White Coat Syndrome Is a Physiological Reality

The trick to overcoming white coat syndrome involves open communication and relaxation techniques—things easier said than done.

white coat syndrome

You may be thinking, “If white coat syndrome disappears when I leave the doctor’s office, what’s the big deal?” It could be a very big deal.

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A person with white coat syndrome experiences elevated blood pressure readings when he or she is in a medical setting. The blood pressure returns to normal when the person leaves the medical office.

Here’s a clue you might have white coat syndrome and not even realize it: If the nurse or physician takes your blood pressure multiple times during an office visit, he or she may suspect you have white coat syndrome. In fact, 15 to 30 percent of us suffer from white coat syndrome, and multiple studies have proven white coat syndrome is real.

We’re not alone in suffering from white coat syndrome. A study published in Journal of Veterinary Internal Medicine from Ohio State University found that anxiety associated with being in a veterinary hospital elevates blood pressure in retired racing greyhounds, a breed known for having higher-than-average blood pressure in the first place.

While white coat syndrome hypertensive readings are real, they’re not enough for a physician to make a diagnosis of high blood pressure (hypertension). While in years past, some doctors would prescribe medications based on the office readings that rarely occurs today. Further evaluation is required.

To separate white coat syndrome from hypertension, your physician may ask you to do regular blood pressure readings at home and report the results. There are monitors that can be worn to regularly read your blood pressure.  A normal blood pressure reading when you’re away from the doctor compared to elevated readings when you’re in the doctor’s office or hospital makes the diagnosis of white coat syndrome.

Not a New Syndrome

It’s believed white coat syndrome was first described by Italian physician Scipione Riva-Rocci, who designed the first cuff-based version of the mercury sphygmonanometer (blood pressure machine).

Dr. Riva-Rocci never received any financial gain from his revision of the blood-pressure machine, as he refused to patent it. He shared his information with Harvey Cushing, M.D., who brought this revised blood pressure monitor to Johns Hopkins Medical School in the United States.  Dr. Cushing, as you may suspect, also discovered Cushing’s syndrome, however, Wikipedia lists his greatest contribution to medicine as the further development of the Riva-Rocci machine.

Apparent white coat syndrome readings were first recorded in 1983. In 1992, Dr. Thomas Pickering, founder of the Center for Behavioral Cardiovascular Health at Columbia Medical School, started calling this reaction “white coat syndrome.”  White coat syndrome occurs due to the anxiety some people feel about going to the doctor’s office and is so named because most physicians where white coats. Over the years, the term morphed into “white coat hypertension,” a much more accurate name.

Why White Coat Syndrome Is a Concern

You may be thinking, “If white coat syndrome disappears when I leave the doctor’s office, what’s the big deal?” It could be a very big deal.

Some doctors think if your blood pressure rises when you’re stressed about an office visit chances are good it rises when you’re under other stressful situations, too, such as during a meeting with your boss about upcoming company lay-offs, and that could become physically damaging. Wearing a 24-hour monitor might give your doctor the information he or she needs to determine if it’s white-coat syndrome or blood pressure elevation under all stressful conditions.

A 2015 study published in Psychology Research and Behavior Management stated: “There is evidence that white coat hypertension is associated with mild and severe physical health outcomes and an increased risk of developing sustained hypertension. Patients with white coat hypertension often progress to sustained hypertension.”

But even if it doesn’t—and you truly only suffer from white coat syndrome—there still may be concern. A 2015 study published in the Journal of the American College of Cardiology found that white-coat syndrome and masked hypertension were “were independently associated with increased aortic stiffness, renal injury, and incident cardiovascular events.”

However, a study reported in Hypertension: Journal of the American Heart Association considered over 69,000 patients with hypertension and found 37 percent of the patients with resistant hypertension had white coat syndrome.

“While those who actually had white coat hypertension are not risk free, their cardiovascular outcomes are much better,” says Alejandro de la Sierra, M.D., lead author of the study. “Those with true resistant hypertension showed high blood pressure at work, during the day and at night. The true resistant group also was more likely to have blood pressures that abnormally rose during the night when they were sleeping.”

What Do You Do?

The most important way to combat white coat syndrome is to learn to trust your physician, and that, says the 2015 study in Psychology Research and Behavior Management, requires an open discussion between physician and patient. The patient needs to feel he or she has some say into testing and treatment options.

“Effective communication and relationship building can reduce the patient’s anxiety about their illness and about their interaction with a physician,” the study states. The patient should be comfortable asking any question, and the doctor should explain things clearly. A doctor’s bedside manner matters, too: “Verbal and nonverbal communication fit into these categories, as a physician can deliver effective communication through nonverbal behaviors such as warm voice tone, appropriate eye contact, a reassuring touch on the arm, or a kind facial expression, for example,” the researchers say.

Medical News Today advises those with white coat syndrome to:

  • Practice relaxation techniques: Breathing exercises and meditation can help. Count things using the senses. “For instance, a person could count three things they can see in the room, two things they can hear, and one thing they can touch. This exercise may help the person focus less on what is worrying them and more on what is around them.” One would suspect the popular practice of mindfulness could help here, too.
  • Request a quiet room: Ask for an exam room away from all the flurry in the doctor’s office, if possible.
  • Take a moment before the reading: Take a few deep breaths before the blood pressure reading to help calm nerves. