White coat hypertension

White coat hypertension refers to elevated blood pressure readings that occur in the presence of medical professionals. This differs from sustained hypertension, which is when a person’s blood pressure is persistently higher than normal. The condition is also known as white coat syndrome or the white coat effect. It gets its name from the white lab coats that are frequently worn by medical professionals. For many years, it was thought to simply be an anxious reaction to being in a medical setting. However, modern research has raised concerns that it could be an indicator of high blood pressure that may occur in other settings that also provoke anxiety. As a result, many medical professionals are reevaluating how they test and treat patients who display white coat hypertension.

Background

Blood pressure is the force that blood applies to arteries as it moves through the circulatory system. Blood is pushed through the system by the pumping action of the heart. It carries nutrients and oxygen to all areas of the body and collects waste material to be removed through the kidneys and liver.

The typical amount of force needed to pump blood is considered normal blood pressure. It is recorded as two separate readings. The first number is the systolic reading, which measures the force with which the heart pumps the blood. The second number is the diastolic reading, which measures how much pressure exists when the heart is resting in between each beat. A normal blood pressure reading is generally considered to be about 120 systolic and 80 diastolic, or 120 over 80.

Some people suffer from high blood pressure with no discernable cause. This is referred to as primary hypertension. Other people have high blood pressure that is triggered by something else, such as medication, another health condition, being overweight, eating foods that have a negative effect on blood pressure, or too much stress. This is known as secondary hypertension. Both forms of hypertension can lead to significant health problems, including heart attacks, strokes, and damage to the kidneys and other organs. While some people may notice symptoms such as headaches or a racing heart, high blood pressure often has no symptoms until it has caused harm to the body. As a result, checking a person’s blood pressure is part of nearly every routine physical exam.

Physicians were first able to measure blood pressure in the late eighteenth century. However, the process involved inserting tubing into an artery and was not a practical method for common use. In the mid-nineteenth century, methods were developed that stopped the blood flow in an arm and externally measured the force using the displacement of mercury in a tube. By 1896, this technique was improved to include the use of an air-inflated cuff similar to those used in modern times. This device is called a sphygmomanometer. Almost as soon as this device was in use, Scipione Riva-Rocci, the Italian internist who developed it, identified that some people had higher blood pressure when they were with a doctor than when they were not. He was the first to document what would be called white coat hypertension.

Overview

For many years, medical professionals considered white coat hypertension to be a benign, or non-harmful, condition. If the patient had normal or near-normal readings after resting for a while or when they were outside of the office, the higher blood pressure readings were dismissed. However, in the 1980s, nearly a century after Riva-Rocci identified the condition, the first significant research into white coat hypertension began. Researchers eventually came to believe that white coat hypertension is a more significant health risk than was originally thought.

The increased risk largely comes from the fact that white coat hypertension is essentially a reaction to the stress of being in a medical setting. Some people become anxious in a doctor’s office, possibly out of fear of being told something is wrong or that they need to make major lifestyle changes. However, there are many other settings that provoke similar anxiety and could prompt a similar increase in blood pressure. This could indicate that the person is subjected to surges in blood pressure at stressful times that could pose a health risk and lead to higher blood pressure. As a result, researchers now believe that white coat hypertension could be an indicator of the development of sustained hypertension.

Although white coat hypertension is an indicator of potential health risks, it is not generally treated with medication. Physicians usually take steps to be sure the patient has true sustained hypertension before prescribing medication because of the risks associated with giving a patient an inappropriate medication. A number of techniques are used to help differentiate white coat hypertension from hypertension. These include retaking the blood pressure after the person has had time to relax in the office, encouraging practices that promote relaxation, and having the patient use a home blood pressure monitor to gather readings outside of the medical office. In some cases, the patient may be asked to wear a monitor that takes blood pressure measurements over a period of time. These ambulatory blood pressure monitors, or ABPM, can help detect patterns that indicate if the patient does have high blood pressure in other settings.

Researchers have also determined that people who have white coat hypertension could also experience blood pressure spikes in situations where they are abruptly frightened or startled. This could be a sign of an undiagnosed anxiety disorder that could possibly be treated. Treatment would in turn improve the patient’s overall mental health and lessening the risk of heart attacks and strokes. The use of an ABPM can help determine if a pattern of blood pressure spikes exists that indicates an anxiety disorder.

Some studies have shown that as many as 30 to 40 percent of people who are treated for high blood pressure may have white coat hypertension, and not sustained hypertension. However, it is estimated that at least 1 and 5 percent of those with white coat hypertension will develop sustained hypertension. This condition is more likely to occur as people age, in those who are obese, and among people of African heritage.

Bibliography

Ben-Yehuda, Eli. “White Coat Syndrome: Causes and Treatments.” Resperate, 22 Jan. 2019, www.resperate.com/blog/hypertension/facts/definition-symptoms/white-coat-syndrome-causes-and-treatments. Accessed 2 March 2019.

Cobos, Briana et al. “White Coat Hypertension: Improving the Patient-Health Care Practitioner Relationship.” Psychology Research and Behavior Management, 2 May 2015, www.ncbi.nlm.nih.gov/pmc/articles/PMC4427265/. Accessed 2 March 2019.

Holland, Kimberly. “Everything You Should Know About White Coat Syndrome.” Healthline, 20 July 2017, www.healthline.com/health/white-coat-syndrome#treatment. Accessed 2 March 2019.

Myers-O’Shea, Brittany. “White Coat Hypertension: A Closer Look.” Pharmacy Times, 28 Aug. 2018, www.pharmacytimes.com/contributor/brittany-myers-pharmd/2018/08/white-coat-hypertension-a-closer-look. Accessed 2 March 2019.

Peacock, Pamela. “World Health Day 2013—A Short History of Sphygmomanometers and Blood Pressure Measurement.” Museum of Healthcare, 7 April 2013, museumofhealthcare.wordpress.com/2013/04/07/world-health-day-2013-a-short-history-of-sphygmomanometers-and-blood-pressure-measurement/. Accessed 2 March 2019.

Sheps, Sheldon G. “White Coat Hypertension: When Blood Pressure Rises at the Doctor’s Office.” Mayo Clinic, 9 Jan. 2019, www.mayoclinic.org/diseases-conditions/high-blood-pressure/expert-answers/white-coat-hypertension/faq-20057792. Accessed 2 March 2019.

“What is High Blood Pressure?” American Heart Association, 2019, www.heart.org/en/health-topics/high-blood-pressure/the-facts-about-high-blood-pressure/what-is-high-blood-pressure. Accessed 2 March 2019.

“White Coat Hypertension (and White Coat Effect.)” Blood Pressure UK, 2008,www.bloodpressureuk.org/BloodPressureandyou/Medicaltests/Whitecoateffect. Accessed 2 March 2019.