- Dilemma: Patient with white-coat hypertension refused surgery
- How to Overcome the “White Coat” Response in Office Blood Pressure Measurement
- Overcoming White Coat Syndrome:
- What is White Coat Syndrome, aka White Coat Hypertension?
- Understanding High Blood Pressure
- What Causes White Coat Syndrome?
- How to Overcome White Coat Syndrome
- 7 ways to reduce stress and keep blood pressure down
- Increased nerve activity may raise blood pressure in anxiety
- HEALTHY HEART BLOG
- Testing your blood pressure in the doctor’s office and at home
- Why do doctors test your blood pressure?
- How do doctors test for high blood pressure?
- Why would doctors recommend home blood pressure monitoring?
- How to use a blood pressure monitor at home
- What your blood pressure numbers mean
- When it comes to managing blood pressure, there’s nothing to lose
By Fred D. Patterson II, Special to the BDN • January 28, 2010 7:57 pm
There is a very serious situation that is currently occurring in Maine. About 30 months ago, the Maine Board of Dental Examiners instituted a policy of mandatory blood pressure screening of all dental patients before any dental intervention is done. This screening is being done in conjunction with a recommendation by the American Heart Association and is not a normative or standard dental procedure carried out for the benefit of the patient, although there are very strong attempts to disguise it as such.
The program is an attempt to force dental patients to have their blood pressure examined and treated by a physician if the screening results exceed certain levels, and the patient is denied dental care until they do. The rationale is that since individuals go to the dentist more often than they normally visit their physician, a number of individuals can be forced to have their high blood pressure treated and address the so-called “national epidemic of high blood pressure.”
The program is actually being carried out by the dental hygienists and the dentist is not present, so that if dental care is denied, it is actually the hygienist and-or other dental office personnel who are carrying out the program and requiring the patient to have medical intervention before dental care is given.
Usually when such programs are introduced, the public is informed through the newspapers or other public media as to the goals and intent of the new procedures. But in this circumstance, the program was not only introduced clandestinely, it was introduced in such a manner as to leave a minimal paper trail with no official policy statements or communication to the dentists, although I have been able to uncover the fact that a letter of instruction was sent to the dental hygienists in Maine some 34 months ago. I have not as yet been able to obtain a copy of the letter.
Dental patients have the right to refuse a blood pressure screening and-or dental X-rays. Dental patients are generally informed of their rights where dental X-rays are concerned, meaning their permission is asked, but in the case of the blood pressure screening they are simply being told that it is mandatory. And they certainly are not being told that they can be denied dental care on the basis of the screening if their blood pressure is not within the acceptable guidelines.
This is clearly a violation of federal health care standards and is an unethical procedure in the dental office designed to enable the forced treatment of high blood pressure. Actually, there is no “national epidemic of high blood pressure” but a national blood pressure statistic that is elevated in large measure due to the demographic of the elderly, and who are being discriminated against in this dental office blood pressure screening program.
The Maine Board of Dental Examiners has instituted a policy that is not only questionable and insensitive to the actual dental care needs of the patients of Maine, but has done so in a dishonest and deceptive manner. This policy, which is a misguided and misbegotten policy in the first place and which should be eliminated, is not being carried out with the informed consent of dental patients and is causing some very serious problems.
The Maine Board of Dental Examiners, the Maine Dental Association and the American Dental Association, although the ADA has taken a complex and cautious position on this, have all conspired to introduce a program that is unethical and a blatant conflict of interest where the provision of dental care for Maine dental patients are concerned. The primary and necessary function of dentistry is to provide dental care and not to become involved in health surveys that unnecessarily and destructively intrude into the province of the health care physician.
Because of this program, I have decided to have all of my dental care performed in Canada, since my denial of dental care in Maine resulted in a very serious dental situation. I was told to go to my physician to have my blood pressure treated after a highly questionable screening and my severely fractured tooth was not even examined.
Fred D. Patterson II of Fort Kent is retired from law enforcement.
© praisaeng / Adobe Stock
Let me ask you a question: how many of you take blood pressure readings on your patients before beginning treatment? For those of you who take blood pressure readings on your patients, bravo to you! You have my respect; you may now skip the rest of this article, pass Go, and collect $200. But for those of you who now find yourselves blushing in embarrassment, as I once did when posed this question, I urge you to continue reading.
A majority of hygienists that I have asked this question admit that they do not take blood pressure readings on their patients.
Until quite recently, I had not used a blood pressure cuff since graduating hygiene school four years ago. As dental hygienists, we are taught from the beginning that we should take our patient’s blood pressures before beginning treatment. We are healthcare providers after all, so why are so many of us neglecting to do it? Why are we ignoring blood pressure readings as a key component of the comprehensive health history review that we should perform at each appointment?
I would wager my favorite scaler that time is a big factor here. If there is one thing you learn in hygiene school, one single thing that becomes a part of your dental hygienist core, it is this: manage your time efficiently. And we do…well, we try to anyway. Many of us find ourselves working in a profession in which we are being asked to do more with less time to do it. It is a sad, but apparently common trend in dentistry these days.
In the days of dentistry past, it was standard to have a 60-minute working window for hygiene recare visit. A simple search on any hygiene forum or blog will reveal that treatment times are being shortened across the country. Many hygienists report that they only have 45 minutes, sometimes a mere 30 minutes, to treat patients regardless of the need for radiographs, periodontal condition, etc. What in the world are we supposed to do with such little time granted to us? Scale every other tooth? Perpetually delay the FMX? Skip full-mouth periodontal charting? I certainly hope not! Hygienists are notably detail-oriented by nature, and we try to give our patients the very best care possible. So, we save time wherever we can, and more often than not, this means that the patient’s blood pressure is not measured. This, my fellow dentites, is an egregious error on our part.
