Impaired Risk Review...
White Coat Hypertension
Robert M. Goldenberg
February 2017

Blood pressure readings are part of virtually every physician encounter and of course every paramedical exam for insurance.  Hypertension, or high blood pressure, has been well studied as a risk factor in health and disease.  The term white coat hypertension, or white coat syndrome, is used to describe individuals whose blood pressure in a clinical setting is significantly higher (or out of normal range) than in normal daytime situations, and believed to be due to transient anxiety during a doctor or medical visit.

Elevated blood pressure is a known cause of many secondary disease phenomenon.  Heart enlargement, coronary artery disease, congestive heart failure, stroke, carotid disease, cognitive impairment and dementia, kidney disease and of course heart attack are all related to uncontrolled high blood pressure.  A blood pressure that rises transiently in the face of a stressful situation generally does not cause long term health side effects.  But one that is elevated for prolonged periods does, and the challenge is differentiating that single high reading from a permanent state of affairs. 

According to the American Heart Association, white coat hypertension may be elevated in 15-25 percent of those who have elevated blood pressure in a doctor’s office or in contact with a health professional.  It is most common in women, nonsmokers, elderly, and those without traditional signs of end organ damage from prolonged blood pressure elevations.  The diagnosis of hypertension is a serious one for many reasons.   It may cause the individual to be put on medications that have their own set of side effects and other interactions within the body. It may cause ratings and disadvantages when applying for life and health insurance.  The cost of medication and unnecessary monitoring visits also add to the importance of a firm diagnosis. 

Optimal blood pressure according to the World Health Organization criteria is a measurement less than 120/80.  Normal blood pressure is under 130/85.  Mild hypertension is described as a blood pressure of 140-160/90-99.  When blood pressure is elevated and sustained over several clinical visits, the diagnosis can be established and treatment with drugs, diet, or both may be instituted.  The challenge is in those who are found on a routine visit with no documented history and subject to many conditions that can cause transient elevation including stress, time of day, the proper size of the blood pressure cuff (cuffs that are too small can cause elevated readings) and, of course, the presence of the white coat and the anxiety associated with a doctor visit.  

There really aren’t a lot of signs a health professional can use to diagnose white coat hypertension on a single visit.  A fast heart rate may be one sign of anxiety.  Nervousness that is clinically apparent can be another.  Recent physical activity, sleep deprivation, even proximity to a large meal can cause elevated blood pressure readings on a sporadic basis.  So what can be done to differential white coat hypertension from elevated pressure that needs regular and effective treatment?  

Ambulatory blood pressure monitoring and patient self assessment with a home blood pressure monitoring device are key differentiators.  Newer machines used properly are on the whole reliably accurate in determining blood pressure.  Many storefront machines in various pharmacies and supermarkets are also helpful.  The definitive method used by doctors is called 24 hour ambulatory blood pressure monitoring.  They are a readout of pressures over the course of a day and take into account stresses of everyday life from the individual’s daily routine as well as record what blood pressures are during rest in the evening.  It helps differentiate occasional blood pressure increases (like in a doctor’s office) from a constant state of elevated blood pressure that does need treatment.

What happens when an isolated blood pressure during an insurance exam is elevated?  First, most white coat hypertension is not severe—numbers that are grossly over normal usually indicate a more serious and constant problem.  The total picture is looked at with help from Attending Physician Statements that will usually document either high blood pressure or white coat syndrome.  Examiners are generally instructed to take blood pressure three times, not only to be sure but to give the individual a chance to calm his or herself and to acclimatize to the situation.  The underwriter will also have the ability to assess if there is end organ damage or anything in the history associated with blood pressure than is chronically elevated.  Finally, blood pressure re-checks may be authorized when a condition is identified that might have caused blood pressure to rise transiently.      

Blood pressures that rise repeatedly in stressful situations may need to be treated as long standing hypertension to keep complications from developing.  Most doctors and healthcare professionals know, however, the importance of making a patient or individual feel comfortable while recording vital signs to minimize the development of white coat hypertension and avoid unnecessary disease labeling and resulting treatments.

Author's Bio
Robert M. Goldenberg

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