(WebMD) — The so-called “white coat effect” is both real and common in the management of hypertension and it may be a significant cause of patient overtreatment, a new study finds.
Researchers from Duke University and the Durham VA Medical Center report that blood pressure readings taken in doctors’ offices were consistently higher than those taken at home or in the research setting.
Doctors largely rely on one or two blood pressure readings taken in their offices to determine if patients need treatment for high blood pressure or if hypertension is adequately controlled in patients who are already on medication.
The researchers concluded that repeated measurements taken at home may help give a more accurate picture of blood pressure control than a single reading in a doctor’s office.
Duke assistant professor of medicine Benjamin J. Powers, MD, who led the research team, says the finding lends credence to the notion that the stress of a medical exam can cause large elevations in blood pressure.
“Blood pressure normally fluctuates from hour to hour, and from day to day” he tells WebMD. “Even knowing this, we were surprised to see how big the differences were between clinic and home readings.”
Close to one in three adults in the U.S. has high blood pressure, but only about half of these people are adequately controlling the condition with drugs, according to the CDC.
While undertreatment is far more common than overtreatment, the new research highlights the largely unrecognized risk of treating patients too aggressively based on falsely high blood pressure readings, Powers says.
The study included 444 male veterans being treated for hypertension who had blood pressure readings taken in three different settings: a doctor’s office, at home with a blood pressure cuff; and in the research setting (which included multiple readings taken by a trained researcher).
Just one in three patients had either consistently controlled or uncontrolled blood pressure across all three settings over the 18-month study.
The researchers concluded that blood pressure needs to be tested five or six times to give the best estimate of the patient’s true status.
(25 votes, average: 4.52 out of 5)
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I am one of those people that has very high blood pressure when taken at the doctor’s office. It can be as high as 178 over 90 – and just two hours before at home it will be 132 iover 78. Thankfully, my doctor is aware of this and treats me accordingly. I just tell her my reading over the last week before I come in.
The history of BP control in patients is based on readings taken in a doctor’s’ offices and therefore by definition includes the affect of ‘white coat syndrome.
Do we have enough information yet to base treatment on ‘real’ BP readings. I believe for diagnosis many doctors add 3mm Hg to ‘at home readings and 7mg to ambulatory readings in order to correlate with their own readings on which treatment has been based for so many years
I’m one of these too! Mine started in my teens…I’ve been watched ever since and taking my own readings at home for the past 15 years. I rarely EVER have a normal BP reading in the doctor’s office. My physician knows this and requires me to bring in a week or two’s worth of readings every visit. It’s not only normal at home, it’s optimal. When pregnant last year, she hospitalized me twice for high BP at my prenatal checks. It was around 160/90 in the office. As soon as I visited the hospital, relaxed in a bed, the readings quickly matched my home readings- 110’s-120’s over 60’s and I was literally released one hour later. When having my baby, my readings were normal for the 3 days b/c the machine was taking it not a person! I know that mine is due to anxiety…flight or fight response. My heart rate is always 120 when I see that cuff! That alone tells the nurses and doctor’s how nervous I am-resting heart rate at home is in low 60’s. I’m prepared for the fact that one day I may need BP meds b/c of heredity(my father’s although we have very different lifestyles, is high), but for now (I’m 33) it’s a healthy diet and exercise, and closely monitoring it at home. My BP has never shown a high reading at home and this has been 15 years. The day it goes up consistenly at home, is when I’ll seek meds. The thing I do worry about is- it probably goes up during ANY stress, not just doctors’ offices.
Finally! And halleluia. Something “acceptable” to show one’s own doctor.
yup thats me, since a stupid Dr scared the heck out of me I have had white coat hypertension and now refuse to let them take it in the office. I take my readings with me to any Dr I have to see.
Yes, I share that ‘club’. My doctor now just tells me the my brand new Omron monitor is wrong! You can’t win. I yet have to find a doctor who takes BP readings as recommended by the Mayo Clinic or the British Hypertension Society and shows the competence of really knowing what they are doing. BP treatment seems to be based on trial and error, which really scares me. I am an architect and would never build a house on the trial and error method (in fact, if I did that I would be out of work now), yet doctors prescribe potent medication on trial and error method.
