1049
LETTERS to the EDITOR
What is low blood pressure? SIR,-As someone interested in the sociology of medicine I am confused by the debatel-3 about the existence of hypotension as a clinical syndrome. This condition seems to be recognised as a serious illness in Germany but Anglo-American physicians do not consider it to be a clinical entity. And when British doctors state that the condition does exist it is often identified as a psychiatric symptom associated predominantly with "neurotic women". How can a clinical entity "exist" in one country but not in another? The British view was reinforced when I circulated a questionnaire to general practitioners, consultants, and student nurses. One respondent commented: "With regard to hypotension as a disease in its own right, this is a continental medical myth". Another said: "It seems that when a patient complains to a doctor of feeling off-colour in Germany there is a real likelihood that the diagnosis of low blood pressure will be made and these rather stupid preparations prescribed. In England, a similar patient will run the risk of getting the label ’nerves’ and a prescription for tranquillisers equally
inappropriately". The difference of view is highlighted in Pemberton’s research.s Visiting an epidemiologist in Dusseldorf, Pemberton noticed some statistics referring to patients absent from work with a diagnosis of hypotension. Not believing that this existed as a primary condition in the UK he asked for a description of it. The reply, given under the heading "constitutional hypotension", was that it exists if the
systolic blood pressure is constantly under 110 mm Hg in men and 100 mm Hg in women. The leading symptoms were listed as "bodily and mental tiredness, giddiness, a tendency to faint, and a tightness around the heart" and treatment consisted of exercise and peripheral vascular constrictors. This perception of a "hypotensive syndrome" is in contrast with an authoritative viewin which patients whose systolic blood pressure is 90-110 mm Hg are regarded as normal and may even have a greater life expectancy than those with normal blood pressure. Others would refute this assumption: for example, Mann2 has identified the possibility of psychiatric morbidity in people with low blood pressure. Although low blood pressure has been regarded as a "nondisease"7.8 or as an "ideal normal" pressure"* recent studies have demonstrated its association with psychosomatic illness or with particular social groups.9,10 Wessley and colleagues’1° population study has in its reference list an overwhelming proportion of research published in psychiatric journals. Robinson also comments on the need for psychotherapeutic help for hypotensive patients and notes that physicians may be applying the hypotension label "to a condition of general medicine presented disproportionately by women, those with less education and income, and older persons."4 Shapiro9 also has asked if a history of low blood pressure"might be a tracer for depression and other emotional problems, particularly among low-income groups" and Reilly’ points to a relation between low blood pressure and "low mood". All this, with Pilgrim and colleagues’ work,3suggests that hypotension should now be a clinical entity in Anglo-American medical discourse. However the defmition of "normal" blood pressure remains difficult,4 and before the "existence" of low blood pressure can be considered there will need to be a consensus amongst doctors about what normal is in this context. Science Studies Centre, School of Social Sciences. University of Bath,
Bath BA2 7AY, UK
GILLIAN HATT
1. Reilly H. Avoid BP drop in the depressed. Gen Practitioner 1992 (Jan 17): 4. 2. Mann A. Psychiatric symptoms and low blood pressure. Br Med J 1992; 304: 64-65 3. Pilgrim JA, Mansfield S, Marmot M. Low blood pressure, low mood? Br Med 1992; J 304: 75-78. 4. Robinson SC. Hypotension: the ideal normal blood pressure. N Engl J Med 1940; 223: 407-16. 5. Pemberton J. Does constitutional hypotension exist? Br Med J 1989; 298: 660-62. 6. Braunwald E, Engelman K. Hypotension and the shock syndrome. In: Wintrobe MM, et al, eds. Harrison’s principles of internal medicine. New York: McGraw-Hill, 1974. 7. Meador CK. The art and science of nondisease. N Engl J Med 1965; 272: 92-94. 8. Robbins JM, Korda H, Shapiro MF. Treatment for a nondisease: the case of low blood pressure. Soc Sci Med 1982; 16: 27-32. 9. Shapiro MF. Low blood pressure: an extinct diagnosis. Can Med Assoc J 1982; 126: 887-88. 10. Wessley S, Nickson J, Cox B. Symptoms of low blood pressure: a population study. Br Med J 1990; 301: 362-65.
