White Coat Syndrome: It Exists

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photo by Carol Duff

Health Editor’s Note:  Have you ever felt uneasy/nervous/anxious when going to a doctor’s appointment? We all do. When you arrive at the waiting room, you may have a long wait.  You rushed there, perhaps breaking speed limits, to get there on time.  You adjusted your schedule to accommodate your appointment time.  You put some planning into this event, but you might still feel pressure or rushed. This has happened to me on more than one occasion.

Now that you are in the office, you have time to think about why you are there.  Maybe you are there for a yearly physical, maybe for a health issue.  You might be in pain, but perhaps more than anything else, you are worried that something really big will be wrong with you.  You do not like to be stuck with needles, and anticipate a possible blood draw if you did not have one done before the appointment. You do not like the smell of the office as it reminds you of other visits. 

You WILL have a blood pressure taken as part of your vital statistics for this visit.  Add your rushing to the appointment, your fear of needles, your concerns that you are really, really sick, that you may be nauseated, very tired from not sleeping normally due to being ill or being worried, and you can be just plain scared of what could be wrong with you……You are pumping adrenalin that is being over released due to your emotional state. High blood pressure due to being in a doctor’s office, being upset while being in a doctor’s office, etc. is called “white coat syndrome.” 

Your blood pressure is taken at the beginning of the visit, and perhaps the person taking it will mention that the reading is a bit high.  So the result of your visit may be a blood pressure reading that will be higher than it should be. Add this to why you were there already, and see a reason for your blood pressure to rise. 

High blood pressure is a concern to your health care provider because chronic elevation of blood pressure can lead to memory loss, loss of consciousness, heart attack, damage to kidneys with resulting loss of kidney function (kidneys are very sensitive to blood pressure), hurt your eyes, cause fluid to back up into the lungs, etc. Some health care providers will leap to labeling you has someone who is now hypertensive (has a high blood pressure) and suffering potential harm to your body. 

There may be the mention of you taking blood pressure medications to try to subdue your “high” blood pressure.  You might even be given a prescription for one of the blood pressure medications.  Maybe you did not need blood pressure lowering medication because your blood pressure was high because that is what happens when you are upset and are pumping extra adrenalin. 

Hopefully the scenario of being given blood pressure medications, for falsely high blood pressure readings will be a thing of the past. A wise move on the clinician’s part is to take a blood pressure reading at the end of the appointment, or to turn off the lights, allow you to relax and take another blood pressure reading or two.  You might even be asked to have to have a blood pressure taken outside the medical office. 

Of course, to prepare yourself for the blood pressure reading, you should not smoke (you should not be doing that anyway), drink coffee or other caffeineated beverages and foods,  empty your bladder, sit quietly.  Mostly, just be aware that this scenario can and does happen, and be able to mention what you know about this process and make suggestions as to how you might be treated so your blood pressure reading will be at its most accurate…….Carol

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    Second BP Measurement Often Brings Better News

Repeat measurement in same office visit is on par with adding a drug

by Nicole Lou, Contributing Writer, MedPage Today

The first in-office blood pressure reading is often misleadingly high, one study suggested.
Patients who initially had high blood pressure readings had a median drop of 8 mm Hg in systolic pressure when they got a repeat measurement — and the greater the initial systolic blood pressure, the greater the difference, according to a group led by Douglas Einstadter, MD, MPH, of Cleveland’s Case Western Reserve University and MetroHealth Medical Center.

Moreover, 36% of repeat readings fell under the old hypertension threshold of 140/90 mm Hg, which is now the threshold for antihypertensives in lower-risk individuals. Overall, repeat measurements brought the hypertension control rate up from 61% to 73%, the investigators reported online in JAMA Internal Medicine.

“While much of the change in systolic blood pressure may be attributed to regression to the mean, the observed decrease remains clinically important, comparable with that associated with addition of an antihypertensive medication,” Einstadter’s group noted.
Having patients go on blood pressure drugs when they don’t need them means they are taking “medications that add little or no benefit to their clinical well-being or clinical outcome,” said Robert Baron, MD, of the University of California San Francisco, writing in an invited commentary.

This becomes an especially relevant problem as the U.S. health care system moves toward value-based care initiatives, such as accountable care organizations and shared savings programs, the study investigators suggested.

Their study was based on the records of the MetroHealth urban safety-net health system’s patients with a problem list diagnosis of hypertension who were seen at a primary care clinic in 2016 (n=38,260).

Of note, these clinics utilize an electronic health record system with a built-in reminder for healthcare providers to remeasure blood pressure when the first reading exceeds 140/90 mm Hg in the clinic, which happened 83% of the time.
Baron suggested that primary care practices develop a clear strategy for best-practice office measurement that may include changes in staff training, work flow, and physical settings to comply with current American guideline recommendations.

“Despite the clinical trial emphasis on office-based measurements, most new practice guidelines now also recommend out-of-office measurement to confirm office-based high blood pressure and for ongoing management of hypertension. Unfortunately, this practice is neither standardized nor fully evidence based,” according to Baron.

