White coat hypertension

Last updated
White coat hypertension
Other namesWhite coat syndrome
Lab coat and scrubs.jpg
A white coat and scrubs

White coat hypertension (WHT), also known as white coat syndrome, is a form of labile hypertension [1] in which people exhibit a blood pressure level above the normal range in a clinical setting, although they do not exhibit it in other settings. [2] It is believed that the phenomenon is due to anxiety experienced during a clinic visit. [3] The patient's daytime ambulatory blood pressure is used as a reference as it takes into account ordinary levels of daily stress.

Contents

Masked hypertension (MH) is the contrasting phenomenon, whereby a patient's blood pressure is above the normal range during daily living but not in a clinic setting. [4]

Diagnosis

In studies, white coat hypertension can be defined as the presence of a defined hypertensive average blood pressure in a clinic setting, although it isn't present when the patient is at home. [5]

Diagnosis is made difficult as a result of the unreliable measures taken from the conventional methods of detection. These methods often involve an interface with health care professionals and frequently results are tarnished by a list of factors including variability in the individual's blood pressure, technical inaccuracies, anxiety of the patient, [6] inadequate cuff size of the instrument (sphygmomanometer) used to measure blood pressure, [7] recent ingestion of pressor substances, and talking, amongst many other factors. Automated blood pressure measurements over 15 to 20 minutes in a quiet part of the office or clinic can reduce (but not eliminate) incorrect blood pressure measures. [8]

People with white coat hypertension do not exhibit the signs indicative of trepidation and their increased blood pressure is often not accompanied by tachycardia. [9] This is supported by studies that repeatedly indicate that 15%–30% of those thought to have mild hypertension as a result of clinic or office recordings display normal blood pressure and no unusual response to pressure stimulus. These persons did not show any specific characteristics such as age that may be indicative of a higher susceptibility to white coat hypertension. [10]

Ambulatory blood pressure monitoring and patient self-measurement using a home blood pressure monitoring device is being increasingly used to differentiate those with white coat hypertension or experiencing the white coat effect from those with chronic hypertension. This does not mean that these methods are without fault. Daytime ambulatory values, despite taking into account stresses of everyday life when taken during the patient's daily routine, are still susceptible to the effects of daily variables such as physical activity, stress and duration of sleep. Ambulatory monitoring has been found to be the more practical and reliable method in detecting patients with white coat hypertension and for the prediction of target organ damage. Even as such, the diagnosis and treatment of white coat hypertension remains controversial.

A 2006 study of 98 patients showed that home blood pressure monitoring is as accurate as a 24-hour ambulatory monitoring in determining blood pressure levels. [11]

Use of breathing patterns has been proposed as a technique for identifying white coat hypertension. [12]

In one Turkish study of 438 consecutive patients, 38% were normotensive, 43% had white coat hypertension, 2% had masked hypertension, and 15% had sustained hypertension. Even patients taking medication for sustained hypertension who are normotensive at home may exhibit white coat hypertension in the office setting. [13]

Implications for treatment

When blood pressure is measured only in a clinic setting, an incorrect diagnosis of hypertension may be made whereas the person actually has white coat hypertension. In general, individuals with white coat hypertension have lower morbidity than patients with sustained hypertension, but higher morbidity than the clinically normotensive. [14] [7]

Related Research Articles

<span class="mw-page-title-main">Cardiology</span> Branch of medicine dealing with the heart

Cardiology is the study of the heart. Cardiology is a branch of medicine that deals with disorders of the heart and the cardiovascular system. The field includes medical diagnosis and treatment of congenital heart defects, coronary artery disease, heart failure, valvular heart disease, and electrophysiology. Physicians who specialize in this field of medicine are called cardiologists, a sub-specialty of internal medicine. Pediatric cardiologists are pediatricians who specialize in cardiology. Physicians who specialize in cardiac surgery are called cardiothoracic surgeons or cardiac surgeons, a specialty of general surgery.

<span class="mw-page-title-main">Blood pressure</span> Pressure exerted by circulating blood upon the walls of arteries

Blood pressure (BP) is the pressure of circulating blood against the walls of blood vessels. Most of this pressure results from the heart pumping blood through the circulatory system. When used without qualification, the term "blood pressure" refers to the pressure in a brachial artery, where it is most commonly measured. Blood pressure is usually expressed in terms of the systolic pressure over diastolic pressure in the cardiac cycle. It is measured in millimeters of mercury (mmHg) above the surrounding atmospheric pressure, or in kilopascals (kPa). The difference between the systolic and diastolic pressures is known as pulse pressure, while the average pressure during a cardiac cycle is known as mean arterial pressure.

