Does this type of elevated BP need to be treated?
It’s perfectly normal to be a little stressed or jittery at the doctor’s office. Maybe you rushed there after dropping off your kids at school or in between meetings at work, worrying about traffic and whether you’d be late. Maybe you’re nervous about the health problem that brought you to the doc and if it could be something serious. Maybe you’re annoyed you’ve been waiting for 20 minutes and there’s still two people ahead of you.
So it’s no wonder that you may be in a slightly less-than-calm mood as the nurse straps a blood pressure cuff around your arm. If you’ve ever worried this in-office stress could skyrocket your results, you’re probably not surprised that there’s a term for this: white coat hypertension, or high blood pressure only in the doctor’s office, but not in everyday life. This phenomenon is so common that it accounts for 15 to 30 percent of patients with elevated blood pressure during a doctor’s visit, according to a 2013 study in the journal Hypertension.
“White coat hypertension is stage fright,” says Satjit Bhusri, MD, a cardiologist at Lenox Hill Hospital. “You’re going to a doctor’s office. You don’t want to hear bad news. You get anxious [and] have that fight-or-flight response.” This produces well-recognizable symptoms: sweaty palms, rapid heartbeat, dilated eyes, constricted blood vessels, and—yep—an elevated BP. But white coat hypertension is a temporary state and not the same as having high blood pressure.
Recognizing white coat hypertension is crucial because it could result in a faulty diagnosis. “You don’t want to be treating blood pressure based on just one or two numbers when the reality is that a patient’s blood pressure is well controlled,” says Michelle Weisfelner Bloom, MD, a cardiologist at Stony Brook University Medical Center.
The opposite can also occur: “You may notice that your blood pressure in the office is perfectly normal but then your blood pressure at home is very high,” says Rachel Bond, MD, a cardiologist at Lenox Hill Hospital. “That’s something called masked hypertension.”
For patients with either masked hypertension or white coat hypertension, regular BP monitoring is recommended.
“These are patients we’re going to want to closely keep an eye on because they are at a little bit of a higher risk of having elevated blood pressure in the future,” says Dr. Bond. A study in the Journal of the American College of Cardiology found that patients over 60 with white coat hypertension who had other risk factors for heart disease (like smoking or obesity) were two times more likely to experience a heart attack than those without other risk factors.
Placing a patient on medication for high blood pressure (when they don’t really have it) could cause unnecessary or even dangerous side effects. Alternatively, failing to recognize masked hypertension could delay necessary treatment and allow the condition to progress. Here’s what high blood pressure does to the body if untreated.
Multiple readings at the doctor’s office and at home can help get a more accurate picture of day-to-day BP. (Here’s more info on how to self-monitor blood pressure at home.) Your doc may recommended home BP tests if they’re not convinced they’re getting an accurate reading in the office, according to Dr. Weisfelner Bloom.
Of course, you don’t have to wait for any diagnosis before proactively taking care of your heart. Here are lifestyle tweaks to have a healthier heart.
Dr. Bloom is an associate professor of medicine at Stony Brook University Medical Center, a fellow of the American College of Cardiology, and a fellow of the Heart Failure Society of America.Satjit Bhusri
Dr. Bhusri is an attending cardiologist at the Lenox Hill Heart & Vascular Institute and an assistant professor of cardiology at Hofstra Northwell School of Medicine.Rachel Bond
Dr. Bond is a cardiologist and associate director of the Women's Heart Health Program at Northwell Health, Lenox Hill Hospital and an assistant professor of cardiology at Hofstra Northwell School of Medicine.
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There are certain situations where
we don't get the whole picture,
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when a patient's sitting in our office.
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White coat hypertension
is stage fright.
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You're going to a doctor's office,
you don't want to hear bad news,
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you get anxious, what happens?
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You had that flight or fight response.
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Everybody has it,
it's like that stage fright you get.
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You have sweaty palms, your heart starts
beating faster, your vessels contract.
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Your eyes are dilated, and your blood
pressure, appropriately, goes up.
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And that's the reading
we get in the office.
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Where a patient may be more nervous, or
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may have a tendency toward a high
blood pressure when they're sitting in
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a doctor's office.
00:00:46,415 --> 00:00:48,998
But in their regular life,
their blood pressure's okay.
00:00:48,998 --> 00:00:52,425
And you don't want to be treating
a blood pressure based on just one or
00:00:52,425 --> 00:00:55,144
if the reality is that a patient's blood
00:00:55,144 --> 00:00:57,770
pressure is well-controlled.
You may notice that your
00:00:57,770 --> 00:01:00,170
blood pressure in the office
is perfectly normal,
00:01:00,170 --> 00:01:03,810
but then your blood pressure
at home is very high.
00:01:03,810 --> 00:01:05,589
And that's something called
00:01:05,589 --> 00:01:08,871
These are patients we're gonna
wanna closely keep an eye on,
00:01:08,871 --> 00:01:12,341
because they are at a little bit of
a higher risk of having elevated
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blood pressure in the future.
So I actually recommend
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blood pressure monitoring at home for
many of my patients.
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Either in patients where I am really not
convinced that the blood pressure is
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accurate when they're in the office.
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Or in a patient where I'm not getting
a good picture of whether there's a big
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fluctuation between times of day,
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And they're only in my office
one time of the day, but I
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have no idea if the blood pressure's going
higher at night or lower in the morning.
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I want to get a better sense,
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and I can do that by asking a patient
to check their blood pressure at home.
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And I can tell them specifically
the time of the day, or
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the times of the day that I want
them to check and report back to me.
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Franklin SS, Thijs L, Hansen TW, O’Brien E, Staessen JA. White-coat hypertension. Hypertension. 2013;62:982-7.Study questions effects of white coat hypertension. Washington, DC: American College of Cardiology, 2016. (Accessed on January 21, 2021 at https://www.cardiosmart.org/News-and-Events/2016/11/Study-Questions-Effects-of-White-Coat-Hypertension.)