White Coat Syndrome or Hypertension?

bp, blood pressure

First let me be clear that White Coat Syndrome is a real diagnosis. Insurance companies even recognize it as a diagnosis, although it is typically coded as “Elevated blood pressure without the diagnosis of hypertension”. In any case it can be a real obstacle to overcome in a doctor’s office, especially in an urgent care where the doctor probably has never seen you before. Let’s go over a few things about hypertension and elevated blood pressure.

Guidelines

I will try not to bore you with the guidelines, but this will explain why it’s not so cut and dry when you ask your doctor, “isn’t that reading high?”  The Joint National Committee published there 7th report on hypertension to the Journal of the American Medical Association (JAMA) in 2003. Those are the guidelines that you are probably somewhat familiar with.  Of course you can imagine that there were 6 previous reports dating back to 1976. The 7th version had the following definitions of BP.

JNC-8 was published in 2014. Through similar methodologies, a panel of experts and specialists formed new a classification of BP. While not considered definitions, these BP goals were more generous. What I relief for the physician. Now we didn’t have to call a 19 year old with a BP of 125/81 a “prehypertensive”. The guidelines were as follows (ignore the last row).

In 2017 the American College of Cardiology and the American Heart Association (ACC/AHA) again redefined hypertension. What is important to note in their findings was that they emphasized the importance of proper technique when taking a BP. Their guidelines were as follows.

Too high or too low?

The 2003 and 2017 guidelines are very similar. While JNC 8 did change the approach in treating a hypertensive, it was too lenient in my opinion. Hypertension itself does not kill. It is when the organs fail because of hypertension that we see heart attacks, strokes and kidney failure.

Keep in mind that seldom does end organ damage occur from one bout of an elevated BP. It typically takes years of untreated hypertension (usually only mild-moderately high) before we see any of this. It is a chronic disease and often referred to the “silent killer” because patients are usually unaware of the destruction it is slowly causing.

Low blood pressure on the other hand is typically not going to kill you, at least in an office setting. Of course extremely low BP (shock) is deadly. But those are not typically the patients that are sitting in a chair talking to me. For this reason I think it is better to err on the side of keeping BP on the lower side. Please keep in mind there are many other factors that are considered when deciding to start a patient on antihypertensive medications.

White Coat Syndrome

White coat syndrome is when a patient’s BP is elevated while a healthcare professional is taking their blood pressure (regardless of whether he/she is wearing a white coat). As a primary care I have seen this many times. Not only does it make the patient uneasy but it also makes me uneasy.

There have been times when I have taken manual BP readings of 190/100 or even higher sometimes. The patient then tells me “I have white coat syndrome” and my BP is normal at home.” 190/100 is a dangerously high BP, and even a one time instance of it can lead to stroke and heart attack. But do I believe the patient that they are getting normal BP at home, and do I trust that there equipment is working properly at home? It is a judgment call for the physician and there have been times when I send the patient to the ER and there are times when I have sent them home. I always tell the patient to bring their BP cuff with them during the next follow up appointment in order to calibrate it.

Inconsistent BP

If you were to take your BP right now and then again in 5 minutes it will be similar but likely not the same. If you were to walk up a flight of stairs, your blood pressure likely will be elevated and not a true representation of your actual resting BP. Would you expect your blood pressure to be the same when you are sleeping as it is when you are in traffic?

In an urgent care setting especially during flu season, you unfortunately, but more than likely will experience a frantic staff, who is trying to get you in and out of the door as quickly as possible.  You most likely are sick or hurt as well. The medical assistant will walk you down a long hallway, sit you down on the exam table and immediately take your blood pressure. You may be out of breath from the walk, have a fever, or even be in pain from a broken bone. While blood pressure is a vital piece of information to the provider, it is not an ideal setting to diagnose hypertension. 90% of my patients that visit an urgent care are walking out with an elevated BP over 120/80. This does NOT mean they have hypertension.

Answer

So what is too high? Unless your BP is extremely elevated to a point where acute organ failure is possible, you shouldn’t worry. A competent doctor should be able to tell you if he/she is concerned. While there are no specific numbers to be concerned about, Emergent Hypertension is defined as a BP over 180/120 along with signs of end organ damage (the doctor will be able to identify). When emergent hypertension is suspected, the provider will likely refer you to the emergency room for acute treatment.

Hypertension

Hypertension is a diagnosis that should be left to the primary care physician. An urgent care is not an ideal setting for making this decision. It is a relatively simple fix with medication or life style change. Not addressing an elevated reading may not have immediate effects but possibly have profound consequences in the future when the damage has already been done.

Comments

  1. Richard M Plotzker

    There was an important study on this, a somewhat disturbing one, that looked at cardiovascular mortality and total mortality based on office and home BP’s/

    https://www.nejm.org/doi/full/10.1056/NEJMoa1712231

    people high in the office and at home did poorly. Some of these people had what the article called masked hypertension, that is it was high but not captured in the office. the white coat people, high in office but normal at home did about as well as the normals. the ones who were high in the office and at home, which they called sustained hypertension, had about the same risk as the masked hypertensives. It questioned the value of random testing in the office, yet the landmark studies following the death of FDR who died of malignant hypertension and prompted funding, were entirely based on repetitive clinic bp’s

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      Author
      FastPass Doc

      thanks for the article, it was a good read. It’s always difficult when you have to take patients at their word when they say their BP is normal at home.

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