<span class="mw-page-title-main">Hypertension</span> Long-term high blood pressure in the arteries

Hypertension, also known as high blood pressure, is a long-term medical condition in which the blood pressure in the arteries is persistently elevated. High blood pressure usually does not cause symptoms itself. It is, however, a major risk factor for stroke, coronary artery disease, heart failure, atrial fibrillation, peripheral arterial disease, vision loss, chronic kidney disease, and dementia. Hypertension is a major cause of premature death worldwide.

A sphygmomanometer, also known as a blood pressure monitor, or blood pressure gauge, is a device used to measure blood pressure, composed of an inflatable cuff to collapse and then release the artery under the cuff in a controlled manner, and a mercury or aneroid manometer to measure the pressure. Manual sphygmomanometers are used with a stethoscope when using the auscultatory technique.

Antihypertensives are a class of drugs that are used to treat hypertension. Antihypertensive therapy seeks to prevent the complications of high blood pressure, such as stroke, heart failure, kidney failure and myocardial infarction. Evidence suggests that reduction of the blood pressure by 5 mmHg can decrease the risk of stroke by 34% and of ischaemic heart disease by 21%, and can reduce the likelihood of dementia, heart failure, and mortality from cardiovascular disease. There are many classes of antihypertensives, which lower blood pressure by different means. Among the most important and most widely used medications are thiazide diuretics, calcium channel blockers, ACE inhibitors, angiotensin II receptor antagonists (ARBs), and beta blockers.

<span class="mw-page-title-main">Indapamide</span> Thiazide-like diuretic drug

Indapamide is a thiazide-like diuretic drug used in the treatment of hypertension, as well as decompensated heart failure. Combination preparations with perindopril are available. The thiazide-like diuretics reduce risk of major cardiovascular events and heart failure in hypertensive patients compared with hydrochlorothiazide with a comparable incidence of adverse events. Both thiazide diuretics and thiazide-like diuretics are effective in reducing risk of stroke. Both drug classes appear to have comparable rates of adverse effects as other antihypertensives such as angiotensin II receptor blockers and dihydropyridine calcium channel blockers and lesser prevalence of side-effects when compared to ACE-inhibitors and non-dihydropyridine calcium channel blockers.

<span class="mw-page-title-main">Pulmonary artery catheter</span> Catheter for insertion into a pulmonary artery

A pulmonary artery catheter (PAC), also known as a Swan-Ganz catheter or right heart catheter, is a balloon-tipped catheter that is inserted into a pulmonary artery in a procedure known as pulmonary artery catheterization or right heart catheterization. Pulmonary artery catheterization is a useful measure of the overall function of the heart particularly in those with complications from heart failure, heart attack, arrythmias or pulmonary embolism. It is also a good measure for those needing intravenous fluid therapy, for instance post heart surgery, shock, and severe burns. The procedure can also be used to measure pressures in the heart chambers.

Sir Richard Peto is an English statistician and epidemiologist who is Professor of Medical Statistics and Epidemiology at the University of Oxford, England.

<span class="mw-page-title-main">Julian Tudor-Hart</span> British general practitioner

Alan Julian Macbeth Tudor-Hart, commonly known as Julian Tudor Hart, was a general practitioner (GP) who worked in Wales for 30 years, known for theorising the inverse care law. He produced medical research and wrote many books and medical articles.

<span class="mw-page-title-main">Perindopril</span> High blood pressure medication

Perindopril is a medication used to treat high blood pressure, heart failure, or stable coronary artery disease.

Hypertensive encephalopathy (HE) is general brain dysfunction due to significantly high blood pressure. Symptoms may include headache, vomiting, trouble with balance, and confusion. Onset is generally sudden. Complications can include seizures, posterior reversible encephalopathy syndrome, and bleeding in the back of the eye.

