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When your doctor makes your blood pressure soar

It could be a case of white-coat hypertension

Published: March 2013

“That’s not me!” exclaimed the 52-year-old stock analyst, a new patient, after I had found her blood pressure high at 150/90. “Just last week it was perfectly normal when I took it at my local CVS.” The numbers remained elevated on two subsequent office visits, so I asked her to purchase a digital blood-pressure monitor for use at home. Repeated checks at different times of the day were normal. So the likely diagnosis? White-coat hypertension, which is high blood pressure that occurs only when a person is in a doctor’s office.

White-coat hypertension was once only hinted at by the variation in blood pressure taken by different professionals at different times. The arrival of the home blood-pressure monitor showed that the diagnosis was plausible. The advent of the ambulatory blood-pressure monitor, which is worn for 24 hours and records blood pressure every 15 minutes, made the diagnosis definitive.

The condition can strike not only when in the room with an authority figure wearing a long white coat and a stethoscope but even in the waiting room in anticipation of such an encounter. Nowadays, it even has its own official diagnostic code number for billing purposes. The number gets quite a workout, given that 30 percent to 40 percent of people with hypertension have this variety.

The why and the who

The theory is that the patient’s adrenaline surges because of the stress of going to the doctor. But there must be more to it than that, because ambulatory readings have shown that the same people can have perfectly normal blood pressure in other high-stress situations, such as public speaking. There are even those who have elevated blood pressure during an office visit, normal readings with a home monitor, and elevated ones with an ambulatory monitor.

In studies that have looked at the demographics of this disorder, age seems to be more of a factor than ethnic origin, and men and women are similarly affected. Compared with people who have normal pressure, those with white-coat hypertension have increased systemic vascular resistance (a measure of susceptibility to high blood pressure), and an increased prevalence of such risk factors as obesity, high triglycerides, elevated LDL (bad) cholesterol, and blood sugar levels in the prediabetic range. Ambulatory recordings also reveal that they have greater variations in blood-pressure measurements than people with normal blood pressure.

Worth treating?

We know from many good studies that treating sustained hypertension can lower the risk of having a stroke, heart failure, and kidney disease. But is it worth treating a disorder that exists only when you see a doctor?

The answers are not easily forthcoming, since early studies found no differences in cardiovascular complications between people with white-coat hypertension and those with normal blood pressure. But as those studies lengthened and accumulated it became apparent that some forerunners of stroke, heart failure, and kidney disease—such as arteriosclerotic plaque in the lining of the carotid arteries, thickening of the heart muscle, and leakage of protein into the urine—were showing up more often in patients with white-coat hypertension than in normal controls. In addition, two recent studies found that people with white-coat hypertension have an elevated risk of developing sustained high blood pressure. Still, there is no solid evidence that treatment will affect the course of the disorder.

I asked a few other doctors in the office to check the stock analyst’s blood pressure. The result was always the same: high. Home and ambulatory measurements showed only normal blood pressures, including an ambulatory reading that took place during what she recalled as a nerve-wracking presentation before her company’s board of directors. At my suggestion, she has lost weight, increased her exercise, and restricted sodium, none of which has made any difference. She continues to use her home blood-pressure monitor twice a week and understands that if and when her numbers begin to climb, drug treatment may become necessary.

Marvin Lipman, M.D.

Chief Medical Adviser and Medical Editor
Editor's Note: This article first appeared in the monthly newsletter Consumer Reports on Health.

   

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