurysm.^[6] Uncontrolled pressure in the blood can lead to further complications such as vascular dementia as the narrowed arteries can reduce and limit blood flow to the brain.^{[ citation needed ]}

Causes

It is important to understand that it is common for blood pressure to rise and fall dramatically when dealing with stressors in people’s everyday life. While these can be normal, others may be serious. Possible causes alone or in conjunction that can cause labile hypertension are in the following criteria.^{[ citation needed ]}

Caffeine: consumption of caffeine may constrict blood vessels that may stimulate and display unexpected spikes in blood pressure. Researchers believe that caffeine could possibly block hormones that normally keep arteries widened. Caffeine may also cause adrenal glands to release adrenaline which causes the blood pressure to dramatically increase.
White Coat Syndrome: occurs in situations when people are anxious with their visit to the doctor or General Practitioner (GP) which can elevate blood pressure readings.^[7]
Pheochromocytoma: Normally, in a healthy person, the non-cancerous tumour that is present in the adrenal gland is responsible for releasing hormones that can cause the blood pressure to change. However, if diagnosed with Pheochromocytoma, there will be a neuroendocrine tumour that is found in the adrenal gland which can cause overproduction of induced hormones that can lead to episodic of high blood pressure.^[8]
Salt: People may develop blood pressure spikes in high sodium intake that is contained in meals. High sodium intake may put extra strain in arteries which causes the muscles in the artery walls to become thicker. The radius inside the artery space will be smaller. As the arteries are constricted, organs such as the heart that receives the blood from the arteries decreases. This will reduces the amount of oxygen and nutrients they need and may cause possible damage to organs. At early stage, it may cause a slight reduction of blood flowing to the heart that may lead to angina. Salt can also cause damage to the brain such that there is reduction of blood that reaches the brain and may lead to vascular dementia. According to The American Heart Association (AHA), the recommended daily salt intake is 2300 mg.
Anxiety: environmental stressors are exposed in daily lives that can cause sudden increase in blood pressure. For example, emotional stressors leads to severe reduction of arterial blood pressure.
Baroreflex failure: In the human body, baroreflexes maintain blood pressure homeostasis. Typically, the three circumstances that baroreflexes can fail are: problems with the central processing, damage to the Autonomic Nervous System which is associated with damage to parasympathetic and sympathetic damage and damage to carotid sinus that can cause failure to afferent signalling. ^[9]

Labile hypertension can occur through exposure to everyday lifestyles. Some of these include are the usage of tobacco. Tobacco significantly increase blood pressure and heart rate temporarily and can damage the artery walls caused by the chemicals that are contained in tobacco.^[10] Chemicals in tobacco include nicotine and carbon monoxide interferes with the cardiovascular system (CVD). Nicotine is a stimulant that releases vasopressin, and can cause the blood vessel to constrict and thus can reduce the amount of blood to flow. Carbon monoxide is a toxic chemical that binds haemoglobin (molecule in the blood that carries oxygen) will decrease the amount of oxygen delivered to the cells and cause damage to other organs in the body.

Damage to the arterial walls can cause vasoconstriction, allowing the arteries to narrow which can increase the risk of heart disease.^[11] Drinking too much alcohol moderately (more than one drink for women and two drinks for men) can cause damage to the heart. Researchers have found that heavy drinkers can lead to episodes of tachycardia, a problem with the electrical signalling that can elevate heart rate. Frequent drinking can lead blood clots and may increase severity of heart attack or stroke.