The
oesophagus and chest pain
SIR,-I was surprised that in your March 7 editorial on the oesophagus and chest pain of uncertain cause you did not mention mitral valve prolapse. Chest pain is a common complaint in patients with mitral valve prolapse,l and its cardiac origin is still poorly understood.2 Oesophageal motility disorders commonly coexist with mitral valve prolapse3 and have proved to be an alternative explanation for these patients’ chest pain 4 The frequency of oesophageal motility disorders in patients with mitral valve prolapse, chest pain, and normal coronary arteriograms is over 50%,5 ranging from 4%6 to 78%.7 Whether you are gastroenterologists, cardiologists, or psychiatrists-and their patients with chest pains may have oesophageal motility disorders, microvascular angina or mitral valve prolapse, and panic disorders-there is a considerable overlap of these pain syndromes. Therefore much more needs to be done to understand the relation between and interactions among these
multisystem disorders. Division of Cardiology, Department of Medicine,
George Washington University Medical Center, DC 20037, USA
Washington
TSUNG O. CHENG
JB, Cheng TO. Mitral valve billowing and prolapse. In: Cheng TO, ed. The international textbook of cardiology New York: Pergamon, 1987: 497-524. 2. Cheng TO. Mitral valve prolapse. Dis Month 1987; 33: 481-534. 3. Hewson EG, Dalton CB, Hackshaw BT, Wu WC, Richter JE. The prevalence of abnormal esophageal test results in patients with cardiovascular disease and unexplained chest pain. Arch Intern Med 1990; 150: 965-69. 4. Cheng TO. Mitral valve prolapse and esophageal motility disorders Postgrad Med 1990; 88: 41 5. Castell DO. The esophagus. Boston: Little, Brown, 1992. 733. 6. Cheng TO. Mitral valve prolapse. Annu Rev Med 1989, 40: 201-11 7. Spears PF, Koch KL. Esophageal disorders in patients with chest pain and mitral valve prolapse. Am J Gastroenterol 1986; 81: 951-54. 1. Barlow
SiR,—We believe that comments in your March 7 editorial referring to our paper’ could be misinterpreted. Your readers might be led to understand that we accept a peristaltic wave amplitude of greater than 50 mg Hg to indicate nutcracker oesophagus (peristalsis of excessive amplitude). This is not so. Our criterion for nutcracker is an average amplitude over ten wet swallows of greater than 120 mm Hg.2 The figure you cite from our table v is the maximum amplitude of peristaltic waves in patients diagnosed with oesophageal spasm. Our defintion of spasm is a run of at least three simultaneous contractions on a raised baseline, which is quite
LETTERS to the EDITOR
What is low blood pressure? SIR,-As someone interested in the sociology of medicine I am confused by the debatel-3 about the existence of hypotension as a clinical syndrome. This condition seems to be recognised as a serious illness in Germany but Anglo-American physicians do not consider it to be a clinical entity. And when British doctors state that the condition does exist it is often identified as a psychiatric symptom associated predominantly with "neurotic women". How can a clinical entity "exist" in one country but not in another? The British view was reinforced when I circulated a questionnaire to general practitioners, consultants, and student nurses. One respondent commented: "With regard to hypotension as a disease in its own right, this is a continental medical myth". Another said: "It seems that when a patient complains to a doctor of feeling off-colour in Germany there is a real likelihood that the diagnosis of low blood pressure will be made and these rather stupid preparations prescribed. In England, a similar patient will run the risk of getting the label ’nerves’ and a prescription for tranquillisers equally
inappropriately". The difference of view is highlighted in Pemberton’s research.s Visiting an epidemiologist in Dusseldorf, Pemberton noticed some statistics referring to patients absent from work with a diagnosis of hypotension. Not believing that this existed as a primary condition in the UK he asked for a description of it. The reply, given under the heading "constitutional hypotension", was that it exists if the
