What is White Coat Hypertension?

Multiple studies have shown that checking the patient’s blood pressure again later in the visit can often bring it down substantially, Juraschek says.

How do I decrease white coat hypertension?

Your doctor might ask if you rushed to get there, but also: Have you eaten today and been staying hydrated? Have you consumed any other substances, whether medications or recreational substances like alcohol? These are all factors that can affect your blood pressure, Leyro says.

Doctor’s appointments mark a snapshot in time, and blood pressure may reflect the most recent behavior. Juraschek cites a scenario of busy weekends of birthday parties or holidays with higher-than-usual sodium intake. Avoid scheduling time with the doctor at busy times.

We can even manage our stress going in. Leyro cites slow-paced breathing: in for four seconds, out for six or as slow as just six breaths per minute at 10 seconds each. The technique, formally known as heart rate variability biofeedback, can change heart rates, promote the parasympathetic system — important for rest, relaxation and recovery — and most relevantly, promote sensitivity in our baroreceptors, which are present in our blood vessels and promote changes in our blood pressure.

And in case you’re wondering, decreasing blood pressure to “artificially low” levels is not likely to be an issue, Leyro says. The effect is unlikely to be that dramatic, but just enough to counteract white coat syndrome. Plus, she notes, the ability to lower our own blood pressure through our own means provides a sense of control.

Home monitoring is key to a diagnosis of hypertension

Considering that hypertension affects a majority of all American adults over the age of 65, and that studies suggest the risk of developing hypertension over a lifetime ranges from about 90 to 100 percent, it makes sense to eventually invest in a blood pressure monitor for use at home, Juraschek says. He also recommends monitors for most middle-aged adults with certain cardiovascular risk factors.

Monitoring from home at various times also provides insights into our bodies, Leyro says, and that’s knowledge we can bring to our doctor so our blood pressure rate there is put into some context. Is my blood pressure typically higher or lower in the morning or later in the day? How do various daily activities affect my blood pressure?

“A lot of times we know our bodies better than our doctors, and our doctors are kind of the experts in medicine,” Leyro says. “And together, when you put our heads together, we can often have more information and come up with better treatment and better intervention.”

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The American Medical Association maintains a registry of approved home monitors called the U.S. Blood Pressure Validated Device Listing, or VDL. Juraschek says they review applications from companies to ensure lab-grade accuracy testing.

Possessing a monitor does not mean constant testing, since normal fluctuations may cause unnecessary anxiety. But Juraschek recommends initiating with two measurements in the morning and two at night over a three- to seven-day period, then averaging the result. This helps avoid the pitfall of basing treatment on isolated readings that are unusually high. For more detailed tips on checking your blood pressure at home, see AARP’s guide to high blood pressure symptoms, causes and tests.

Alternatively, Juraschek says, if the office reading is significantly lower, you can address this with your doctor and suggest you may have masked hypertension — the opposite effect of white coat syndrome — and see how that can be addressed. Masked hypertension occurs when blood pressure is normal in the doctor’s office but high in your everyday life. For example, if you regularly smoke but avoid doing so prior to your doctor’s appointment, your blood pressure may appear lower than it actually is normally.

In addition, it’s recommended that the diagnosis of hypertension be based on two office visits, Juraschek says, because the variability in blood pressure measurement is greater between visits than within a single visit.

How serious is white coat hypertension?

We know that normal blood pressure measurements both at home and at a medical clinic are the best-case scenario and represent the lowest risk of hypertension, and that high blood pressure in both settings suggests the highest risk, Juraschek says. So where do we place those intermediate categories of white coat syndrome and masked hypertension?

Epidemiology literature and observational studies suggest that those with masked hypertension are somewhat “second-tier worse off,” Juraschek says. They are better off than those with sustained hypertension or hypotension, which is low blood pressure that comes with its own risks such as passing out. But part of what puts those with masked hypertension in a potentially higher risk category is that something that is not detected in a clinical setting may get undertreated, he says. And the debate about white coat hypertension gets even more complicated.

Some geriatricians would say any blood pressure measurement is a true blood pressure measurement, regardless of white coats and the context of the high blood pressure — that it’s still not a good thing and we should recognize that mildly increased risk, Juraschek says. Other medical professionals might care only about home-based blood pressure readings, so they don’t treat people unnecessarily. Juraschek believes in considering multiple factors to inform the decision about treatment, in consultation with your doctor.

Older adults deserve high blood pressure treatment

Older adults tend to have higher blood pressures overall as well as more variable blood pressures, Juraschek says. He acknowledges a larger debate over whether treatment is worthwhile at advanced ages when virtually everyone is prone to hypertension.

Cardiovascular disease is the number one cause of death in older adults, a risk that increases with age. Juraschek cites “robust evidence” among adults age 80 to 85 that shows how blood pressure medication reduces stroke, cardiovascular events and even dementia. Older patients should have a leading role in decisions about their treatment, involving family members and other social supports as needed.

“I think more than any other group, older adults require special attention and tailoring of approaches to the individual patient based on their circumstance,” Juraschek says.

Leyro emphasizes the importance of getting additional data points on elevated blood pressure to better understand what’s going on. And just as hypertension must be taken seriously, white coat syndrome should not be dismissed as not really hypertension. Left untreated, patients with white coat syndrome have a higher risk of heart disease, even potentially with fatal results.

“My approach is, if you see high blood pressure, we shouldn’t just ignore that and say, ‘Oh, that was whatever,’ even if there’s a good explanation for it,” Juraschek says. “I think we should note it and have a plan to follow up on it.”