White Coat Hypertension

[Ratsima]

Whenever I go to the hospital my blood pressure is huge. It's been that way for decades. When I got my physical exam for my Retirement Visa 12 years ago, the doctor convinced me to start taking a low dose of hypertension medication and told me there was no such thing as "white coat hypertension".

Shortly after I arrived, the public health nurses came to our house to check everyone's blood pressure. Everyone was OK except me. The nurse asked if I was taking medication and I told her I was. She asked to see it. Then she said, "You better stop because your blood pressure is very low."

I stopped.

Still, every time I go in it's very high.

But, when I measure it myself, at home, it's normal. Over a two week period taken at different times a day it averaged 129/79 with an average pulse of 64. (My waking pulse is around 50.) I've checked the home sphygmomanometer by using it to test other people with known normal blood pressure. It seems fine.

I've showed my home measurements to doctors and nurses and they sort of shrug their shoulders and say it seems OK.

But, as I age I wonder if I'm fooling myself. Ny mother died of a heart attack when she was 82 and my Dad, age 92, had a stroke when he was in his 50s.

Any thoughts?

[moja]

I suffer from white coat hypertension as well! If I have my blood pressure done at the hospital it is much too high but when I take it at home it is OK - I have now convinced the hospital to use the blood pressure readings I take at home and they are happy!

[Ratsima]

Thanks.

[VincentD]

Wow! Didn't know it had such a fancy name! (The instrument, not the condition). If you have your pressure taken immediately after you get in (me usually after struggling with Bangkok traffic) it's usually high. They make me wait another ten minutes or so and it usually settles down by then.
Think it's those lovely nurses and their cute uniforms that does it for me...

[Ratsima]

Indeed. And for reasons I can't fathom, the Bangkok hospital here in Korat is incredibly well-fitted in that area.

[STEVE G]

I was just reading in the Times this morning that the opposite effect is found to affect some patients as well in that some people have elevated blood pressure due to stress or whatever but they relax in the doctors office where they're away from the cause of the stress thereby masking the problem.

[Ratsima]

Ah, so the mystery deepens….

[Big Boy]

My problem is those blood pressure machines. If they use one of those, I probably died 10 years ago. Use the old method of pump and stethoscope, I'm 'usually' fine every time.

[J.J.B.]

The 'pump' is the sphygmomanometer, the device that can measure the pressure in the cuff. The cuff is inflated to a pressure that occludes the blood flow in the arm (larger ones for the upper arm, smaller ones for the wrist) and the stethoscope placed on the brachial artery just on the inside the elbow to hear when this has happened. Then the pressure is released and you are listening for the blood to begin pulsing through the artery. This is the pressure your heart is exerting on your circulatory system - the systolic pressure and is denoted by the first number. You keep listening while continuing to deflate the cuff until you can no longer hear the blood pulsing. This is when the pressure exerted by your artery walls equals that of the cuff - the diastolic pressure, which is denoted by the second number.

The "average" person (there is no such thing) is supposed to have a pressure of 120/80 but this is greatly impacted by whether you are seated, standing, or lying down. Your diastolic blood pressure usually increases with age. Blood can pool in different parts of the body, something many people experience when feeling faint after suddenly standing (postural hypo-tension. Few people realise that the body's blood vessels that carry blood away from the heart contain muscular walls that also contract after the heart beats in order to keep blood flowing. Diseases of the circulatory system are a real problem and are made worse by conditions such as diabetes, obesity and many more.

White Coat Hypertension is a real condition and is widely cited in the literature. You should take your blood pressure after at least five minutes resting in the same position (generally seated) and BB is right that using machines provides a greater margin of error than the traditional audio method. I had to learn to take audio blood pressure readings at university and it's pretty hard. You need to have pretty good hearing, be able to tell when the blood pumping starts and stops and there is a large degree of subjectivity in that, probably at least 10mmHg at each measurement point. The machines should be properly calibrated on a regular basis and sometimes it's hard to pick the best spot on the brachial artery. It's pretty simple mechanics but will be affected for a broad number of reasons.