systolic blood pressure is constantly under 110 mm Hg in men and 100 mm Hg in women. The leading symptoms were listed as "bodily and mental tiredness, giddiness, a tendency to faint, and a tightness around the heart" and treatment consisted of exercise and peripheral vascular constrictors. This perception of a "hypotensive syndrome" is in contrast with an authoritative viewin which patients whose systolic blood pressure is 90-110 mm Hg are regarded as normal and may even have a greater life expectancy than those with normal blood pressure. Others would refute this assumption: for example, Mann2 has identified the possibility of psychiatric morbidity in people with low blood pressure. Although low blood pressure has been regarded as a "nondisease"7.8 or as an "ideal normal" pressure"* recent studies have demonstrated its association with psychosomatic illness or with particular social groups.9,10 Wessley and colleagues’1° population study has in its reference list an overwhelming proportion of research published in psychiatric journals. Robinson also comments on the need for psychotherapeutic help for hypotensive patients and notes that physicians may be applying the hypotension label "to a condition of general medicine presented disproportionately by women, those with less education and income, and older persons."4 Shapiro9 also has asked if a history of low blood pressure"might be a tracer for depression and other emotional problems, particularly among low-income groups" and Reilly’ points to a relation between low blood pressure and "low mood". All this, with Pilgrim and colleagues’ work,3suggests that hypotension should now be a clinical entity in Anglo-American medical discourse. However the defmition of "normal" blood pressure remains difficult,4 and before the "existence" of low blood pressure can be considered there will need to be a consensus amongst doctors about what normal is in this context. Science Studies Centre, School of Social Sciences. University of Bath,
Bath BA2 7AY, UK
GILLIAN HATT
1. Reilly H. Avoid BP drop in the depressed. Gen Practitioner 1992 (Jan 17): 4. 2. Mann A. Psychiatric symptoms and low blood pressure. Br Med J 1992; 304: 64-65 3. Pilgrim JA, Mansfield S, Marmot M. Low blood pressure, low mood? Br Med 1992; J 304: 75-78. 4. Robinson SC. Hypotension: the ideal normal blood pressure. N Engl J Med 1940; 223: 407-16. 5. Pemberton J. Does constitutional hypotension exist? Br Med J 1989; 298: 660-62. 6. Braunwald E, Engelman K. Hypotension and the shock syndrome. In: Wintrobe MM, et al, eds. Harrison’s principles of internal medicine. New York: McGraw-Hill, 1974. 7. Meador CK. The art and science of nondisease. N Engl J Med 1965; 272: 92-94. 8. Robbins JM, Korda H, Shapiro MF. Treatment for a nondisease: the case of low blood pressure. Soc Sci Med 1982; 16: 27-32. 9. Shapiro MF. Low blood pressure: an extinct diagnosis. Can Med Assoc J 1982; 126: 887-88. 10. Wessley S, Nickson J, Cox B. Symptoms of low blood pressure: a population study. Br Med J 1990; 301: 362-65.
The
oesophagus and chest pain
SIR,-I was surprised that in your March 7 editorial on the oesophagus and chest pain of uncertain cause you did not mention mitral valve prolapse. Chest pain is a common complaint in patients with mitral valve prolapse,l and its cardiac origin is still poorly understood.2 Oesophageal motility disorders commonly coexist with mitral valve prolapse3 and have proved to be an alternative explanation for these patients’ chest pain 4 The frequency of oesophageal motility disorders in patients with mitral valve prolapse, chest pain, and normal coronary arteriograms is over 50%,5 ranging from 4%6 to 78%.7 Whether you are gastroenterologists, cardiologists, or psychiatrists-and their patients with chest pains may have oesophageal motility disorders, microvascular angina or mitral valve prolapse, and panic disorders-there is a considerable overlap of these pain syndromes. Therefore much more needs to be done to understand the relation between and interactions among these
multisystem disorders. Division of Cardiology, Department of Medicine,
George Washington University Medical Center, DC 20037, USA
Washington
TSUNG O. CHENG
JB, Cheng TO. Mitral valve billowing and prolapse. In: Cheng TO, ed. The international textbook of cardiology New York: Pergamon, 1987: 497-524. 2. Cheng TO. Mitral valve prolapse. Dis Month 1987; 33: 481-534. 3. Hewson EG, Dalton CB, Hackshaw BT, Wu WC, Richter JE. The prevalence of abnormal esophageal test results in patients with cardiovascular disease and unexplained chest pain. Arch Intern Med 1990; 150: 965-69. 4. Cheng TO. Mitral valve prolapse and esophageal motility disorders Postgrad Med 1990; 88: 41 5. Castell DO. The esophagus. Boston: Little, Brown, 1992. 733. 6. Cheng TO. Mitral valve prolapse. Annu Rev Med 1989, 40: 201-11 7. Spears PF, Koch KL. Esophageal disorders in patients with chest pain and mitral valve prolapse. Am J Gastroenterol 1986; 81: 951-54. 1. Barlow
SiR,—We believe that comments in your March 7 editorial referring to our paper’ could be misinterpreted. Your readers might be led to understand that we accept a peristaltic wave amplitude of greater than 50 mg Hg to indicate nutcracker oesophagus (peristalsis of excessive amplitude). This is not so. Our criterion for nutcracker is an average amplitude over ten wet swallows of greater than 120 mm Hg.2 The figure you cite from our table v is the maximum amplitude of peristaltic waves in patients diagnosed with oesophageal spasm. Our defintion of spasm is a run of at least three simultaneous contractions on a raised baseline, which is quite