As you probably know, the American Academy of Cardiologists, the American Heart Association, and nine other health groups just changed the defining parameters of high blood pressure1. Hypertension was formally diagnosed at a systolic reading of 140 and a diastolic reading of 90. Now, a systolic reading of 130 and a diastolic reading of 80 warrants a hypertension diagnosis. This change in qualifier now means that 46 percent of Americans have high blood pressure, which is 14 percent more than defined by the old limits1. All hygienists know that there is a direct link between periodontal health and heart health. Considering this new standard, the oversight in the routine of our practice must not continue.
Several months ago, I started a full-time position in a progressive office. One of the first things my new employer asked me to incorporate into my routine, as her recently acquired (and only) hygienist, was to take blood pressure readings on each hygiene patient. I immediately and enthusiastically complied. Each patient I’ve treated over the last four months has had their blood pressure taken prior to beginning treatment.
My routine is as follows: I take blood pressure once with a wrist cuff, and if it falls in a hypertensive range I take it twice more with an arm cuff. If the reading remains above 130/80, I proceed with treatment, present my findings to the dentist, and we strongly advise the patient to consult with their primary care physician. If the blood pressure approaches 180/110, however, I immediately dismiss the patient and advise that they return with clearance for treatment from their PCP or a cardiologist. And you know what? I’ve dismissed at least ten patients over the last four months alone. Several patients we have dismissed have gone to the ER of their own volition just because the numbers we recorded concerned them enough. One patient returned to thank us the following day because we helped diagnose an underlying condition that he was unaware was affecting his health.
I cannot say that I am terribly shocked; an astounding number of patients see their dentist more regularly than they see their physician. High blood pressure is stress on the body that can exacerbate a wide variety of health conditions, including many that could become life-threatening to our patients. Not unlike gingivitis or periodontal disease, many patients are completely unaware that they have hypertension until it is diagnosed.
As hygienists, we are the first line of defense when it comes to finding oral conditions and diseases. It is our duty as clinicians and patient advocates to alert the dentists to our findings so that we can best educate the patient and guide them towards appropriate treatment. We have neglected to realize the disservice we do our patients by neglecting to measure their blood pressure in our chairs.
Once upon a time, each of us swore an oath vowing to deliver a full measure of competent care to the public that trusts us to do so. If we are ever to bridge the gap between medicine and dentistry, we must educate our patients on our concerns for their heart health. We must campaign for a higher standard of care than we have been delivering. I urge each of you to try to take the time to start checking your patients’ blood pressure. I promise you will be amazed by what you find.
NOW READ: Bridging the Gap between Medicine and Dentistry
Dilemma: Patient with white-coat hypertension refused surgery
A patient who suffers known ‘white-coat’ hypertension is sent to you from a pre-op assessment clinic because her blood pressure is high. Despite a recent, normal 24-hour blood pressure reading, the clinic sends her back again when her blood pressure is too high during their assessment, instructing you that ‘the anaesthetist will not go ahead unless her blood pressure is treated’. What should you do?
GP trainer: Contact the anaesthetist directly
This is likely to be a stressful time for the patient who is eagerly awaiting their operation. First, explore the patient’s record and review their 24-hour ambulatory result, to confirm their clinic and 24-hour blood pressure readings support the diagnosis of white-coat hypertension. In case the anaesthetist is unaware of the 24-hour blood pressure reading, try to speak to them directly to inform them of the result and when and why it was done.
If this does not persuade the anaesthetist, explore with them why they are still reluctant to anaesthetise the patient. There may be a good reason from an anaesthetic point of view that you are not aware of. If not, explain it is clinically unsafe for you to treat a normal 24-hour blood pressure reading, based on NICE guidance on diagnosis and management of hypertension.1
If unable to contact the particular anaesthetist involved, speak to one of their colleagues or the pre-operative nurse to discuss your concerns further.
If you are unable to reach agreement, then involve your local hypertension service by either speaking to a consultant or writing a letter for advice to the appropriate service relaying the concerns highlighted by the anaesthetic team and the results of your ambulatory monitoring. Copy your referral to the relevant anaesthetist. Ensure you explain to the patient at each step what the plan is.
Dr Pipin Singh is a GP trainer in Wallsend, Tyne and Wear
GP hypertension expert: Write to the clinic citing pre-op guidelines
We know patients can experience elevated blood pressures during measurement by a healthcare professional – particularly in hospital settings.2 If surgery records indicate 24-hour blood pressure control is good, we can attribute any disparity to the white-coat effect.
In this case, our patient’s future care is being compromised. The British and Irish Hypertension Society and Association of Anaesthetists of Great Britain and Ireland recently produced joint guidelines for pre-operative blood pressure care, which state that GPs should only refer patients for elective surgery with mean blood pressure readings in the past 12 months of less than 160/100mmHg – and that pre-operative assessment clinics need not measure blood pressure in patients whose systolic and diastolic blood pressures are documented as below 160/100mmHg in the referral letter from primary care.3,4
So assuming the patient’s normal 24-hour blood pressure reading was provided with the referral (and many local referral policies now require this) the clinic should not have repeated her blood pressure at all.
You could therefore simply write to the secondary care team and refer them to the published guidelines.
The guidelines also include a template letter for communication between surgeon and GP when this dilemma is encountered.
Dr Chris Clark is a GP in Devon and executive board member of the British and Irish Hypertension Society
Medicolegal adviser: Focus on the patient’s interests
The GMC states that doctors must make the care of their patients their first concern.5
In the first instance, the GP must be satisfied that the diagnosis of white-coat hypertension has been made appropriately.
If further tests are required, you should assess the patient, taking account of their history and if necessary examining them, and then arrange suitable investigations.
If satisfied with the white-coat hypertension diagnosis, explain the situation clearly to the patient, who may be confused by the differing opinions or disappointed by the delay.
The GMC reminds doctors that they must work collaboratively with colleagues, respecting each other’s expertise and contributions, and sharing all relevant information with colleagues. In this case, you could contact the anaesthetist directly, so they have all the relevant detail from a colleague with a better understanding of the patient’s condition than a clinician undertaking a one-off pre-operative assessment.
All appropriate steps as outlined above should be taken to determine whether or not the requested treatment is needed. The GMC states that doctors must prescribe drugs or treatment only when they have adequate knowledge of the patient’s health and are satisfied that the medications serve the patient’s needs.5
The focus should remain on the patient as an individual and doctors must work with colleagues in the ways that best serve the patient’s interests.
You could also view it as a learning opportunity and enquire whether the clinic has an established protocol in respect of patients with white-coat hypertension and, if not, it may be something the pre-assessment clinic decides to review.
Dr Greg Dollman is a medicolegal adviser at the Medical and Dental Defence Union of Scotland
1 NICE. Hypertension: The clinical management of primary hypertension in adults, CG127. 2011.
2 Adiyaman A, Aksoy I, Deinum J et al. Influence of the hospital environment and presence of the physician on the white-coat effect.
J Hypertens 2015; 33: 2245–9
3 Hartle A, McCormack T, Carlisle J et al. The measurement of adult blood pressure and management of hypertension before elective surgery. Anaesthesia 2016;71:
4 McCormack T, Carlisle J, Anderson S et al. Preoperative blood pressure measurement: what should GPs be doing? Br J Gen Pr 2016; 66:230-31
5 GMC. Good medical practice. 2013.
How to Overcome the “White Coat” Response in Office Blood Pressure Measurement
Q: A patient whose blood pressures in my office are consistently in the range of 160/95 to 100 mm Hg tells me that her measurements at home, using her son’s oscillometric blood pressure device, are always below 135/85 mm Hg. What is the best method for establishing a diagnosis of office hypertension?
A: You have addressed an issue that is increasingly recognized as a major problem in clinical practice: office hypertension, or “white coat hypertension.” As many as 25% to 35% of patients tend to have higher blood pressures in their provider’s office than they do on self-determination at home, particularly with one of the many oscillometric devices now available for single blood pressure measurements.
WHITE COAT HYPERTENSION VS WHITE COAT EFFECT
The term “white coat hypertension” is used to describe the patient who has persistently elevated clinic or office blood pressure (higher than 140/90 mm Hg) and normal daytime ambulatory blood pressure (lower than 135/85 mm Hg). The term “white coat hypertension” is reserved for those who are not receiving antihypertensive drug therapy and must be distinguished from white coat effect, which is a very common response to an office visit.1
White coat effect can be observed in most hypertensive patients as an elevated office blood pressure with a lower awake ambulatory or home blood pressure, regardless of the presence or absence of hypertension. White coat effect tends to be most apparent with the initial blood pressure measurement, but it can be observed in multiple provider-measured blood pressures during an office visit. In most cases, white coat effect represents patient anxiety about the office visit. It may result in misdiagnosis of hypertension or the severity of hypertension and may lead to overly aggressive therapeutic measures.
Both white coat hypertension and white coat effect can be countered by the use of an automated and programmable oscillometric device that enables the determination of multiple readings in the home.
SHORTCOMINGS OF OFFICE BLOOD PRESSURE MEASUREMENT
Most practitioners still rely on auscultatory aneroid devices or mercury sphygmomanometers to measure blood pressure. Despite the distribution of guidelines for accurate measurement in the office setting, overall accuracy and reproducibility of blood pressure measurement remains poor.2
Patients are rarely advised to refrain from smoking cigarettes or drinking coffee within 30 minutes of a blood pressure measurement, and observers remain guilty of too rapid deflation of the blood pressure cuff during a measurement. Conversation during blood pressure measurement can also contribute to higher readings. In addition, failure to support the arm, with the forearm horizontal and the cuff at heart level, is associated with higher blood pressure and heart rate. Some offices may not have a large blood pressure cuff for overweight patients or a pediatric cuff for children or adults with arms of small circumference. Miscuffing, or the use of an inappropriately sized blood pressure cuff, is a common source of error.
All of these issues affect the accurate measurement of blood pressure in the office and have been stressed for decades in national and international guidelines. Time constraints and a busy practice setting also contribute to these deficiencies. As a result, treatment decisions may be significantly affected by higher blood pressure readings. Most office blood pressures are obtained by the physician or other provider with an auscultatory device, and a major contributor to higher readings is the presence of the provider during the measurement.
NEWER OPTIONS FOR BLOOD PRESSURE MEASUREMENT
In the past decade, numerous studies have reported that 24-hour ambulatory blood pressure monitoring (ABPM) as well as self-measurement of blood pressure in the home with an oscillometric device serve as better predictors of future cardiovascular events than conventional blood pressures obtained in the physician’s office.3,4 Unfortunately, ABPM, despite its proven diagnostic value, is not readily available nor is it cost-effective for long-term management of hypertension.
Self-monitoring of blood pressure at home has now become widely available with the marketing of single-measurement, relatively inexpensive oscillometric blood pressure devices. Blood pressures of lower than 135/85 mm Hg outside the clinician’s office are considered normal with these devices, while blood pressures of lower than 140/90 mm Hg are considered normal in the physician’s office with currently used aneroid devices. Keep in mind that optimal use of home blood pressure devices requires the same simple maneuvers required in the physician’s office.
Most home oscillometric devices are available in different cuff sizes. Blood pressures at home should be obtained at periodic intervals and ideally at different times of the day, such as morning and evening. Measurements should be recorded in a diary and made available to the patient’s physician at the time of office visits. Although the use of home oscillometric blood pressure devices is not widely recommended by practicing physicians, the measurements obtained can be of significant value, not only in the evaluation of possible office hypertension but also in the long-term management of hypertension. However, even in the minority of clinical practices that are now using single-measurement oscillometric devices, they, too, are associated with many of the same measurement problems that lead to overestimation of blood pressure in the office setting.
In the past 5 years, a number of new programmable devices have been developed for office measurement of blood pressure.5,6 These devices utilize oscillometric technology and can be programmed to take multiple readings in the absence of a clinician observer in the room, thus reducing the common white coat response. These devices provide the ability to obtain 3 to 5 readings at intervals of 1, 2, and 3 minutes while the patient rests comfortably in a quiet room. The white coat response can be seen to dissipate within 3 minutes of the observer leaving the examination room. At least one of these devices, the BpTRU, which can take up to 5 blood pressure readings, provides average readings that are comparable to those obtained with 24-hour ABPM.7
The time required for blood pressure measurement with these devices is as little as 5 minutes, which makes them a viable option for busy practices. As the cost of these devices decreases, they will likely become more widely used in the outpatient setting.
Overcoming White Coat Syndrome:
What is White Coat Syndrome, aka White Coat Hypertension?
The nurse tightens the blood pressure cuff around your arm and slaps the velcro into place. She pumps air into the cuff and it squeezes around your arm, slowly suffocating it. You silently question why they haven’t invented a better contraption to measure blood pressure. Soon the discomfort passes—until the nurse tells you the reading. Your blood pressure is reading at 140/90, clinically considered high systolic blood pressure.
If your reading registers high at the doctor’s office—but blood pressure monitoring in any other setting it is normal—you may be suffering from white coat syndrome, sometimes referred to as white coat hypertension or blood pressure phobia. So, what is white coat syndrome? It is an elevated blood pressure reading without the diagnosis of hypertension. The ICD 10 code (diagnosis code) for this syndrome is R03.0. It is also closely related to iatrophobia, the fear of doctors.
Understanding High Blood Pressure
Let’s be honest, “high blood pressure” is a term that’s thrown around a lot and we should all be familiar with it. However, in reality, few of us truly understand what it means. So, here is a short synopsis of blood pressure:
Systolic Pressure: According to The American Heart Association, this is the measurement of the blood pressure your blood is exerting against your vessels when your heart is beating.
Diastolic Pressure: This is the blood pressure your heart is exerting against your vessels when your heart is resting between beats.
High Blood Pressure: Healthy blood vessels are flexible and expand and contract with your blood pressure. Vessels can narrow and constrict (from age, disease, or unhealthy diet) which makes it more difficult for the heart to pump blood through your vessels. This creates an increase in blood pressure—in other words, high blood pressure. See the chart below for normal blood pressure by age, along with minimum and maximum readings.
What Causes White Coat Syndrome?
If you’re anything like me, it’s not just your blood pressure that spikes around health care professionals. My heart races, my palms are sweaty, and I seem to forget everything that I meant to relay to my Doctor. Here are the prevailing theories about what causes this phenomenon.
Early Signs of Future Problems
The Mayo Clinic argues that it’s an early sign of issues with high blood pressure and that if you experience white coat hypertension you’re at a higher risk for cardiovascular problems. Perhaps the temporary rise in blood pressure is enough to contribute to a long-term problem.
However, other reputable research shows that developing cardiovascular disease (in patients who exhibited some white coat effects) was influenced by the age of the patients, not the high blood pressure due to the syndrome. In layman’s terms—your blood vessels age with you. The older you get, the more your vessels can contract and narrow. Consequently, the older you are, the more pronounced your high blood pressure is when you are exhibiting white coat hypertension.
Experts currently agree that you can drive up your blood pressure if you are actively anxious. Therefore, being anxious is directly related to blood pressure monitoring at the doctor’s office, as well as simply being around medical professionals. People who struggle with it may fear the discomfort that comes with the tightening of the blood pressure monitor cuff. Perhaps it is the fear of what the measurement will show. The anticipation of this is enough to set off high blood pressure. If you deal with generalized anxiety out of the context of the doctors office you are more likely to struggle with this phenomenon as well.
The American Journal of Hypertension published a study in which they sought to show that white coat hypertension is a fear of having one’s blood pressure checked. You can indeed experience fear and discomfort while having your blood pressure taken. This anxiety can lead to a higher blood pressure reading and even avoidance of the procedure. They, however, would argue that it extends beyond high blood pressure readings in a doctor’s office and would extend to readings in one’s home as well.
How to Overcome White Coat Syndrome
Is there a cure for severe white coat hypertension? Or just the garden variety version? Is it something you can truly get rid of? We believe you can beat the condition with the right protocol. Here are five steps to overcoming white coat syndrome:
Measuring blood pressure is a tricky business. Measure some people’s while they are in a doctor’s surgery and it will be deceptively high; others will be misleadingly low. According to research fellow Dr James Sheppard, it is very much “a variable thing – if you rely on a one-off reading, it might be unusually high or low”, given that levels fluctuate throughout the day.
The British Heart Foundation (BHF) estimates as many as 7 million people in the UK have undiagnosed hypertension – referred to as the “silent killer” because it is often without obvious symptoms – although there’s no way of telling whether so many remain undiagnosed because they are not being tested, or because they are giving artificially low readings. The common outcome is vulnerability to conditions such as heart attacks and strokes, so we should welcome new research published by Oxford University that looks at ways of calculating our true blood pressure reading by overcoming problems experienced in a clinical setting.
One explanation for misreadings, “white-coat syndrome”, might sound like something out of The X-Files, but it’s the simple idea that the stress around a doctor’s visit can cause artificially high blood pressure. But, according to Emily Reeves, a senior cardiac nurse at the BHF, there are ways to mitigate this: “It sounds silly, but it’s about trying to control your anxiety … taking a few minutes out and having a deep breath.”
But could there be an anti-white coat effect, too? Some reports have suggested, off the back of Sheppard’s research, that patients may be so calmed by the presence of medical professionals, with their clipboards and charming bedside manners, that it is causing their blood pressure to read lower than it actually is.
