Hours Ambulatory

Hours Ambulatory

White coat hypertension

Diagnosis

In studies, white coat hypertension can be defined as the presence of a defined hypertensive average blood pressure in an office setting but not at home.

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 blood pressure, technical inaccuracies, anxiety of the patient, recent ingestion of pressor substances, and talking, amongst many other factors. The most common measure of blood pressure is taken from a noninvasive instrument called a sphygmomanometer. "A survey showed that 96% of primary care physicians habitually use a cuff size too small," adding to the difficulty in making an informed diagnosis. For such reasons, white coat hypertension cannot be diagnosed with a standard clinical visit. It can be reduced (but not eliminated) with automated blood pressure measurements over 15 to 20 minutes in a quiet part of the office or clinic.

Patients of white coat hypertension do not exhibit the signs indicative of trepidation and their increased blood pressure is often not accompanied with tachycardia. This is supported by studies that repeatedly indicate that 150% 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.

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, is 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.

Recent studies showed home blood pressure monitoring is as accurate as a 24 hour ambulatory monitoring in determining blood pressure levels. Researchers at the University of Turku, Finland studied 98 patients with untreated hypertension. They compared patients using a home blood pressure device and those wearing a 24hr ambulatory monitor. Researcher Dr. Niiranen said that, "home blood pressure measurement can be used effectively for guiding anti-hypertensive treatment". Dr. Stergiou added that home tracking of blood pressure, "is more convenient and also less costly than ambulatory monitoring".

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

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.

Implications for treatment

In general, individuals with white coat hypertension have lower morbidity than patients with sustained hypertension, but higher morbidity than the clinically normotensive.

However, it should be remembered that all the established published trials on the consequences of high blood pressure and the benefits of treating are based on one-time measurement in clinical settings rather than the generally slightly lower readings obtained from ambulatory recordings.

The debate and conflicting ideas revolve around whether or not it would be feasible to treat white coat hypertension as there still is no conclusive evidence that a temporary rising in blood pressure during clinic visits has an adverse effect on health.

In fact, many cross sectional studies have shown that "target-organ damage (as exemplified by left ventricular hypertrophy) is less in white-coat hypertensive [patients] than in sustained hypertensive [patients] even after the allowance has been made for differences in clinic pressure". Many believe that patients with "white coat" hypertension do not require even very small doses of antihypertensive therapy as it may result in hypotension but must still be careful as patients may show signs of vascular changes and may eventually develop hypertension.

See also

Look up white coat hypertension in Wiktionary, the free dictionary.

Blood pressure

Hypertension

Home blood pressure monitoring

References

^ "Hypertension: Overview - eMedicine". http://emedicine.medscape.com/article/889877-overview. 

^ Pickering TG, Eguchi K, Kario K (June 2007). "Masked hypertension: a review" ([dead link] Scholar search). Hypertens. Res. 30 (6): 47988. doi:10.1291/hypres.30.479. PMID 17664850. http://joi.jlc.jst.go.jp/JST.JSTAGE/hypres/30.479?from=PubMed. 

^ 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): 4526. PMID 18320786. http://tip.org.pl/pamw/issue/search.html?lang=en&search=18320786. 

^ Jhalani, Juhee a; Goyal, Tanya a; Clemow, Lynn a; Schwartz, Joseph E. b; Pickering, Thomas G. a; Gerin, William a. Anxiety and outcome expectations predict the white-coat effect.. 10(6), December 2005. Lippincott Williams & Wilkins, Inc.. pp. pp317319. http://www.bpmonitoring.com/pt/re/bpm/abstract.00126097-200512000-00006.htm;jsessionid=LpvGzJN7PDC1yqJtnQj3ZWfmzgdnhWycyzsKybSHsr2FLx3hR1vh!1805002056!181195629!8091!-1. 

^ a b Pickering T (1994). "Blood pressure measurement and detection of hypertension". Lancet 344 (8914): 315. doi:10.1016/S0140-6736(94)91053-7. PMID 7912303. 