Diagnosis

Ambulatory blood pressure monitoring: A non-invasive portable device that can monitor and record blood pressure automatically during specific time of the day, especially is focused on people who have White Coat Syndrome as it can reduce the elevation of blood pressure during the visit in the examination room.^[12] This can allow doctors to identify results and observe patterns.^[13] Patients who normally undergo ambulatory blood pressure monitoring are suggested to keep record on the periods of awake and asleep times, medication intake and periods when exposed to exercise. This allows the clinicians to eliminate the transition periods when blood pressure rapidly elevates.^[14]

The blood pressure reading is recorded as two numbers, systolic and diastolic. The systolic blood pressure represents the amount of pressure the blood is applying against artery walls during heartbeats whereas the diastolic blood pressure shows while the heart is resting between beats.^{[ citation needed ]}

Electrocardiogram (EKG or ECG): A clinical test to measure and record electrical conductivity of the heart. It helps determine defects of heart electrical activity, rhythm and rate to help assist in diagnosis of heart defects that may affect in heart rhythm such as tachycardia and coronary artery blood flow (e.g. ischemia). Electrodes are placed on the surface of the skin and connected to the amplifier to detect electrical changes in the cardiac muscle when it is depolarising and repolarising.^{[ citation needed ]}

Treatment

There are no specific set criteria to treat labile hypertension. This is because the condition is not yet well defined and makes it difficult for doctors to treat labile hypertension as medications are usually given for patients who have hypertension. Generally, doctors will suggest people to monitor and observe their blood pressure throughout the day, preferably for 24 hours, as commonly prescribed medications available today for blood pressure may not be effective. Because labile hypertension is mainly caused by anxiety, in occurrence to short term situations, doctors will often prescribe anti-anxiety medications that may help reduce any stressors. Some of the common medications to reduce anxiety includes:^{[ citation needed ]}

Alprazolam (Xanax): oral tablet that has an enhancing effect to help prevent panic or anxiety disorders.
Clonazepam (Klonopin): oral tablet that helps prevent seizures and panic attacks.
Diazepam (Valium): may help reduce the effect of anxiety when withdrawal with alcohol intake.
Lorazepam (Ativan): Should be taken in short period of time between 2-4weeks that reduces anxiety.

Long-term treatment of anxiety that requires daily medication would include: Paroxetine (Paxil), Sertraline (Zoloft), Escitalopram (Lexapro), Citalopram (Celexa). Otherwise, a prescription drug called Clonidine is used to lower blood pressure by relaxing the blood vessels. This will prevent life threatening problems such as stroke, heart attacks and kidney problems.^{[ citation needed ]}

Beta blockers are medications that often prevent paroxysmal and labile hypertension as they interact with the sympathetic nervous system. Beta blockers help reduce blood pressure by blocking the effects of hormone epinephrine, also known as adrenaline. The effect of taking beta blockers can help lower the heart rate as well as help improve the blood flow by opening up the blood vessels widely. Doctors may prescribe beta blockers as one of the medications that help reduce blood pressure , including diuretics and calcium channel blockers.^{[ citation needed ]}

Management

Labile hypertension can be initially treated through behavioural modifications. Behavioural factors such as the mental activity of an individual or emotional status should be managed. Anxiety is one of the common forms of mental illness, there are increasing risks that can affect physical health problems. Therefore, to reduce stress and anxiety, reduction to smoking and alcohol, decreasing intake of salt or having regular aerobic activity are some examples of therapy that can help manage cases of labile hypertension. By reducing alcohol intake, the systolic blood pressure will lower by 2-4mm Hg and the diastolic blood pressure by 1–2 mm Hg.^{[ citation needed ]}

However, doctors will preferably suggest patients to monitor blood pressure at home during modification of lifestyle and behavioural changes.^{[ citation needed ]}

Epidemiology

The prevalence of labile hypertension in USA is estimated to have more than 40 million adults which can develop the risks of hemorrhagic stroke.^[15] Labile hypertension is most common in Charlottesville, Virginia with up to 11% of the population. Average age who have labile hypertension is 64±13 years.^[16] It was found that ageing was one of the characteristics that highly associates with fluctuations of blood pressure such that during day or night time, the systolic and diastolic pressure alternates and shows abnormal diurnal pattern.^{[ citation needed ]}