But Sheppard is not convinced. Inaccuracies, he says, are often just bad luck. Or, for instance, “if someone has a job that involves lots of physical activity, their blood pressure might generally be high during the daytime, then at the doctor’s they’re more relaxed than in their daily routine”.
“In an ideal world,” says Sheppard, “we’d do 24-hour blood pressure monitoring on everybody” – but this is expensive and uncomfortable. Instead, his team has learned to recognise who might be most at risk – men, for example, and those previously diagnosed with high blood pressure – and created an algorithm that will warn health professionals if there is a higher chance of “a masked effect reverse white coat syndrome”.
Reeves, who was also “baffled” by the idea of anyone being calmed by a white coat – “I guess different people find different things relaxing” – says that over-40s should go for regular NHS health checks in any case, to make sure their hearts aren’t working harder than they should be.
7 ways to reduce stress and keep blood pressure down
When it comes to preventing and treating high blood pressure, one often-overlooked strategy is managing stress. If you often find yourself tense and on-edge, try these seven ways to reduce stress.
- Get enough sleep. Inadequate or poor-quality sleep can negatively affect your mood, mental alertness, energy level, and physical health.
- Learn relaxation techniques. Meditation, progressive muscle relaxation, guided imagery, deep breathing exercises, and yoga are powerful relaxation techniques and stress-busters.
- Strengthen your social network. Connect with others by taking a class, joining an organization, or participating in a support group.
- Hone your time-management skills. The more efficiently you can juggle work and family demands, the lower your stress level.
- Try to resolve stressful situations if you can. Don’t let stressful situations fester. Hold family problem-solving sessions and use negotiation skills at home and at work.
- Nurture yourself. Treat yourself to a massage. Truly savor an experience: for example, eat slowly and really focus on the taste and sensations of each bite. Take a walk or a nap, or listen to your favorite music.
- Ask for help. Don’t be afraid to ask for help from your spouse, friends, and neighbors. If stress and anxiety persist, talk to your doctor.
Along with these ways to reduce stress, add in a healthy lifestyle — maintaining a healthy weight, not smoking, regular exercise, and a diet that includes fruits, vegetables, whole grains, lean protein, and healthful fats — and high blood pressure could be a thing of the past.
For more information on lifestyle changes to treat high blood pressure and how to choose the right medication if needed, read Controlling Your Blood Pressure, a Special Health Report from Harvard Medical School.
As a service to our readers, Harvard Health Publishing provides access to our library of archived content. Please note the date of last review on all articles. No content on this site, regardless of date, should ever be used as a substitute for direct medical advice from your doctor or other qualified clinician.
Beautiful young female doctor is checking the blood pressure of the patient. (iStock)
If you’ve never had a problem with your blood pressure before, it can be jarring to hear that your reading measured higher than the normal cutoff of 120/80 millimeters of mercury (mm Hg).
But you don’t need to freak out just yet.
Blood pressure is the force of your blood pushing against the walls of your blood vessels. If your blood pressure is consistently high, it can damage those vessels, raising your risk of conditions like heart attack, stroke, or even erectile dysfunction, says the American Heart Association.
Related: 6 guys who suffered a heart attack tell you what it really feels like
But normal blood pressure that’s just temporarily higher—even up to 15 to 20 points above usual— is pretty much harmless, says Orlando Health Physicians Internal Medicine Group internist Benjamin Kaplan, M.D.
In fact, there are a number of innocent things that can also be responsible for a fleeting BP spike. Here are 6 to consider if your reading seems weirdly high.
1. Doctors freak you out.
If you get nervous the second you step into your doctor’s office, your heart might start pounding.
“The body essentially reacts in a fight-or-flight manner, increasing the heart rate and getting ready to make a move,” says Dr. Kaplan.
Experts call the resulting increase in blood pressure “white coat hypertension,” which can cause your reading to spike by as much as 15 points, suggests a review published in Hypertension.
Taking deep breaths in through your nose and out through your mouth can help you calm down, which will slow your heart rate and bring your blood pressure back down to normal, says Dr. Kaplan.
Related: How to de-stress in under 2 minutes
Waiting until the end of your appointment to have your BP measured might help, too. “By then, you’ll hopefully have all of your questions answered, and you’ll be less anxious,” he says.
2. You rushed to your appointment.
It’s happened to all of us: The only available parking spot is a block away—and you have 5 minutes to make it to your doctor’s office on the building’s third floor. That’s bad news for your blood pressure, and not just because of the effect of the mental stress of being late.
When you walk fast or run, your heart rate increases as it pumps more blood to power your muscles. More blood pumping through your vascular system means more pressure on the walls of your blood vessels.
That causes your blood pressure to temporarily rise, says Dr. Kaplan.
Related: 3 ways to stop procrastinating
If your doctor takes your blood pressure before your heart rate has had a chance to return to normal—which can take up to 30 minutes, depending on how fast your heart was beating—the reading will probably be higher than you expect.
So instead of having your BP checked at the beginning of your appointment, ask your doctor if he can wait until the end.
“By then, your body’s physiology will have come back to a normal resting state,” Dr. Kaplan says. And your BP reading will be more accurate.
3. You have to pee badly.
When your bladder is full, your body signals the release of stress hormones like adrenaline, which activate your fight-or-flight response. That causes your blood vessels to constrict, which can raise your blood pressure by as much as 15 points, says New Providence, New Jersey cardiologist Steve Sheris, M.D.
As you might’ve guessed, the fix is pretty easy.
If you get to the doctor’s office and you have to pee, don’t hold it in. Go, and then let the doc take your BP, Dr. Sheris says. Your BP should go back to normal in three or four minutes.
Related: How to stop getting up at night to pee
4. You drank coffee or an energy drink.
The culprit here is the caffeine, though experts aren’t sure exactly how it sends your blood pressure skyrocketing.