<span class="mw-page-title-main">Ambulatory blood pressure</span> Technique for measuring blood pressure over regular intervals

Ambulatory blood pressure, as opposed to office blood pressure, is the blood pressure over the course of the full 24-hour sleep-wake cycle. Ambulatory blood pressure monitoring (ABPM) measures blood pressure at regular intervals throughout the day and night. It avoids the white coat hypertension effect in which a patient's blood pressure is elevated during the examination process due to nervousness and anxiety caused by being in a clinical setting. ABPM can also detect the reverse condition, masked hypertension, where the patient has normal blood pressure during the examination but uncontrolled blood pressure outside the clinical setting, masking a high 24-hour average blood pressure. Out-of-office measurements are highly recommended as an adjunct to office measurements by almost all hypertension organizations.

Prehypertension, also known as high normal blood pressure and borderline hypertensive (BH), is a medical classification for cases where a person's blood pressure is elevated above optimal or normal, but not to the level considered hypertension. Prehypertension is now referred to as "elevated blood pressure" by the American College of Cardiology (ACC) and the American Heart Association (AHA). The ACC/AHA define elevated blood pressure as readings with a systolic pressure from 120 to 129 mm Hg and a diastolic pressure under 80 mm Hg, Readings greater than or equal to 130/80 mm Hg are considered hypertension by ACC/AHA and if greater than or equal to 140/90 mm Hg by ESC/ESH. and the European Society of Hypertension defines "high normal blood pressure" as readings with a systolic pressure from 130 to 139 mm Hg and a diastolic pressure 85-89 mm Hg.

CYT006-AngQb was an investigational vaccine against angiotensin II, designed to lower blood pressure. It was somewhat effective in clinical trials, but less so than conventional drugs against hypertension.

Renal sympathetic denervation (RSDN) is a minimally invasive, endovascular catheter based procedure using radiofrequency ablation or ultrasound ablation aimed at treating resistant hypertension. Nerves in the wall of the renal artery are ablated by applying radiofrequency pulses or ultrasound to the renal arteries. This causes reduction of sympathetic afferent and efferent activity to the kidney and blood pressure can be decreased. Early data from international clinical trials without sham controls was promising - demonstrating large blood pressure reductions in patients with treatment-resistant hypertension. However, in 2014 a prospective, single-blind, randomized, sham-controlled clinical trial failed to confirm a beneficial effect on blood pressure. A 2014 consensus statement from The Joint UK Societies did not recommend the use of renal denervation for treatment of resistant hypertension on current evidence. More recent sham-controlled trials suggest renal denervation can lead to lower systolic blood pressure.

<span class="mw-page-title-main">Blood pressure measurement</span> Techniques for determining blood pressure

Arterial blood pressure is most commonly measured via a sphygmomanometer, which historically used the height of a column of mercury to reflect the circulating pressure. Blood pressure values are generally reported in millimetres of mercury (mmHg), though modern aneroid and electronic devices do not contain mercury.

Thomas G. Pickering was a British physician and academic. He was a professor of medicine at College of Physicians and Surgeons, Columbia University Medical Center in New York City. He was an internationally renowned expert in clinical hypertension and a leader in the fields of hypertension and cardiovascular behavioral medicine. He coined the term "white-coat hypertension" to describe those whose blood pressure was elevated in the doctor's office, but normal in everyday life. He later published the first editorial describing "masked hypertension". He also discovered and gave his name to the Pickering Syndrome, where bilateral renal artery stenosis causes flash pulmonary edema.

Una Martin is an emeritus professor of clinical pharmacology and was formerly the deputy pro-vice chancellor for equalities at the University of Birmingham. She is an expert in hypertension and ambulatory monitoring. She is a Fellow of the British Pharmacological Society.

<span class="mw-page-title-main">Labile hypertension</span> Medical condition

Labile hypertension occurs when there are unexpected changes in blood pressure. The term can be used to describe when people have blood pressure measurements that abruptly fluctuate from being abnormally high, approximately 140/90mm Hg or over and returns to its normal range.

Refractory hypertension(RfHTN) is hypertension, a high blood pressure, that remains uncontrolled on maximal or near-maximal therapy, that includes the use of ≥5 antihypertensive agents of different classes. Agents used include a long-acting thiazide-like diuretic (such as chlorthalidone) and spironolactone. Refractory hypertension is typically associated with increased sympathetic nervous system activity. The phenotype of refractory hypertension was first proposed in a retrospective analysis of patients referred to the University of Alabama at Birmingham Hypertension Clinic whose blood pressure could not be controlled on any antihypertensive regimen.