My blood pressure was always low at home,125/77 –133/80.Then in 2008 I went to the doctor for a physical. hadn’t been to a doctor for 25 years. My blood pressure was 180/90 after a 2 hour wait in an overcrowded waiting room! The doctor spent 5 minutes with me ,just long enought to scare the crap out of me by saying those 5 words,”U have high blood pressure”. He convinced me I was going to have a stroke and gave me prescriptions for HBP drugs. The doctor scare and the HBP drugs actually gave me High Blood Pressure! They over medicated me which led to insomnia and depression of which the doctors prescribed more drugs for. This year with the help of a good doctor and a shrink I have been able to cut the medication in half. I am still slowly cutting back. and plan to be off all the drugs by 2012 with God’s help! I plan on writing a book about the three years I spent in hell including suicide attempt all cause by being over medicated by a doctor that was in to big of a hurry! Dr. Faheen
I also can relate to this experience. Ten years ago I followed the doctor’s advice and took medication. I lived a year of sheer hell, the accumulation of ‘minor’ side effects also drove me close to suicide. There was not a single day in my life anymore where I could get up in the morning and feel good about another day coming. On top of that I started to suffer from depression, which I never had before, and is unknown in my family. All was blamed on either ‘menopausal’ or being a hypochondriac. I requested doctor’s correspondence and I have proof of this. A specialist wrote to my doctor: “She describes symptoms I never ever heard of!” I lost once a prescription and he wrote: “She left the prescription behind, which is a clear indication that she will not take the medication.”
And this from a qualified specialist; They were ‘assumptions’ not based on fact! When I realised I left the script behind I rang the reception and asked them to mail it to me.
I also believe women run the far greater risk of not being taken seriously when they complain about side-effects of BP medication. Most drug trials, incidentally, are carried out on healthy men and not middle-aged women. Is there a possibility that men do suffer less side-effects, hence the trials are safer to be carried out on men?
Wow,I can’t believe I got this email today, could have used this yesterday. Yesterday was my annual GYN exam, almost didn’t go because I knew they would take my BP it would be high and that would be all they would focus on. I take BP pills, monitor my pressue at home where it is generally in a very acceptable range. When I explain that I have severe white coat syndrome or cuff anxiety, they roll their eyes at me. I have had this problem since my early 20’s, I’m in my early 50’s now. I have sought help to get over this but unfortunately nothing helps. Glad to read an article that back ups the syndrome, not all doctors believe it. I know that I am proof that the syndrome is alive and well.
The articles on this issue of white coat are very interesting. I have the white coat effect which is very predominant. At the home setting my blood pressure is usually 120/75 to 140/80. But in the hospital setting it jumps to 160/90 to 180/100. My doctor understands this though he is still of the opinion that I should be on medications. I am comforted by the fact that many others are in the similar situation.
My blood pressure readings in the doctor’s office are nearly always done wrong. I am seated on the exam table (no back support) and often without arm support. The nurse often talks to me and asks questions, which require an answer, so I am talking during the test. All of these can raise blood pressure readings.
Yes, same here. I mentioned this in one of my previous posts. My doctor makes me sit bolt upright in a chair, back not supported, arm straight down onto the desk. Then she pumps it up furiously, releases it just as fast and cries: “YES! You have high blood pressure!” One reading only / visit.
I have noticed the same thing. Trouble is for an aviation medical the doc has to do the measurement in his office. Last time I took a few extra antenolol and that did the trick. I don’t like doing it the readings at home are usually ok, and it’s temporary and I am healthy.
Me too! At home my BP averages 114/65, at the doctor’s office it has been as high as 155/90.
My doctor does not believe in white coat syndrome. She says “Well how would you handle just the everyday stress?” I know my BP is up when I go in the doctor’s office. They bring me in and take my BP right away instead of letting me sit and get used to being there. And you’re right, that’s what they focus on. When I go to my OB/GYN for my annual, they take my BP and it’s normal. But then, the nurse who takes me in and takes it is so congenial and she relaxes me. I wish more doctor’s could have staff like that. I think we’re all over medicated!
I have had several arguments with my doctors in the past due to the same problem. When they take my blood pressure at their office it is always elevated (sometimes 190/110) but in my home it seldom goes above 140/80 and normally it is around 125/77). I have even stopped going to see my doctor due to this cause and because the very fact of having those pressure readings there contitutes a real danger of stroke or another cardiovascular event in their own offices! (due to the threatening effect of a doctor’s visit on impressive psyches). It is a good idea to have a weekly record of your BP home readings and to bring them to your medical appointments before any inexperienced nurse ever places a sphygmomanometer cuff around your arm.
My doctor realizes this discrepancy and prefers to treat the high reading saying this is when a stroke is likely to occur and we have to protect against it.
