White Coat Hypertension

Medically reviewed and updated by: Hussain Abdeh MPharm: 2211840

Updated on: 16/06/2021

What is white coat syndrome?

White coat syndrome (also known as white coat hypertension) is a very common condition, in which a patient experiences high blood pressure and heightened anxiety when in a clinical situation, such as a doctor's office. At other times, the patient's blood pressure may be completely normal; however, when visiting a medical professional, the readings are elevated. White coat syndrome could affect as many as 1 in 8 patients to varying degrees.

This can be particularly tricky for doctors to accurately read blood pressure in patients that suffer from white coat syndrome.

Although they share many similarities, white coat hypertension and situational anxiety are two separate conditions. Situational anxiety is triggered by certain events and normal everyday occasions whereas white coat hypertension is specifically triggered by a clinical setting such as a doctors surgery.

White coat hypertension can cause strain on your heart from the stress. If this happens often enough or over long periods, this can become a health risk, leading to the risk of long-term damage to your heart. For this reason, it is very important that this syndrome is controlled and treated.

A second condition that some people suffer from is masked hypertension, which is where your blood pressure is normal when taken at a doctor's office, but is higher in different settings.

What causes white coat syndrome?

Feeling nervous when visiting the doctor may seem entirely natural to many patients. However, white coat syndrome can have serious effects. If a patient's blood pressure is elevated, procedures or treatments may be cancelled or postponed, meaning that the patient does not get the medical attention they need. Some estimates say that up to 1 in 8 patients suffer from white coat syndrome to varying degrees.

The name for this condition is due to people being afraid of seeing doctors or medical professionals in white coats, which can raise their anxiety levels.

White coat hypertension causes a temporary increase in your blood pressure. It may not seem particularly dangerous if this only happens occasionally, but some doctors believe that white coat hypertension could lead to real hypertension.

Studies have shown that people who suffer from white coat hypertension are at an increased risk of suffering from:

• Heart failure
• Heart attack
• Stroke
• Other cardiovascular events

Another study showed that death from heart disease has also been linked with white coat hypertension.

How much does white coat syndrome affect blood pressure?

Of course, the precise effects of white coat syndrome vary from patient to patient. However, an increase in blood pressure is a feature of this condition. The difference in blood pressure when measured at home and at the doctor's office can be vast. At home, the top (systolic) number could be, on average, 10mmHg lower than at the doctor's, while the bottom (diastolic) number could be 5mmHg lower.

These are only averages. Depending on the patient, the difference could be much larger. In fact, some patients could see differences of up to 30mmHg. That makes it difficult for a doctor to measure if a patient really has high blood pressure, or is merely suffering from white coat syndrome.

Does anxiety raise your blood pressure?

Yes. Studies have seen patients fitted with 24-hour blood pressure monitors, which measure the changes in blood pressure over a continuous period throughout the day. Blood pressure readings can change significantly, depending on the levels of anxiety or stress a patient is experiencing. High blood pressure (hypertension) is a permanent problem for some patients, but temporary spikes are common when experiencing anxiety.

White coat syndrome can lead to ongoing problems with high blood pressure, making it important to monitor and treat the issue.

How is white coat syndrome diagnosed?

If your doctor finds that you have a high blood pressure reading, they may ask you to come back and see them again, several times over the next few weeks or months. This will allow them to check the blood pressure measurement over an extended time period, to see if this is a long-term problem.

However, you may suffer from white coat hypertension when you go back to have your blood pressure monitored again. To try and prevent this from happening, a doctor might suggest that you take blood pressure readings outside of the clinical setting. This will help them to diagnose white coat syndrome as the blood pressure reading outside of a clinical setting should reduce back down to normal a normal level.

One way this can be achieved is to have a home blood pressure monitor, which you can purchase online. This will allow you to take accurate blood pressure readings by not having to take them in an environment you find stressful.

Alternatively, they may recommend an ambulatory blood pressure monitor, which you will wear for between 24 and 48 hours. This device tracks your blood pressure every 20 to 30 minutes.

According to Sheldon G. Sheps: MD, some doctors now believe that white coat hypertension might signal that you are at risk of developing high blood pressure as a long term condition.

Treatment for white coat syndrome

First of all, it is important for patients to feel comfortable and relaxed before their blood pressure is taken. A patient should try to get to their medical appointment with plenty of time, and sit calmly while waiting to be seen. If white coat syndrome continues, a patient and doctor can discuss the possibilities of home blood pressure monitoring. This could give a more accurate blood pressure reading. It is possible to purchase a home blood pressure monitor, so you can avoid the anxiety that comes with going to the doctor's office or a hospital.

Many treatments involve cooperation between the patient and the medical centre. The medical centre can work to ensure that the patient is always seen by the same doctors and nurses; familiar faces can help lower anxiety.

White coat hypertension does not usually require high blood pressure treatments, as the blood pressure typically reduces back to a normal level when the individual leaves a clinical setting.

In some cases, blood pressure medication, or beta blockers such as propranolol, may be required. This should always be discussed with a doctor. Medical professionals are well aware of white coat syndrome and will try to identify it in patients before prescribing any medications. However, if the patient requires ongoing treatment for another condition, and their elevated blood pressure is causing problems, then medication might be necessary.

You may also be able to prevent suffering from the white coat effect by practising relaxation techniques, such as breathing exercises, before you go to visit your doctor.