References

  1. ↑ Mann, Samuel J. (2009). "The Clinical Spectrum of Labile Hypertension: A Management Dilemma". The Journal of Clinical Hypertension. 11 (9): 491–497. doi: 10.1111/j.1751-7176.2009.00155.x . PMC   8673041 . PMID   19751461. S2CID   9378265.
  2. ↑ "Hypertension: Overview". eMedicine. 9 November 2022.
  3. ↑ Swan, Norman (20 June 2010). Health Minutes - Hypertension. Archived from the original on 2021-12-22. Retrieved 27 August 2010.
  4. ↑ Pickering TG, Eguchi K, Kario K (June 2007). "Masked hypertension: a review" (–). Hypertens. Res. 30 (6): 479–88. doi: 10.1291/hypres.30.479 . PMID   17664850.
  5. ↑ Ruxer J, Mozdzan M, Baranski M, Wozniak-Sosnowska U, Markuszewski L (October 2007). ""White coat hypertension" in type 2 diabetic patients". Pol. Arch. Med. Wewn. 117 (10): 452–6. PMID   18320786.
  6. ↑ Jhalani, Juhee a; Goyal, Tanya a; Clemow, Lynn a; Schwartz, Joseph E. b; Pickering, Thomas G. a; Gerin, William a (December 2005). "Anxiety and outcome expectations predict the white-coat effect". Blood Pressure Monitoring. 10 (6). Lippincott Williams & Wilkins, Inc.: 317–319. doi:10.1097/00126097-200512000-00006. PMID   16496447. S2CID   2058260.
  7. 1 2 Pickering T (1994). "Blood pressure measurement and detection of hypertension". Lancet. 344 (8914): 31–5. doi:10.1016/S0140-6736(94)91053-7. PMID   7912303. S2CID   41756474.
  8. ↑ Pickering, TG; Hall, JE; Appel, LJ; et al. (2005). "Recommendations for blood pressure measurement in humans and experimental animals: Part 1: blood pressure measurement in humans: a statement for professionals from the Subcommittee of Professional and Public Education of the American Heart Association Council on High Blood Pressure Research". Hypertension. 45 (5): 142–61. doi: 10.1161/01.HYP.0000150859.47929.8e . PMID   15611362. See p. 146, Masked Hypertension or Isolated Ambulatory Hypertension.
  9. ↑ Pickering T, James G, Boddie C, Harshfield G, Blank S, Laragh J (1988). "How common is white coat hypertension?". JAMA. 259 (2): 225–8. doi:10.1001/jama.259.2.225. PMID   3336140.
  10. ↑ McGrath B (1996). "Is white-coat hypertension innocent?". Lancet. 348 (9028): 630. doi:10.1016/S0140-6736(05)65069-6. PMID   8782749. S2CID   6990525. - commentary on:
    Glen S, Elliott H, Curzio J, Lees K, Reid J (1996). "White-coat hypertension as a cause of cardiovascular dysfunction". Lancet. 348 (9028): 654–7. doi:10.1016/S0140-6736(96)02303-3. PMID   8782756. S2CID   35890241.
  11. ↑ Niiranen TJ, Kantola IM, Vesalainen R, Johansson J, Ruuska MJ (May 2006). "A comparison of home measurement and ambulatory monitoring of blood pressure in the adjustment of antihypertensive treatment". Am. J. Hypertens. 19 (5): 468–74. doi: 10.1016/j.amjhyper.2005.10.017 . PMID   16647616.
  12. ↑ Thalenberg JM, Póvoa RM, Bombig MT, de Sá GA, Atallah AN, Luna Filho B (October 2008). "Slow breathing test increases the suspicion of white-coat hypertension in the office". Arq. Bras. Cardiol. 91 (4): 243–9, 267–73. doi: 10.1590/s0066-782x2008001600010 . PMID   19009177.
  13. ↑ Helvaci MR, Seyhanli M (2006). "What a high prevalence of white coat hypertension in society!". Intern. Med. 45 (10): 671–4. doi: 10.2169/internalmedicine.45.1650 . PMID   16778338.
  14. ↑ Khan TV, Khan SS, Akhondi A, Khan TW (2007). "White coat hypertension: relevance to clinical and emergency medical services personnel". MedGenMed. 9 (1): 52. PMC   1924974 . PMID   17435652.
This page is based on this Wikipedia article
Text is available under the CC BY-SA 4.0 license; additional terms may apply.
Images, videos and audio are available under their respective licenses.