Two possibilities? It might signal to your body to produce more adrenaline, which speeds up your heart rate. It could also cause your blood vessels to constrict, according to the Mayo Clinic.
Caffeine seems to affect blood pressure more in people who generally don’t drink coffee than those who are already used to the stuff, says Dr. Kaplan.
Related: Why coffee makes you poop
Regular coffee drinkers could have a spike of up to 5 mm Hg. And if you don’t normally drink it, your BP could jump by as much as 15 mm Hg.
So if you don’t normally guzzle double espressos, the day of your annual physical isn’t the time to start. But even if you drink coffee or energy drinks daily, don’t walk into your appointment with the stuff in hand.
Most experts agree that patients should steer clear of caffeine for at least 30 minutes before having their BP taken, Dr. Kaplan says.
5. You sat with your legs crossed.
Sitting with your legs crossed compresses the veins in your legs, which can cause blood to pool up down there.
To compensate and make sure enough blood makes it to other important parts of your body—like your chest—your heart starts pumping more blood, says Dr. Sheris. And that sends your blood pressure up, sometimes by as much as 8 mm Hg.
For the most accurate BP reading, you should sit in a comfortable, upright position.
Your feet should be flat on the floor and your elbows should rest on the armrest of the chair, Dr. Sheris says. The position is standard protocol, so if you aren’t sitting right, your doctor should let you know. (If you’re at a self-serve BP reading place like a pharmacy, and you’re not sure that you’re sitting correctly, ask the pharmacist for help.)
6. The exam room is freezing.
When it’s chilly, the blood vessels near the surface of your skin constrict to send more blood towards your core. This helps keep you your vital organs warm, but it can also drive up your BP by as much as 20 mm Hg, says Dr. Sheris.
When your blood vessels are narrower, the blood flowing through them exerts more pressure.
Since you can’t exactly crank the heat in the doctor’s building—or keep your coat on when he’s taking your BP—the best you can do is make sure you’re not too cold beforehand. If the room seems weirdly chilly, you could leave your coat on until right before the reading.
But if you’re always freezing no matter what, mention it to your doctor—she might recommend that you try taking your BP at home.
So should you worry about one high blood pressure reading?
If you get one strange reading, don’t worry too much.
Your doctor should take at least two BP readings, at least one minute apart, and average the two readings, recommends the American Heart Association. But if your BP seems higher than usual, and one of the above factors was in play, mention it to your doctor. He can decide if you should wait longer before taking the second reading.
“It’s the average of many BP readings that matters,” says Dr. Kaplan. “You need to have elevated readings on multiple days to have the official diagnosis of hypertension.”
If the number continues to measure over 140/90 (which is the cutoff for high blood pressure), you and your doctor can talk about lifestyle changes that can help bring them down—like exercising, eating right, cutting back on salt and alcohol, and quitting smoking—as well as any possible meds like acetaminophen, antidepressants, NSAIDs, or corticosteroids.
First published on MensHealth.com
Increased nerve activity may raise blood pressure in anxiety
Researchers from the University of Iowa studied the responses of two groups of volunteers after they experienced physiological and mental stressors. One group of people had chronic anxiety as determined by standardized scales used to measure anxiety and depression. The control group did not have anxiety. The research team placed the volunteers’ hands in an ice-water bath for two minutes to assess their responses to physiological stress. After a brief recovery period, the participants verbally solved simple math problems as fast as they could for four minutes to induce mental stress. Before the start of each test, the researchers gave the participants a two-minute “warning” countdown.
The research team inserted a tiny microelectrode into a nerve near the back of the participants’ knee to measure sympathetic nerve activity throughout testing. They monitored the volunteers’ rate of blood flow and blood pressure in the upper arm and heart rate via a finger cuff during both activities. Blood samples showed that the anxiety group had higher levels of norepinephrine, a hormone that sympathetic nerve fibers release in response to stress, before testing began. Norepinephrine causes the blood vessels to contract, which raises blood pressure.
The researchers observed increased nerve responses in both groups before and during the ice bath and math activities. However, the increase “was significantly greater among compared with , suggesting an enhanced sympathetic anticipatory response,” the research team wrote.
Heart rate increased during the two-minute countdown, another sign that the anticipation of impending stress or discomfort caused physiological changes in the body. However, there was no significant difference between the anxiety and control groups. “Future studies are warranted to determine whether augmented is associated with deleterious end-organ consequences in persons with anxiety and cardiovascular disease or cardiovascular disease risk factors,” the researchers wrote.
HEALTHY HEART BLOG
White coat hypertension, also known as white coat syndrome, is a condition where a patient’s blood pressure is higher when taken in a medical setting than it is in other settings, such as at home. The term received its name from the white coats that medical professionals wear. It is important to know if you suffer from white coat hypertension as higher than normal blood pressure readings during a doctor’s visit might lead to misdiagnosis and overmedication.
What causes white coat hypertension?
White coat hypertension is a condition affecting patients who experience stress or anxiety at a medical setting such as doctor’s office or hospital. This results in a higher than normal blood pressure reading during their visit. White coat hypertension usually occurs with those who feel nervous for a nurse or doctor to measure their blood pressure. Those who are suspected to suffer from white coat syndrome are usually advised to measure their blood pressure at home and bring their home collected data to their doctor’s appointment for comparison and an accurate diagnosis.
Can anxiety make blood pressure go up?
While occasional anxiety does not cause long-term high blood pressure, it can cause temporary spikes in blood pressure during those anxiety episodes. If those temporary spikes in blood pressure occur every day or frequently, they can damage blood vessels, the heart, and kidneys in the long run or cause high blood pressure. Talk to a healthcare provider about medication if your anxiety interferes with your daily activities.
What is masked hypertension?
Masked hypertension is the opposite of white coat hypertension. Patients with masked hypertension have normal blood pressure readings at the doctor’s office but have high blood pressure readings in other settings, such as in their home. Both white coat syndrome and masked hypertension are concerning conditions as both might lead to a wrong diagnosis and medication errors and both paint a strong case for the need of frequent BP monitoring outside the doctor’s office or hospital.