Most docs will look at you and give a pretty casual listen, citing 120/80 unless they consider a good reason not to. Measurement over time (two weeks) at the same time of day and with a similar level of resting beforehand is a good idea, running to the hospital or becoming nervous or impatient will probably not provide the best result.

[migrant]

My doctor in the states is very particular on the taking of blood pressure. He doesn't let his nurses do it.

When I told him my pressure at home was better he asked that I bring in the machine and show him how I do it.
He made some changes to the way I was strapping the cuff on. It changed my readings a little.

So my moral is to make sure your machine is a good one

[Big Boy]

My problem is those blood pressure machines. If they use one of those, I probably died 10 years ago. Use the old method of pump and stethoscope, I'm 'usually' fine every time.

Well, just to prove me wrong.

I'm not long back from the dentist. I am such a wuss at the dentist, they were quite concerned for my well being today. Before they would do any work on this shivering wreck, they insisted on checking my blood pressure. The nurse brings in one of those damned machines. Oh good thinks I, I'm absolutely terrified, I'll push the reading off the scale, and I can get out of here. FFS 118/79

[Khundon1975]

WOW BigBoy 118/79 when sat in a dentist chair. Looks like you could live forever. Seems like your move to LOS has done you good.

I don't mind the dentist and my BP levels are now (after a change in my meds) within normal range, for an old fart.
My wife hates the dentist and had a filling the other day. As she never has an anesthetic injection, I bet her BP was off the scale. Serves her right.

I am due to have my yearly 7 day heart monitor fitted in early April, doesn't show BP, just how the heart muscle is working.
Strangely, the wife always seems to check my Life insurance policy around this time.

[Bristolian]

The condition is not so uncommon. I have suffered with it for at least the last 10 years. The number of times my blood pressure gets questioned during medical checks and pre-op, I could not count. I have a real and uncontrollable fear of hospitals and, bless them dentists!!! I also have a very low threshold of pain. Combine the two and the dislike of white coat establishments is.....fortunately the BKK hospital that I use is well versed in my unconditional and irrational fear. They deal with it accordingly, down to the point of muscle relaxants prior to some procedures that I have endured in the past. Still hate the sight of hospital uniforms!

[Ratsima]

So, what it comes down to is that measuring blood pressure is a highly inaccurate art. Doing it manually is a difficult skill. The machines are highly inaccurate. Readings are adversely affected by White Coat Hypertension and, possibly, positively affected by the inverse (opposite?) of White Coat Hypertension.

What, then, are we to believe?

[Khundon1975]

So, what it comes down to is that measuring blood pressure is a highly inaccurate art. Doing it manually is a difficult skill. The machines are highly inaccurate. Readings are adversely affected by White Coat Hypertension and, possibly, positively affected by the inverse (opposite?) of White Coat Hypertension.

What, then, are we to believe?

Ratsima I don't believe that measuring BP the manual way is a difficult skill, as you suggest.
My GP does it this way and even if she was off by one or two points on the Systolic/Diastolic measurements that is OK.
She would have to get the measurements wrong by 10 or more points, for me to be worried. If she did, she should not be practicing medicine as a GP.

The machines that are in use, can and do, give varying readings, dependent on a multitude of factors.

However, what they do is important and give the doctors a general reading/trend, for them to use in diagnosing hypertension.
I have a machine at home and only take readings in the evening, when I am relaxed. I look at the average over the last 30 days and never panic if I get the odd (high/low) reading occasionally, as that, in itself, could lead to panic and high BP.

If a doctor confirms hypertension in a patient and prescribes medication like Amlodipine or other drugs, they usually wait 3 months for the drug to take effect, before they do another BP check.
No need to panic.


"What, then, are we to believe?"

I believe, that the moon is made of cheese.