Related Research Articles

Blood pressure (BP) is the pressure of circulating blood against the walls of blood vessels. Most of this pressure results from the heart pumping blood through the circulatory system. When used without qualification, the term "blood pressure" refers to the pressure in a brachial artery, where it is most commonly measured. Blood pressure is usually expressed in terms of the systolic pressure over diastolic pressure in the cardiac cycle. It is measured in millimeters of mercury (mmHg) above the surrounding atmospheric pressure, or in kilopascals (kPa). The difference between the systolic and diastolic pressures is known as pulse pressure, while the average pressure during a cardiac cycle is known as mean arterial pressure.

Hypertension, also known as high blood pressure, is a long-term medical condition in which the blood pressure in the arteries is persistently elevated. High blood pressure usually does not cause symptoms itself. It is, however, a major risk factor for stroke, coronary artery disease, heart failure, atrial fibrillation, peripheral arterial disease, vision loss, chronic kidney disease, and dementia. Hypertension is a major cause of premature death worldwide.

Orthostatic hypotension, also known as postural hypotension, is a medical condition wherein a person's blood pressure drops when standing up or sitting down. Primary orthostatic hypotension is also often referred to as neurogenic orthostatic hypotension. The drop in blood pressure may be sudden, within 3 minutes or gradual. It is defined as a fall in systolic blood pressure of at least 20 mmHg or diastolic blood pressure of at least 10 mmHg after 3 minutes of standing. It occurs predominantly by delayed constriction of the lower body blood vessels, which is normally required to maintain adequate blood pressure when changing the position to standing. As a result, blood pools in the blood vessels of the legs for a longer period, and less is returned to the heart, thereby leading to a reduced cardiac output and inadequate blood flow to the brain.

A sphygmomanometer, also known as a blood pressure monitor, or blood pressure gauge, is a device used to measure blood pressure, composed of an inflatable cuff to collapse and then release the artery under the cuff in a controlled manner, and a mercury or aneroid manometer to measure the pressure. Manual sphygmomanometers are used with a stethoscope when using the auscultatory technique.

Hypotension, also known as low blood pressure, is a cardiovascular condition characterized by abnormally reduced blood pressure. Blood pressure is the force of blood pushing against the walls of the arteries as the heart pumps out blood and is indicated by two numbers, the systolic blood pressure and the diastolic blood pressure, which are the maximum and minimum blood pressures within the cardiac cycle, respectively. A systolic blood pressure of less than 90 millimeters of mercury (mmHg) or diastolic of less than 60 mmHg is generally considered to be hypotension. Different numbers apply to children. However, in practice, blood pressure is considered too low only if noticeable symptoms are present.

Pulse pressure is the difference between systolic and diastolic blood pressure. It is measured in millimeters of mercury (mmHg). It represents the force that the heart generates each time it contracts. Healthy pulse pressure is around 40 mmHg. A pulse pressure that is consistently 60 mmHg or greater is likely to be associated with disease, and a pulse pressure of 50 mmHg or more increases the risk of cardiovascular disease. Pulse pressure is considered low if it is less than 25% of the systolic. A very low pulse pressure can be a symptom of disorders such as congestive heart failure.

Afterload is the pressure that the heart must work against to eject blood during systole. Afterload is proportional to the average arterial pressure. As aortic and pulmonary pressures increase, the afterload increases on the left and right ventricles respectively. Afterload changes to adapt to the continually changing demands on an animal's cardiovascular system. Afterload is proportional to mean systolic blood pressure and is measured in millimeters of mercury.

Essential hypertension is a form of hypertension without an identifiable physiologic cause. It is the most common type affecting 85% of those with high blood pressure. The remaining 15% is accounted for by various causes of secondary hypertension. Essential hypertension tends to be familial and is likely to be the consequence of an interaction between environmental and genetic factors. Hypertension can increase the risk of cerebral, cardiac, and renal events.

