Saturday, June 20, 2009

White-Coat Hypertension, Panic, and Blood Pressure

"White-Coat Hypertension" is defined as a diagnosis of high blood pressure based on clinical measurements in people who do not have high blood pressure outside the doctor's office. It is commonly accepted that white-coat syndrome occurs in about 20% of all people diagnosed with hypertension [1]; some have speculated that the frequency may run as high as 30%. This means that somewhere between one in five and one in three people being treated for high blood pressure actually has normal blood pressure.

For a time, some in the medical community contended that white-coat hypertensives should be treated with medications, arguing that either 1) these patients probably suffered damage from such surges in blood pressure, or 2) that people with white-coat hypertension would probably go on to develop true hypertension. Both of these beliefs have been shown to be incorrect in the case of the vast majority of patients. The dangers and extra costs of unneccessary medication are now considered to outweigh any benefits from treating typical white-coat hypertensives.

In a previous post, I discussed many reasons that doctor's-office readings tended to be high. On top of these procedural errors by medical staff, many people experience considerable anxiety in doctor's offices (often without realizing it). Certainly very few people would list a doctor's office or hospital as the most relaxing environment they can imagine. (Although there is a very small percentage of patients who exhibit what is called "masked hypertension." These people for some reason show lower blood pressure in doctor's offices, and higher blood pressure when out in the real world.)

Strictly speaking, "white-coat hypertension" applies only to those patients who have normal blood pressure outside the doctor's office. But the effect seen in white-coat hypertension--a jump in measured blood pressure of up to 23 points systolic and 10 points diastolic--also exists in people who have high blood pressure.

For example, consider a patient who has a blood pressure of 160/95. Now, that's hypertension by any definition of the term. But that same patient may get readings in a doctor's office of 180/105, which is rather severe hypertension. If this effect persists, then even after treatment and medication that has reduced true, out-of-office blood pressure to 120/80, this patient will still read as 140/90 on doctor's visits, which will probably result in additional medications being prescribed.

As far as I can tell, there's no name for this effect. It's probably a kind of panic disorder. Whatever its name, I have it. I can take a blood pressure reading in my car out in the parking lot, walk into the doctor's office, and promptly get a second reading 20 points higher systolic, and 8-10 points higher diastolic.

I first discovered I had hypertension when they took a routine blood-pressure reading at an urgent-care clinic. Although higher blood pressures are commonly found during illness or after injury, mine was 185/111. This sent the staff into a tizzy, and they insisted I couldn't be treated for my injury, or in fact be allowed to leave, until my blood pressure came down. "This is a medical emergency," they said. "You need to relax!" Being told that you're in a medical emergency isn't the most relaxing thing in the world, and naturally they managed over the next hour to push my blood pressure higher and higher, topping out at 221/121.

It isn't something so simple as a fear of doctors. It's somehow a fear of the measurement itself. Researchers working with ambulatory blood-pressure monitoring have found that many patients with white-coat hypertension have a jump in blood pressure when they measure it themselves, though the rise is much smaller. Someone whose blood pressure leaps by 20 points in a doctors office may get readings 5-10 points too high taking their blood pressure themselves in the comfort of their homes.

It has long been known that panic disorders can raise both systolic and diastolic blood pressure readings. One study found that systolic pressures could rise as much as 36 points [2]. There is a widespread myth in the medical community that panic attacks only raise systolic blood pressure, but this belief is false; diastolic pressure doesn't jump as high systolic, but increases of 5-10 points in diastolic pressure are not uncommon.

Many people find the squeezing of the blood-pressure cuff around the upper arm to be unpleasant or unnerving. If the patient is concerned about the outcome of the reading, the continual increasing pressure tends to raise the level of concern; in my own case, when the cuff continues inflating for what seems like a prolonged period, I begin to wonder, "My God, how high can my blood pressure be, anyhow?" and my heart begins to hammer. In effect it becomes a race between the cuff inflation rate and my increasing blood pressure, and the longer the cuff takes to inflate and begin deflation, the longer my blood pressure has to gather itself together and rise too damn high.

Okay, so maybe I'm weird. But as it turns out, this isn't just a problem for for me. Studies have found that overinflating cuffs raises systolic blood pressure, even in those who aren't nervous and don't perceive the cuff as being overinflated [3]. Although I haven't seen any studies on the trend towards autoinflating cuffs, these new automatic devices often wildly overpressure the patient's arm. What's worse, they often do it in stages, tightening to what seems like an intolerable level and then "listening;" and then deciding that the pressure is still insufficient, swelling even further and further. Overtightening in and of itself raises blood pressure, and I'm certain that any careful study would show that taking extra time to overtighten raises blood pressure even further.

I now ask the doctor or nurse to measure my blood pressure with manual inflation, since human beings are far less likely to overinflate the cuff. Ironically, though, many hospitals and HMOs now insist on the use of automatic blood pressure cuffs "to eliminate human error." The result is usually that someone comes, straps you into a cuff one size too small for your arm (resulting in an artificially high reading), the machine overinflates (resulting in an artificially high reading), and then spends too long deflating (which, if you are at all prone to anxiety over the result, also results in an artificially high reading). No wonder blood pressure problems seem to be on the rise across the nation.

Your mind can influence your blood pressure strongly in a matter of seconds. When you think about it, this makes sense: when a saber-toothed tiger leapt out from behind a bush, your ancestors didn't have time to wait around for a gradual increase in their blood pressure before responding; your blood pressure has to be able to leap even faster than that saber-toothed cat.

Wrapping a blood-pressure cuff around your arm certainly isn't as vivid an experience as having a predator attack you, but medical people nowadays do their best to frighten people about the dangers of hypertension. I'm sure this is all well-intentioned--doctors and nurses complain that they see too many patients ignore high blood pressure and then go on to have debilitating strokes a few years down the road. But for those of us who are of a less phlegmatic disposition, they succeed in turning every blood pressure reading into a situation fraught with life-and-death implications.

I always take my own blood pressure three times, and I've noticed an interesting trend. If my first reading disturbs me--if it is higher than I'd like--then then next two readings climb even higher. On the other hand, after a good initial reading, each successive reading will tend to be lower as I relax with relief.

Everyone with hypertension ought to be aware that their readings might be strongly influenced by psychological factors, and that doctor's-office readings may be biased strongly upwards. I wish I could offer a reliable cure for this problem, but I don't have one (though I will discuss the problem and possible solutions further in future posts). I can offer this one element of hope: If a big part of your blood-pressure problem is in your mind, then you may be able to cure yourself much more quickly than if it were simply physical.

[1] Pickering, Thomas G., White Coat Hypertension: Time for Action. Circulation. 1998; 98:1834-1836.

[2] White, William B., and Laurence H. Baker, Ambulatory Blood Pressure Monitoring in Patients With Panic Disorder. Arch Intern Med. 1987; 147(11):1973-1975.

[3] Kugler, J et al. Rise in Systolic Blood Pressure During Sphygmomanometry Depends On The Maximum Inflation Pressure of the Arm Cuff. J Hypertension. July 1994. 12(7):825-9.

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  3. Are you sure you're not me!!! When I go to my Doc. whom I love and have been with for years, when the nurse takes my BP, it is through the roof, and I mean high - last month, regular check up it was 190/100, and I pre-warn it will be horrific! Doc checks it again after we've visited for a while and it's down to 133/88. I do take BP meds. What drives me crazy is wherever you go now, i.e.; dentist, eye doc, they all take your BP, and the looks on their collective faces is amusing. It's like they don't believe me when I say I have WCS, (and probable hypertension). They act like they want to call the ambulance right away! My readings are fine at home. One other thing I agree with re: how BP is taken. Ideally, you're supposed to be sitting upright, feet planted, arm level with heart...most of the time, I'm sitting on a damn examining table, legs swinging and a variety of 'methods' - too loose, too tight - used for the reading. I get so tired of all this and it just increases my anxiety every time I have it taken. Thanks for your great personal story, it truly is 'me'.

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  8. I heard that a diet high in sodium and low in potassium can cause high blood pressure, so cutting down on salt and eating foods high in potassium could help control or even reverse this disease.

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  10. I'm so glad I found your post. I have that same issue I go to the doctor and when they bring out the blood pressure cuff my blood pressure skyrockets. I keep track at home so I know I don't have high blood pressure. My primary care physician is also aware of my problem. I bring my readings to my appointments. Thanks so much now I don't feel like such a baby because of my freak outs.

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    Replies
    1. Karen: There are loads of people just like us. I even get anxiety with my own blood pressure cuff - the first time I take it, it's high, I wait, get over the 'expectation' that it will be high, then take it again, and it's normally fine. But the truth be told, I do have high blood pressure (not astronomically so), it goes with the personality I think! No matter how many deep breaths, talking to myself etc., at the Doc's prior to it being taken, it makes no difference - it is what it is. Good luck, you're not a baby at all.

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  13. When I visit friends in the hospital, I am amazed at how many aids and sometimes nurses do not take blood pressures properly. Too small of cuffs, patients talking while taking the reading and wrong placement. In addition to white coat hypertension, there are other reasons for mistaken high blood pressure

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