Nonetheless, “ABPM [ambulatory blood pressure monitoring] should be used more than it currently is. It is not clear that it is needed in every patient (as suggested by current guidelines), but it certainly can be useful in a larger number of patients,” the editorialist said. “Finding even a few patients in each primary care practice who do not need medications is well worth it. This may be especially true in patients with lower cardiovascular risk.”

Moreover, ABPM can help confirm good control throughout the day in high-risk patients, especially those with existing cardiovascular disease, he added.

“As we continue to debate the thresholds and goals of high blood pressure treatment, we will need to better explain to patients the benefits and harms of each approach and solicit their preferences. The least we can do is better define their risk with better measurement of blood pressure,” Baron concluded.

The work was funded by the Centers for Disease Control and the Mount Sinai Health Care Foundation of Cleveland.

Einstadter and Baron disclosed no relevant conflicts of interest.

Primary Source
JAMA Internal Medicine
Source Reference: Einstadter D, et al “Association of repeated measurements with blood pressure control in primary care” JAMA Intern Med 2018; DOI: 10.1001/jamainternmed.2018.0315.

Secondary Source
JAMA Internal Medicine
Source Reference: Baron RB “Treating blood pressure correctly by measuring it correctly” JAMA Intern Med 2018; DOI: 10.1001/jamainternmed.2018.0311.


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Biography
Carol graduated from Riverside White Cross School of Nursing in Columbus, Ohio and received her diploma as a registered nurse. She attended Bowling Green State University where she received a Bachelor of Arts Degree in History and Literature. She attended the University of Toledo, College of Nursing, and received a Master's of Nursing Science Degree as an Educator.

She has traveled extensively, is a photographer, and writes on medical issues. Carol has three children RJ, Katherine, and Stephen - two daughters-in-law; Suzy and Katie - two granddaughters; Isabella Marianna and Zoe Olivia - and one grandson, Alexander Paul. She also shares her life with husband Gordon Duff, many cats, two rescue pups, and two guinea pigs.

Carol's Archives 2009-2013

3 COMMENTS

  1. Lol it’s the same feeling you would get if you drove to the South side of Chicago and realized you went too far into gang territory. It’s called intuition Carol. It’s just a different gang. Both will kill you without blinking an eye. Your realization is coming soon. You just haven’t heard from real people who know better, let alone have any understanding of how God works. Can’t wait to hear from Ian the Ignorant about me being a ranting nutjob. Here is a perfect example, Homeopathy. I’m sure Carol already has an article in preparation about the dangers of Homeopathy since the FDA is attempting to outlaw it. Meanwhile this kind of medicine is the most effective and longest standing medicine in the planet. Don’t tell a white coat that though, their head may explode because they can’t comprehend medicine, only treatments.

  2. Of course you should feel nervous about going to the doctor. They have no clue what they are doing! Allopathy is garbage and anyone still connected to their intuition knows this. The cures are simple and hiding in plain sight. When you feel nervous about going to the doctor that is God telling not to go. All is self. God works through all things natural and white coats are completely cut off from nature. Curing anything is simple when you know the universal knowledge. There is a mineral or a combination of plants that can restore any health deficiency but the author doesn’t know that because she still lives inside one of the most evil machines on the planet. White coats are murders, thieves, and ignoramuses who are guilty by association with the slave holders of humanity. Real medicine has nothing to do with allopathy. It has to do with clean living, clean water, plants, planets, and pure Divine intent.

  3. Carol does us all a service here. I was initially diagnosed with high blood pressure the Monday after I’d run and finished a cross country marathon in Germany. What the hell, this is supposed to make me healthy! Of course, I was an Army First Sergeant at the time, and living largely on coffee. The doc I was talking to was about 5’2″ weighed less than my rucksack, and was wearing scrubs over a t-shirt and running shorts and high end Nikes. She smiled at me, and said “First Sergeant, I have high blood pressure.” About 18 months later, I was at Fort Lewis, still a First Sergeant and still unwilling to admit to high blood pressure as a problem. Guess what! I ended up going in for weekly evaluations, and they’d have me sit quietly, in the dark and one medic told me to think about birds or something, anything except being a First Sergeant. Yeah, I have high blood pressure, but that first in the door reading would drop quite a bit after I’d sat there for 15 minutes or so and at least tried to think about something besides the life of a Headquarters Company First Sergeant.

    Today when I go in for something, the nurses will say that’s a bit high after I ask what the score is. I tell them to wait five minutes and take it again…and inevitably both numbers have dropped between 10 and 15 points.

    No body goes to the doctor for a good time…if you do, seek help elsewhere. But take a little control over you diagnosis and you’ll have some control over your treatment that makes sense. Any idiot can decide to stop taking medication; graveyards are full of them. Force your doc to make good recommendations by getting better data out of your examination.

    And hell, high blood pressure is largely, as that doc told me 25 years ago, genetics. Most chronic things wrong with you are genetic at root. Don’t consider yourself a moral failure for high BP or other similar stuff. But, don’t be an idiot about it either…

Comments are closed.