White coat hypertension (WHT), more commonly known as white coat syndrome, is a form of labile hypertension in which people exhibit a blood pressure level above the normal range in a clinical setting, although they do not exhibit it in other settings. It is believed that the phenomenon is due to anxiety experienced during a clinic visit.

Valvular heart disease is any cardiovascular disease process involving one or more of the four valves of the heart. These conditions occur largely as a consequence of aging, but may also be the result of congenital (inborn) abnormalities or specific disease or physiologic processes including rheumatic heart disease and pregnancy.

A hypertensive emergency is very high blood pressure with potentially life-threatening symptoms and signs of acute damage to one or more organ systems. It is different from a hypertensive urgency by this additional evidence for impending irreversible hypertension-mediated organ damage (HMOD). Blood pressure is often above 200/120 mmHg, however there are no universally accepted cutoff values.

In medicine, systolic hypertension is defined as an elevated systolic blood pressure (SBP). If the systolic blood pressure is elevated (>140) with a normal (<90) diastolic blood pressure (DBP), it is called isolated systolic hypertension. Eighty percent of people with systolic hypertension are over the age of 65 years old. Isolated systolic hypertension is a specific type of widened pulse pressure.

Prehypertension, also known as high normal blood pressure and borderline hypertensive (BH), is a medical classification for cases where a person's blood pressure is elevated above optimal or normal, but not to the level considered hypertension. Prehypertension is now referred to as "elevated blood pressure" by the American College of Cardiology (ACC) and the American Heart Association (AHA). The ACC/AHA define elevated blood pressure as readings with a systolic pressure from 120 to 129 mm Hg and a diastolic pressure under 80 mm Hg, Readings greater than or equal to 130/80 mm Hg are considered hypertension by ACC/AHA and if greater than or equal to 140/90 mm Hg by ESC/ESH. and the European Society of Hypertension defines "high normal blood pressure" as readings with a systolic pressure from 130 to 139 mm Hg and a diastolic pressure 85-89 mm Hg.

<span class="mw-page-title-main">Acute decompensated heart failure</span> Medical condition

Acute decompensated heart failure (ADHF) is a sudden worsening of the signs and symptoms of heart failure, which typically includes difficulty breathing (dyspnea), leg or feet swelling, and fatigue. ADHF is a common and potentially serious cause of acute respiratory distress. The condition is caused by severe congestion of multiple organs by fluid that is inadequately circulated by the failing heart. An attack of decompensation can be caused by underlying medical illness, such as myocardial infarction, an abnormal heart rhythm, infection, or thyroid disease.

Orthostatic syncope refers to syncope resulting from a postural decrease in blood pressure, termed orthostatic hypotension.

$<span class="mw-page-title-main">Heart failure with preserved ejection fraction</span> Medical condition$

Heart failure with preserved ejection fraction (HFpEF) is a form of heart failure in which the ejection fraction – the percentage of the volume of blood ejected from the left ventricle with each heartbeat divided by the volume of blood when the left ventricle is maximally filled – is normal, defined as greater than 50%; this may be measured by echocardiography or cardiac catheterization. Approximately half of people with heart failure have preserved ejection fraction, while the other half have a reduction in ejection fraction, called heart failure with reduced ejection fraction (HFrEF).

Arterial blood pressure is most commonly measured via a sphygmomanometer, which historically used the height of a column of mercury to reflect the circulating pressure. Blood pressure values are generally reported in millimetres of mercury (mmHg), though aneroid and electronic devices do not contain mercury.

Hypertension is managed using lifestyle modification and antihypertensive medications. Hypertension is usually treated to achieve a blood pressure of below 140/90 mmHg to 160/100 mmHg. According to one 2003 review, reduction of the blood pressure by 5 mmHg can decrease the risk of stroke by 34% and of ischaemic heart disease by 21% and reduce the likelihood of dementia, heart failure, and mortality from cardiovascular disease.