This is true. At the same time BP readings do fluctuate and even healthy people can have high readings when under pressure. I’ve done an advanced driving workshop and a young woman had a BP monitor strapped to her arm. During the test drives around the race track her BP rose to 180/120. It would be bizarre to suggest she could have a stroke at that point, especially since her BP at any other time was below what is now regarded as ‘normal BP’.
So I guess it also depends on other factors, such as age, general health, blood chemistry, etc. With all the health dangers that are around, from flu to high blood pressure, cancer, etc. one could develop a fear of living. No wonder people are getting stressed.
I too find that my pressure is high…thanks for sharing your situations…..I feel relieved that I’m not the only one that has this problem.
i suffered 9 years of highblood pressure,but my problems started when i became severely depressed,i was given antidepressant and some other tablets as i became paranoid at some stage,but instead of getting me better for one thing the after effect of the mental health meds created me to suffer highblood pressure up till now,there was a time my bloodpressure was so high that it broke the veins in my eyes and it made my eyes bleed,and it affected me which now i have one side of my heart swollen,sometimes the doctors are not aware in what their prescribe for the patients,am not better am worsed off now.
That is true the effect of going to doctor office
make your blood pressure to go up higher. I went
to doctor in April this year and i my blood pressure
was 160 over 100 but they do wrong. So all the doctors
are doing cause the problem not help the problem.
Also the machine that you purchase is incorrect possible 20 points higher. When do you reading at
the doctor office your arm should be not below your
heart is should be same level heart so actual reading.
Doctors will refer to hospital if they feel there is high blood pressure but the 24 hour monitor is, I feel , even more unreliable. To wear something worn by someone else for all personal care and sleeping, for 24 hours including workplace is a guaranteed way of raising blood pressure – who knows how clean the previous person or equipment is and then there is the ‘wait’ for the next reading in 20 mins or so?
Keeping your own record is the only way I have found of proving no medication is warranted – and this is still a major ‘fight’.
The new 24-hour monitors are actually quite small and more of less comfortable to wear. I had a unit that I wore on a belt and could be taken off during the night. The wires did not bother me too much.
As for hygiene; The tabs that stick to your skin are replaced for each person and the unit is being wiped down (as far as I know). I don’t think hygiene is a real concern here. The regular intervals of readings are somewhat of a nuisance, but may be you could take a day off work?
I had a 24-hour monitor twice and the overall result was less than at the doctor’s surgery. I had one reading during the day which was 160/90 and the doctor took this as the reading to (try) to treat me for high blood pressure. The lowest was 112/60, which was ignored. The readings in between, and what I was doing at that time was also ignored. My blood chemistry is perfect, I am fit and healthy, and not overweight. This is not taken into account either. What matters to most doctors it seems, is that number. And they try everything to hammer it down, and when it has been hammered into submission, not matter how rotten you feel, the doctor is happy.
Having said all that… I still believe people need to be aware of their blood pressure, their general health, weight, fitness, etc. There are situations where medication is definitely warranted.
Any BP over 120/80 in considered Pre-Hypertensive (the numbers have become tightened up in recent years). Keep in mind that a normal BP for each individual may change the risk and numbers. As for myself, my average daily BP is between 80-90 over 45-60. This would be very low for someone who is normally 120/80. The rule is, anything over 30mmHg above your normal average BP is dangerous. Even if just a one-time-event due to stress you are still at high risk. Here are the facts: A rise in your BP directly results in increased pressure in your arteries and veins. If you have a clot in one of your peripheral veins (sometimes noted as a DVT) this increased pressure can dislodge that clot and it moves through the veins towards the heart, lungs and other vital organs including the brain. This clot will become lodged in a smaller artery and cut the circulation to that area of the organ. This is called either a PE in the lungs (pulmonary embolism) or a stroke (Ischemic stroke in the brain). Either are life threatening and can result in death even if treated right away depending on the conditions. This is why Hypertension is often refered to as THE SILENT KILLER. So, take any episode of HTN seriously and follow directions for eating right, taking needed medications and pay attention to your body and f/u with your doctor.
You are right, LJ.
– But how do I know that I may have a clot?
– Will the clot go away and the risk be reduced if I take medication to lower blood pressure?
– Will the medication prevent the clot from being dislodged?
My blood chemistry is just about perfect, I am trim and fit, but my BP at the clinic is borderline, sometimes higher.
Yesterday, while walking I was nearly run over by a SUV turning across the side-walk into the owner’s driveway. My heart almost stopped seeing the gleaming bull bar so close to my body!