How high blood pressure in the office can be white coat hypertension

“But doc, my blood pressure is always normal at home.”  I wish I had a dollar for every time I have heard that line and I know it is true.

When some patients come to see me, their blood pressure is abnormally high (above 130/90) and this is known as “white coat hypertension.”  Although it has been thought to be from anxiety about seeing the doctor, even long established patients who have no conscious anxiety can exhibit elevated blood pressure in the office.

Because blood pressure naturally fluctuates and the office visit is not a “normal” setting,  it is important for patients who have hypertension (high blood pressure) to have their own BP cuff at home.  Now that devices are automated and easy to use, everyone with hypertension should be monitoring their BP in the comfort of their own home.  I advise multiple readings over a week at different times of day.  Get a reading when resting and when rushing around.  Take the BP after you exercise and after a meal.  It is important to keep a log and write it down.  Only then can we see patterns and know if the blood pressure is controlled or not.

Blood pressure readings in the doctors office are not necessarily the most accurate.  Patients are often rushed trying to get parked and in on time.  Medical assistants can use the wrong size cuff or not position the arm correctly.  Auscultation (listening) is not very accurate due to errors.  It is the multiple readings over time that give a more accurate picture of blood pressure control.

High blood pressure in the office can be true hypertension or it can be “white coat hypertension” that is usually controlled at home.  If a patient is on blood pressure medication and has controlled BP at home, I will not add more medication just because they are elevated in the office.  If a patient has not been diagnosed with hypertension and the BP is elevated in the office … that patient is advised to get their own home cuff and return with readings for us to review.  This way we can minimize unnecessary and expensive medication and make sure we are protecting the patient as well.

Toni Brayer is an internal medicine physician who blogs at EverythingHealth.

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  • soloFP

    If the BP is elevated at the office, then it may be elevated at the patient’s workplace, during arguments, during exercise, and during other stressful situations. Unless the BP gets too low on meds, advocating antihypertensive makes sense.

  • ninguem

    Toni Brayer, MD – “…….Blood pressure readings in the doctors office are not necessarily the most accurate……”

    And the automated ocillometric device purchased at Wal-Mart is better?

    “……Patients are often rushed trying to get parked and in on time……”

    And they’re rushed to get into the movie theater, the beauty parlor appointment, mad at the guy who flipped the bird in traffic, mad at the spouse for all the usual reasons, watching the evening news, reading the electric bill, paying taxes, and all the other stuff in life. If the stress of a doctor’s office raises blood pressure, so do all sorts of other things, every day.

    “….Medical assistants can use the wrong size cuff or not position the arm correctly. Auscultation (listening) is not very accurate due to errors…..”

    This bothers me. If a doctor’s office can’t get vital signs right, it’s time to find another line of work. Accepting human error from time to time, it’s strange to think a layperson is going to do better at home with an automated device.

    “….It is the multiple readings over time that give a more accurate picture of blood pressure control…..”

    Finally, something that doesn’t raise my blood pressure.

    That’s why we have ICD Code 796.2
    “Elevated blood pressure reading without diagnosis of hypertension”. I use the code all the time. You get marginal numbers, the doctor should check the blood pressure again, personally; follow over time with the usual dietary and lifestyle advice. And yes, check the numbers at home. I give the patient the same story about stress of the office, patient says it’s normal at home, I ask the patient if the cop checked your blood pressure when he pulled you over for speeding. They seem to get the point. If the elevated pressure persists, then treat.

  • Evan

    Easy enough to tell the difference with a 24 hour ambulatory BP test.

  • Diora

    If the BP is elevated at the office, then it may be elevated at the patient’s workplace, during arguments, during exercise, and during other stressful situations. Unless the BP gets too low on meds, advocating antihypertensive makes sense.

    There is sometihng special about doctor’s office for some of us. It’s the idea that something might be found that is wrong with you that’s so much more stressful than all the little things. I don’t care if I am pulled over for speeding, it’s just money, and i have enough. I don’t care about some car trouble. The news on tv don’t happen to me – so I can emphasize or get upset but not the same almost visceral anxiety I get at the doctor. You assume that if the visit to a doctor stresses us, then other things do as well, but it’s not a fact. There is something special about concern over our health.

    We have a large stationary machine at work that’s supposed to be accurate, and whenever I measure my blood pressure at work it’s normal. When I go to a doctor, even if I anticipate doctor’s visit, my blood pressure starts going up that day. I measure it on the same machine at work before doctor’s visit and it’s already up in the morning simply because of anticipation. It’s up significantly when I am at the doctor. Just the fear of having my blood pressure measured and it’s being high and having to take medications for life is enough to get my blood pressure up. Other things in live – who cares.

    Medications have side effects, having to take medication for life changes your life in a way. If I only get high blood pressure around medical tests and I KNOW IT because I TEST IT EVERY DAY, tell me why I should take medication?

  • Diora

    easy enough to tell the difference with a 24 hour ambulatory BP test.
    You cannot remove the awareness of this monitor. I’d imagine if a doctor were to give me this monitor, I’d be thinking about it every moment of the day. I’d be aware of it, I’d worry what it shows for the duration of time it’s on me. It’ll be like an exam in high school only worse because it’s about my health and whether or not I’ll have to take drugs for the rest of my life. And yes, I’ll be worried more about it than I ever worry about other things in life, because other things may only affect things like my career or money or other unimportant things.

  • http://www.drjoe.net.au Dr Joe

    Given that blood pressure can potentially change every time the heart beats,the ‘snapshot” we get in the office can never be totally representative. The white coat factor adds to this.
    We need to be very sure that prescribing pills for blood pressure is actually necessary before subjecting people to the cost and potential side effects of medications.

  • DF

    And to the cost of the “diagnosis” that then gets tacked on to life insurance, health insurance, LTC insurance, etc and increases those costs. At least check it at the beginning of the visit and the end before making any judgements. I work in health care and used to work in a primary care clinic doing follow up care for med changes for DM, HTN, coumadin, etc. So we routinely did BP checks. Anytime we got a high first reading, we always re-checked it after a few minutes of talking. Usually most people drop after a few minutes of relaxed conversation. Even mine always seems to be a tad bit high at any doctor visit, but when I donate platelets every month, it’s in the low-normal range. So being on the “other side of the cuff” makes me “white coat” too.

  • Leslie

    Once I read all of the official AHA procedures and suggestions for measuring blood pressure correctly, I was floored at how many times I have had mine taken incorrectly. Not one medical assistant has ever suggested I take the measurement on an empty bladder. They take it as soon as you’ve just walked down a hallway into the exam room. Sometimes they take it while you’re having a conversation. Half the time they take the readings through a shirt sleeve. Sometimes my arm is not at heart level or supported properly. Sometimes I’ve been sitting there with my legs crossed. It goes on.

    At one doctor visit last year, the person took my blood pressure *through my wool sweater sleeve*.

    If you can’t take a vital sign correctly you have no business working in medicine.