The main pathophysiology of heart failure is a reduction in the efficiency of the heart muscle, through damage or overloading. As such, it can be caused by a wide number of conditions, including myocardial infarction, hypertension and cardiac amyloidosis. Over time these increases in workload will produce changes to the heart itself:

<span class="mw-page-title-main">Hypertension and the brain</span>

Hypertension is a condition characterized by an elevated blood pressure in which the long term consequences include cardiovascular disease, kidney disease, adrenal gland tumors, vision impairment, memory loss, metabolic syndrome, stroke and dementia. It affects nearly 1 in 2 Americans and remains as a contributing cause of death in the United States. There are many genetic and environmental factors involved with the development of hypertension including genetics, diet, and stress.

References

↑ Hypertension Suzanne Oparil,1 Maria Czarina Acelajado,2 George L. Bakris,3 Dan R. Berlowitz,4,5 Renata Cífková,6 Anna F. Dominiczak,7 Guido Grassi,8,9 Jens Jordan,10 Neil R. Poulter,11 Anthony Rodgers,12 and Paul K. Whelton13, doi: 10.1038/nrdp.2018.14
↑ Eich, R. H.; Cuddy, R. P.; Smulyan, H.; Lyons, R. H. (1966-08-01). "Hemodynamics in Labile Hypertension: A Follow-Up Study". Circulation. 34 (2): 299–307. doi: 10.1161/01.CIR.34.2.299 . ISSN 0009-7322. PMID 5969360.
↑ Raj, Satish R.; Luther, James M.; Sato, Kyoko; Diedrich, André (April 2009). "'Labile hypertension' can be due to autonomic nervous system failure". Kidney International. 75 (8): 860, author reply 860–1. doi: 10.1038/ki.2008.665 . PMID 19337219.
↑ Mann, Samuel J. (1999-04-12). "Severe Paroxysmal Hypertension (Pseudopheochromocytoma): Understanding the Cause and Treatment". Archives of Internal Medicine. 159 (7): 670–674. doi:10.1001/archinte.159.7.670. ISSN 0003-9926. PMID 10218745.
↑ Mann, Samuel J. (November 2015). "Labile and Paroxysmal Hypertension: Common Clinical Dilemmas in Need of Treatment Studies". Current Cardiology Reports. 17 (11): 99. doi:10.1007/s11886-015-0646-0. ISSN 1534-3170. PMID 26370555. S2CID 207326490.
↑ Mann, Samuel J. (2009). "The Clinical Spectrum of Labile Hypertension: A Management Dilemma". The Journal of Clinical Hypertension. 11 (9): 491–497. doi: 10.1111/j.1751-7176.2009.00155.x . ISSN 1751-7176. PMC 8673041 . PMID 19751461. S2CID 9378265.
↑ Khan, Tipu V.; Khan, Safa Shakir-Shatnawi; Akhondi, Andre; Khan, Teepu W. (2007-03-13). "White Coat Hypertension: Relevance to Clinical and Emergency Medical Services Personnel". Medscape General Medicine. 9 (1): 52. ISSN 1531-0132. PMC 1924974 . PMID 17435652.
↑ Pagán, Ricardo J.; Kurklinsky, Andrew K.; Chirila, Razvan (November 2014). "A 61-year-old man with fluctuating hypertension". Cleveland Clinic Journal of Medicine . 81 (11): 677–682. doi: 10.3949/ccjm.81a.13142 . PMID 25368218.
↑ Heusser Karsten; Tank Jens; Luft Friedrich C.; Jordan Jens (2005-05-01). "Baroreflex Failure". Hypertension. 45 (5): 834–839. doi: 10.1161/01.HYP.0000160355.93303.72 . PMID 15837841.
↑ Farsalinos, Konstantinos; Cibella, Fabio; Caponnetto, Pasquale; Campagna, Davide; Morjaria, Jaymin Bhagwanji; Battaglia, Eliana; Caruso, Massimo; Russo, Cristina; Polosa, Riccardo (2016). "Effect of continuous smoking reduction and abstinence on blood pressure and heart rate in smokers switching to electronic cigarettes". Internal and Emergency Medicine. 11 (1): 85–94. doi:10.1007/s11739-015-1361-y. ISSN 1828-0447. PMC 4747988 . PMID 26749533.
↑ Kannel, W B; Sorlie, P; Gordon, T (June 1980). "Labile hypertension: a faulty concept? The Framingham study". Circulation. 61 (6): 1183–1187. doi: 10.1161/01.CIR.61.6.1183 . ISSN 0009-7322. PMID 7371131.
↑ McGrath, Barry P. (2002-06-17). "Ambulatory blood pressure monitoring". The Medical Journal of Australia. 176 (12): 588–592. doi:10.5694/j.1326-5377.2002.tb04590.x. PMID 12064958. S2CID 30889136.
↑ National Clinical Guideline Centre (UK) (2011). Hypertension: The Clinical Management of Primary Hypertension in Adults: Update of Clinical Guidelines 18 and 34. National Institute for Health and Clinical Excellence: Guidance. London: Royal College of Physicians (UK). PMID 22855971.
↑ O’Brien, Eoin; Dolan, Eamon; Asayama, Kei; Hara, Azusa; Li, Yan; Staessen, Jan A. (2017-05-01). "Blood Pressure Measurement Anno 2016". American Journal of Hypertension. 30 (5): 453–463. doi: 10.1093/ajh/hpw148 . ISSN 0895-7061. PMID 28052877.
↑ Varon, Joseph (October 2007). "Diagnosis and management of labile blood pressure during acute cerebrovascular accidents and other hypertensive crises". The American Journal of Emergency Medicine. 25 (8): 949–959. doi:10.1016/j.ajem.2007.02.032. ISSN 1532-8171. PMID 17920983.
↑ Elliott, Matthew R.; Soto Soto, Jose M.; Haley, William E.; Fitzpatrick, Peter M.; Dwyer, Jamie P. (2013). "Labile hypertension: characteristics of a referred cohort". Clinical and Experimental Hypertension. 35 (3): 207–212. doi:10.3109/10641963.2012.712180. ISSN 1525-6006. PMID 22917450. S2CID 5426441.