^ 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. http://hyper.ahajournals.org/cgi/content/full/45/1/142. Retrieved 2009-10-01.  See p. 146, Masked Hypertension or Isolated Ambulatory Hypertension.

^ Pickering T, James G, Boddie C, Harshfield G, Blank S, Laragh J (1988). "How common is white coat hypertension?". JAMA 259 (2): 2258. doi:10.1001/jama.259.2.225. PMID 3336140. 

^ McGrath B (1996). "Is white-coat hypertension innocent?". Lancet 348 (9028): 630. doi:10.1016/S0140-6736(05)65069-6. PMID 8782749.  - commenatry on:

Glen S, Elliott H, Curzio J, Lees K, Reid J (1996). "White-coat hypertension as a cause of cardiovascular dysfunction". Lancet 348 (9028): 6547. doi:10.1016/S0140-6736(96)02303-3. PMID 8782756. 

^ 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): 46874. doi:10.1016/j.amjhyper.2005.10.017. PMID 16647616. 

^ Thalenberg JM, Pvoa RM, Bombig MT, de S 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): 2439, 26773. PMID 19009177. http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0066-782X2008001600010&lng=en&nrm=iso&tlng=en. 

^ Helvaci MR, Seyhanli M (2006). "What a high prevalence of white coat hypertension in society!" ([dead link] Scholar search). Intern. Med. 45 (10): 6714. doi:10.2169/internalmedicine.45.1650. PMID 16778338. http://joi.jlc.jst.go.jp/JST.JSTAGE/internalmedicine/45.1650?from=PubMed. 

^ Khan TV, Khan SS, Akhondi A, Khan TW (2007). "White coat hypertension: relevance to clinical and emergency medical services personnel". MedGenMed 9 (1): 52. PMID 17435652. PMC 1924974. http://www.medscape.com/viewarticle/552593. 

v  d  e

Cardiovascular disease: vascular disease  Circulatory system pathology (I70-I99, 440-456)

Arteries, arterioles

and capillaries

Inflammation

Arteritis (Aortitis)  Buerger's disease

Arterial occlusive disease/

peripheral vascular disease

Arteriosclerosis

Atherosclerosis (Foam cell, Fatty streak, Atheroma, Intermittent claudication)  Monckeberg's arteriosclerosis  Arteriolosclerosis (Hyaline, Hyperplastic, oxycholesterol, cholesterol, LDL, trans fat)

Stenosis

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Other

Fibromuscular dysplasia  Degos disease  Aortoiliac occlusive disease  Raynaud's phenomenon/Raynaud's disease  Erythromelalgia

Aneurysm/dissection/

pseudoaneurysm

torso: Aortic aneurysm (Thoracic aortic aneurysm, Abdominal aortic aneurysm)  Aortic dissection  Coronary artery aneurysm

head/neck: Cerebral aneurysm  Intracranial berry aneurysm  Carotid artery dissection  Vertebral artery dissection  Familial aortic dissection

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Vascular nevus

Spider angioma  Halo nevus  Cherry hemangioma

Veins

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Phlebitis

Venous thrombosis/

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primarily lower limb (Deep vein thrombosis)

abdomen (May-Thurner syndrome, Portal vein thrombosis, Budd-Chiari syndrome, Renal vein thrombosis)

upper limb/torso (Paget-Schroetter disease, Mondor's disease)

head (Cerebral venous sinus thrombosis)

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Other

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Arteries or veins

Vasculitis  Thrombosis  Embolism (Pulmonary embolism, Cholesterol embolism, Paradoxical embolism)  Angiopathy (Macroangiopathy, Microangiopathy)

Blood pressure

Hypertension

Hypertensive heart disease  Hypertensive nephropathy  Essential hypertension   Secondary hypertension (Renovascular hypertension)  Pulmonary hypertension  Malignant hypertension  Benign hypertension  Systolic hypertension  White coat hypertension

Hypotension

Orthostatic hypotension

vascular navs: anat/physio/dev, noncongen/systemic vasculitis/congen/neoplasia, symptoms+signs/eponymous, proc

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