I received a question from one patient regarding her concern about high blood pressure or hypertension at her physician’s office. She told me that her blood pressure at home is always below 135/85 mm Hg, but interestingly, her blood pressure surges significantly at her physician’s office. She is confused and does not know which numbers should be relied on. She is especially concerned because of her strong family history of stroke and coronary artery disease. Her father died at age 45 of a massive heart attack, and her aunt suffered a massive stroke at a young age.
White Coat Hypertension
This issue is increasingly recognized as a major problem in current clinical offices and is known as hypertension or white coat hypertension. As many as 10-20% of patients tend to have higher blood pressure (depending on the definition) in their physicians’ offices than they do at home. I also see this problem very often in my own office. The term “white coat hypertension” is used to describe the patient who has persistently elevated office blood pressure (higher than 140/90 mm Hg) and reliable out-of-office blood pressure measurements (less than 140/90 mm Hg). One study has shown that patients who had higher blood pressure on their first visit to a new physician had an average of a 15 to 7 mm Hg drop in the systolic and diastolic blood pressure, respectively, by the third visit.
Diagnosis of Hypertension
It has been recommended that patients with mild to moderate high blood pressure should not be diagnosed with hypertension unless the blood pressure remains elevated after three to six visits or there is evidence of ongoing end organ damage.
The cardiovascular risk associated with white coat syndrome is unknown. Patients with white coat syndrome may develop persistent hypertension in the future. I always have major issues with downplaying any signs and symptoms related to general health. It is important to confirm that the patient continues to have well-controlled blood pressure at home. Ordering a 24-hour ambulatory blood pressure monitoring (ABPM), as well as measuring blood pressure in the home with an oscillometric device, could help us to evaluate this matter closely. This process may be particularly useful for patients with fluctuating blood pressure readings in the office and wide discrepancies between readings at home and in a physician’s office (white coat syndrome).
Factors That Can Affect Blood Pressure Measurement
It is also important for everybody to know that smoking cigarettes or drinking coffee within 30 minutes of a blood pressure measurement should be avoided. Conversation during a blood pressure measurement can also contribute to higher readings. In addition, failure to support the patient’s arm and having the cuff at heart level is associated with high blood pressure and heart rate. The size of the blood pressure cuff should be adjusted to the size of the patient’s upper arm.
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