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[1] Hypertension Suzanne Oparil,1 Maria Czarina Acelajado,2 George L. Bakris,3 Dan R. Berlowitz,4,5 Renata Cífková,6 Anna F. Dominiczak,7 Guido Grassi,8,9 Jens Jordan,10 Neil R. Poulter,11 Anthony Rodgers,12 and Paul K. Whelton13, doi: 10.1038/nrdp.2018.14

[2] Eich, R. H.; Cuddy, R. P.; Smulyan, H.; Lyons, R. H. (1966-08-01). "Hemodynamics in Labile Hypertension: A Follow-Up Study". Circulation. 34 (2): 299–307. doi: 10.1161/01.CIR.34.2.299 . ISSN 0009-7322. PMID 5969360.

[3] Raj, Satish R.; Luther, James M.; Sato, Kyoko; Diedrich, André (April 2009). "'Labile hypertension' can be due to autonomic nervous system failure". Kidney International. 75 (8): 860, author reply 860–1. doi: 10.1038/ki.2008.665 . PMID 19337219.

[4] Mann, Samuel J. (1999-04-12). "Severe Paroxysmal Hypertension (Pseudopheochromocytoma): Understanding the Cause and Treatment". Archives of Internal Medicine. 159 (7): 670–674. doi:10.1001/archinte.159.7.670. ISSN 0003-9926. PMID 10218745.

[5] Mann, Samuel J. (November 2015). "Labile and Paroxysmal Hypertension: Common Clinical Dilemmas in Need of Treatment Studies". Current Cardiology Reports. 17 (11): 99. doi:10.1007/s11886-015-0646-0. ISSN 1534-3170. PMID 26370555. S2CID 207326490.