Why do I have white coat syndrome?

White coat syndrome (also known as white coat hypertension) is most commonly caused by anxiety from having your blood pressure reading taken at a doctor's office. The name for this syndrome is taken from the fear a person may experience when seeing doctors and other medical professionals wearing white coats in a clinic setting.

This anxiety can affect your normal blood pressure levels, resulting in a high reading.

Is white coat syndrome a real thing?

Yes, white coat syndrome is a real thing, which can cause damage and strain to the heart. If the hypertension continues in the long term, the level of damage can be increased and become more serious.

Should white coat hypertension be treated?

You can reduce the risk of white coat hypertension by using a blood pressure monitor at home, which will remove the stress of having to visit a clinic setting and help you to remain calm. Your doctor may recommend an ambulatory blood pressure monitor, which you will wear for between 24 and 48 hours, and will take a blood pressure reading every 20 to 30 minutes, for a more consistent and accurate reading.

Beta blockers such as propranolol tablets are highly effective at treating anxiety. Although anxiety and white coat hypertension share many similarities, propranolol is not indicated for the treatment of White Coat Hypertension.

Is white coat hypertension a long-term problem?

Some doctors believe that white coat hypertension is one of the risk factors of people developing high blood pressure as a long-term medical condition. This is because even a temporary rise in blood pressure may lead to a long-term high blood pressure problem.

White coat hypertension vs hypertension

White coat hypertension is when high blood pressure occurs at a doctor's office or within another medical setting, such as a hospital. Regular hypertension is when high blood pressure occurs in various places and scenarios, not just limited to a clinical environment.

Around 15 to 30 percent of people who have high blood pressure in a doctor's office actually have white coat hypertension. However, having the white coat effect dose not necessarily mean that you have general hypertension. By the same token, not everyone who has general hypertension will have high blood pressure in a medical setting.

Masked hypertension is a different condition, which can occur when your blood pressure reads normally when in a clinic setting but is higher in non-medical settings.

What is masked hypertension?

Masked hypertension is essentially the opposite of white coat hypertension. This problem arises when a patient has a normal blood pressure reading when it is taken at a doctor's office, but their blood pressure reading is high in other settings, such as at home or at work. Masked hypertension and white coat hypertension are both problematic conditions due to the fact that either of them may lead to an inaccurate blood pressure reading. This may then lead to an incorrect diagnosis and treatment recommendation.

How can I prevent white coat syndrome?

The stress and worry that the white coat effect can bring upon a person may be enough for normal blood pressure levels to rise significantly while they are in a doctor's office.

Some of the following techniques may help to lessen the white coat effect and allow your doctor to take a more accurate blood pressure reading:

• Relaxation techniques, such as breathing exercises or meditation before the appointment can help people to calm down before they go to the doctor. Counting exercises while in the doctor's office, such as counting how many objects they can see in the office, can also help a person who is feeling anxious to take their mind off the blood pressure monitoring.
• If you are still feeling anxious when you arrive at the doctor's office, take a moment to take a few deep breaths and gather your thoughts. Ask your doctor if you can take a minute or two to calm down to ease into the clinical environment before they apply the blood pressure monitor. Taking a moment to adjust to your environment may make a significant difference to your blood pressure measurement.
• If the busy activity of being in a clinic setting makes you anxious, you may find that moving to a quieter room in the building to have your blood pressure taken can help you to calm down. Ask your doctor if it is possible to have your blood pressure taken in a different room.
• Taking a friend to distract you can help some people to relax while they are having their blood pressure taken. Your friend can talk to you about something else while you are having your blood pressure monitored, thus taking your mind off the situation. Alternatively, some people might find it more beneficial to sit in silence and take some deep breaths.

Is white coat syndrome dangerous?

White coat syndrome may not pose an immediate danger to someone's health, but some doctors believe that this problem may cause high blood pressure as a chronic condition if it is not controlled.

White coat hypertension can also pose a danger of you being given an inaccurate diagnosis by your doctor, due to an inaccurate blood pressure measurement. This can result in you being given unnecessary or excessive medication to treat high blood pressure.

If you suffer from either white coat hypertension or masked hypertension, speak to your doctor about home blood pressure monitoring. This will allow your doctor to gain an accurate measurement by monitoring your blood pressure for a prolonged period. It also shows your health care provider if you might be suffering from white coat syndrome.

Can beta blockers treat white coat hypertension?

Beta blockers such as Bisoprolol and Propranolol are a prescription-only medication that are often prescribed for conditions such as high blood pressure, heart failure, angina, heart attacks and an irregular heartbeat. Propranolol can also be used to treat anxiety.

They usually come in the form of tablets and work to slow down the heart by blocking the action of adrenaline and other hormones.

Beta blockers come in various different types; if you need to be treated for another problem and the white coat hypertension is causing complications, your doctor will prescribe the most appropriate type for you to take for white coat hypertension.

A beta blocker medication will only be prescribed for white coat hypertension if your doctor deems it to be absolutely necessary.

Resources

https://www.webmd.com/anxiety-panic/features/beyond-white-coat-syndrome

https://www.nhs.uk/conditions/high-blood-pressure-hypertension/treatment/

https://www.mayoclinic.org/diseases-conditions/high-blood-pressure/symptoms-causes/syc-20373410

https://www.nhs.uk/conditions/beta-blockers/