Is white coat hypertension dangerous?
While white coat hypertension may not cause immediate danger, some doctors believe that white coat hypertension might indicate a risk of developing high blood pressure as a long-term condition. It is also dangerous in a way that this temporarily increase in your blood pressure is likely to be misdiagnosed as ongoing hypertension, leading to unnecessary and unwanted overmedication. This is why frequent blood pressure monitoring at home is important as it can easily alert your medical health care provider about the possible presence of white coat syndrome.
How to treat white coat hypertension?
Although there is no known cure for white coat hypertension, frequent measuring of blood pressure levels at home or place of work and comparing those results with the doctor’s results can easily alert the medical professional of the potential presence of white coat syndrome. Such home BP monitoring should be always done with a medically validated device such QardioArm which makes it easy and convenient to take an accurate measurement anytime, anywhere and store the BP history in the app, ready for the next in-office doctor visit or email it beforehand if necessary.
The companion Qardio App allows you to set reminders to take your blood pressure regularly, and stores your readings in easy to read charts and graphs. Learn more about smart blood pressure monitoring with QardioArm.
Post contributed by Natalie Cassidy.
Mayo Clinic 1
Mayo Clinic 2
For decades, doctors have been aware of a phenomenon known as “white coat hypertension” — when a patient gets higher blood pressure readings at the doctor’s office than they do at home, perhaps because they’re anxious in the clinic — but previous studies have shown inconsistencies in its effects.
Now, a large new meta-analysis confirms patients with the condition are more than twice as likely to die from a cardiac event as those whose blood pressure readings are always normal.
These same patients have a 33% increased mortality risk and are 36% more likely to experience a cardiac event like a heart attack, according to the study published Monday in Annals of Internal Medicine.
The analysis, which pulled data from 27 studies of the condition, paints a far clearer picture of the issue than earlier, single studies did, its authors noted. The findings are also particularly important for public health efforts to address heart disease and stroke, since hypertension is a known risk factor for those events but has no known symptoms. They point, too, to the importance of accurate blood pressure monitoring that patients can take on their own, some researchers argued.
“We were very interested in just clarifying the actual risk of isolated office high blood pressure with a normal blood pressure at home,” said Dr. Jordana Cohen, the paper’s first author and an assistant professor at the University of Pennsylvania Perelman School of Medicine. “It pulls the results together to give us, sort of, a stronger sense of truly what the signal is.”
The study also distinguished between two types of patients who had abnormal blood pressure readings in the doctor’s office — some received medications to bring down their blood pressure and some did not. Those who did get medication had no increased risk for cardiovascular events or death compared to those with normal blood pressure.
Cohen said the two findings together should encourage doctors to more closely monitor patients who show white coat hypertension if they aren’t getting medication — but also that they could be overtreating people with similar readings if they receive antihypertensive medication.
“In most situations, may be more prone to side effects from the blood pressure medications or to having low blood pressure as a result of their blood pressure medications,” Cohen said.
That finding calls into question the proper treatment for white coat hypertension, she said, suggesting the importance of further studies to examine what kind of interventions might be best.
“We’re not sure if treating it with the blood pressure medication helps,” she said. “You don’t want to cause them to have low blood pressures outside of the office, since normally, their blood pressure is normal outside of the office. But we don’t know what to do about it.”
Before this meta-analysis, many previous studies didn’t distinguish between patients with these results who got medication and those who did not, according to Cohen.
The study also divided patients into further subgroups. Cohen and her colleagues found that there was also an elevated risk of cardiovascular events or mortality when the patients in the study were older, when the duration of the study was five years or longer, and when ambulatory blood pressure monitoring systems were used as opposed to home blood pressure monitoring systems, compared to patients whose blood pressure readings were always normal.
Several researchers who weren’t involved in the new paper cautioned that meta-analyses like this one often consider too many variables. Dr. Stanley Franklin, a retired University of California, Irvine, professor who has published numerous studies on white coat hypertension, also pointed out that while some of the included studies may have performed valid, robust analyses, others may not have — compromising the integrity of the meta-analysis as a whole.
Cohen argued that while that may be true in some cases, the inconsistency in the data available to them was exactly why a meta-analysis was necessary — “because you’re never going to design one single study that gets at every single one of those issues.”
She pointed out that even when different studies were excluded from the subgroup analyses, the main results remained consistent — which made the researchers “much more convinced that these findings are real.”
“When you pull all of the results of every available study together, no matter how you cut it, and if you’re very, very stringent about the quality of the studies, you still end up finding that untreated white coat hypertension is associated with this increased risk, whereas treated white coat effect not,” Cohen said.
Paul Munter, who co-wrote an editorial on the study, said this was an important study because it “synthesizes the most contemporary data” and shows the importance of out-of-office blood pressure monitoring.
“Once people start blood pressure lowering medications, they’re going to be on it for the rest of their lives, and so it’s still useful to have the extra information on someone’s blood pressure before asking them to take medication for the rest of their life,” said Munter, an associate dean for research at the University of Alabama at Birmingham School of Public Health.
Cohen and others are also hoping the research will encourage insurers to cover ambulatory blood pressure monitors, in which patients wear a belt around their body, attached to a cuff on their upper arm, and which take blood pressure readings periodically. Right now, most doctors rely on home blood pressure monitoring, in which doctors entrust patients to take their own readings. That can be flawed — when patients take their own blood pressure readings, they often forget or remove measurements they don’t like from the datasets, making the data less reliable.
But ambulatory monitors are expensive, and few insurers cover them.
Dr. William White, previous president of the American Society of Hypertension, argued that the new data highlights their importance — and their relative value. Preventing cardiac events like strokes or heart attacks could save the health care system far more than the devices cost over time.