[6] Mann, Samuel J. (2009). "The Clinical Spectrum of Labile Hypertension: A Management Dilemma". The Journal of Clinical Hypertension. 11 (9): 491–497. doi: 10.1111/j.1751-7176.2009.00155.x . ISSN 1751-7176. PMC 8673041 . PMID 19751461. S2CID 9378265.

[7] Khan, Tipu V.; Khan, Safa Shakir-Shatnawi; Akhondi, Andre; Khan, Teepu W. (2007-03-13). "White Coat Hypertension: Relevance to Clinical and Emergency Medical Services Personnel". Medscape General Medicine. 9 (1): 52. ISSN 1531-0132. PMC 1924974 . PMID 17435652.

[8] Pagán, Ricardo J.; Kurklinsky, Andrew K.; Chirila, Razvan (November 2014). "A 61-year-old man with fluctuating hypertension". Cleveland Clinic Journal of Medicine . 81 (11): 677–682. doi: 10.3949/ccjm.81a.13142 . PMID 25368218.

[9] Heusser Karsten; Tank Jens; Luft Friedrich C.; Jordan Jens (2005-05-01). "Baroreflex Failure". Hypertension. 45 (5): 834–839. doi: 10.1161/01.HYP.0000160355.93303.72 . PMID 15837841.

[10] Farsalinos, Konstantinos; Cibella, Fabio; Caponnetto, Pasquale; Campagna, Davide; Morjaria, Jaymin Bhagwanji; Battaglia, Eliana; Caruso, Massimo; Russo, Cristina; Polosa, Riccardo (2016). "Effect of continuous smoking reduction and abstinence on blood pressure and heart rate in smokers switching to electronic cigarettes". Internal and Emergency Medicine. 11 (1): 85–94. doi:10.1007/s11739-015-1361-y. ISSN 1828-0447. PMC 4747988 . PMID 26749533.

[11] Kannel, W B; Sorlie, P; Gordon, T (June 1980). "Labile hypertension: a faulty concept? The Framingham study". Circulation. 61 (6): 1183–1187. doi: 10.1161/01.CIR.61.6.1183 . ISSN 0009-7322. PMID 7371131.

[12] McGrath, Barry P. (2002-06-17). "Ambulatory blood pressure monitoring". The Medical Journal of Australia. 176 (12): 588–592. doi:10.5694/j.1326-5377.2002.tb04590.x. PMID 12064958. S2CID 30889136.

[13] National Clinical Guideline Centre (UK) (2011). Hypertension: The Clinical Management of Primary Hypertension in Adults: Update of Clinical Guidelines 18 and 34. National Institute for Health and Clinical Excellence: Guidance. London: Royal College of Physicians (UK). PMID 22855971.

[14] O’Brien, Eoin; Dolan, Eamon; Asayama, Kei; Hara, Azusa; Li, Yan; Staessen, Jan A. (2017-05-01). "Blood Pressure Measurement Anno 2016". American Journal of Hypertension. 30 (5): 453–463. doi: 10.1093/ajh/hpw148 . ISSN 0895-7061. PMID 28052877.

[15] Varon, Joseph (October 2007). "Diagnosis and management of labile blood pressure during acute cerebrovascular accidents and other hypertensive crises". The American Journal of Emergency Medicine. 25 (8): 949–959. doi:10.1016/j.ajem.2007.02.032. ISSN 1532-8171. PMID 17920983.

[16] Elliott, Matthew R.; Soto Soto, Jose M.; Haley, William E.; Fitzpatrick, Peter M.; Dwyer, Jamie P. (2013). "Labile hypertension: characteristics of a referred cohort". Clinical and Experimental Hypertension. 35 (3): 207–212. doi:10.3109/10641963.2012.712180. ISSN 1525-6006. PMID 22917450. S2CID 5426441.

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