“It’s silly to not want to cover this test, because in the long run, it would pay for itself,” he said. “This actually increases knowledge of how important it is to accurately diagnose people. You just need to know what they really are, because if you can’t figure that out, it’s impossible, you’re just guessing.”
For now, Cohen is recommending that those with white coat hypertension adopt a better diet and exercise, while monitoring their blood pressure out of the office regularly, with the important caveat that it is an accurate blood pressure measuring device — a list of which will come out this summer from the American Medical Association.
“There’s no such thing right now as a smartwatch, that can actually check a blood pressure without having a cuff, like an actual blood pressure cuff on it,” Cohen said. “And so it’s just very important to be a savvy consumer about these things.”
Testing your blood pressure in the doctor’s office and at home
Why do doctors test your blood pressure?
Hypertension or high blood pressure (HBP) is the biggest risk factor for heart disease and stroke, so taking your blood pressure helps prevent a wide range of cardiovascular diseases and conditions. HBP can lead to heart attack, congestive heart failure, atherosclerosis, stroke, and other conditions from kidney problems to respiratory disorders.
It’s because of the wide-reaching effects of blood pressure that doctors make a blood pressure check part of every appointment. You should have a blood pressure check at least every two years, and more often if your doctor recommends.
How do doctors test for high blood pressure?
Doctors use a sphygmomanometer to take systolic and diastolic measurements, the phases when the heart pumps blood and then rests.
A cuff fits over the wrist or upper arm and inflates, constricting the arteries. When the air is released, the first sound detected with a stethoscope or automated blood pressure monitor is the systolic pressure. The silence that follows marks the diastolic pressure.
According to the American Heart Association (AHA), nervousness or “white coat syndrome” can result in an abnormally high blood pressure during the office visit. On the flip side, someone who’s usually hypertensive can have an atypically lower reading on the day they visit their doctor. These are two reasons home blood pressure monitoring can give a more wholistic picture.
Why would doctors recommend home blood pressure monitoring?
The American Heart Association (AHA) recommends home blood pressure monitoring for anyone with high blood pressure. This applies to almost half of all U.S. adults or about 103 million people. New blood pressure guidelines have increased awareness of the prevalence of hypertension, nearly tripling the number of men aged 20 to 44 and almost doubling the number of women under 45 identified as hypertensive.
Whether they’re being proactive about future high blood pressure or keeping an eye on an existing hypertensive condition, home monitoring is a way for anyone to take charge of their heart health.
How to use a blood pressure monitor at home
There are a variety of home blood pressure monitors available, including wrist and upper arm devices. Some blood pressure monitors let you share your results with a doctor from any location.
When to take your blood pressure:
- Measure your blood pressure at least twice a day
- Take the first measurement in the morning
- Don’t take it right after you wake up
- Measure your blood pressure before eating or taking medication
- Take the second reading in the evening
- Take two or three readings each time you measure to make sure the results are accurate
How to get the best reading when using a blood pressure monitor:
- Avoid food and caffeine for 30 minutes before measuring
- A full bladder can affect your numbers
- Sit quietly for a few minutes before your reading
- Keep your legs and ankles uncrossed
- Keep your back supported
- Don’t talk while taking your BP
- Always use the same arm
- Rest your arm at heart level
- Put the cuff on bare skin
- Don’t roll your sleeves up too tightly
What your blood pressure numbers mean
A blood pressure reading shows up as two numbers, with the top number representing the systolic pressure and the bottom showing the diastolic pressure.
For a normal reading, the systolic number should be less than 120 and the diastolic one less than 80.
If your numbers don’t line up with those measurements, don’t be alarmed. Just check in with your doctor for advice. Meanwhile there are many lifestyle habits you can adopt to maintain a healthy blood pressure.
New ACC/AHA Blood Pressure Guidelines: Check-in Time
It’s been over a year since the new blood pressure guidelines were released and 103 million Americans were recategorized with high blood pressure. That’s nearly 1 in 2 of us. How are YOU doing?
Category Systolic mmHg
(top number) Diastolic mmHg
(bottom number) Normal Less than 120 and Less than 80 Elevated 120 to 129 and Less than 80 High blood pressure
Hypertension stage 1 130 to 139 or 80 to 89 High blood pressure
Hypertension stage 2 140 or higher or 90 or higher Hypertensive emergency
See your doctor right away higher than 180 and/
or Higher than 120 Source: American College of Cardiology and American Heart Association 2017 High Blood Pressure Clinical Practice Guidelines
When it comes to managing blood pressure, there’s nothing to lose
You can prevent high blood pressure, and related problems like stroke, by getting enough exercise, eating fruits and vegetables, not smoking, and avoiding unhealthy fats. These habits are also great for your heart and can even improve your mood.
For other ways to feel great about healthy blood pressure and a healthy heart, join us in Going for Zero™.
Lifestyle changes and medication often are used in combination to treat a patient’s hypertension.
The most commonly used medications are Angiotensin-Converting Enzyme (ACE) inhibitors, Angiotensin II Receptor Blockers (ARBs) and calcium channel blockers. Diuretics and adrenergic blockers can also be helpful in controlling blood pressure.
Some patients may have resistant hypertension, in which blood pressure may remain elevated despite the use of three or more different medications. This condition requires careful evaluation by the physician, as these patients may be at increased risk of heart attack or stroke.
In the most difficult cases of resistant hypertension, the condition may be a result of underlying factors, including hyperaldosteronism. In such cases, an interdisciplinary approach, such as the one employed by the Hypertension Center in the Cedars-Sinai Heart Institute, is vital for establishing an accurate diagnosis and initiating effective treatment.
Patients with accurately diagnosed white-coat hypertension who do not have consistently high blood pressure at any other time may not need treatment with medications. However, patients with this condition should be monitored by their physician, as they may be at an increased risk of developing hypertension in the future.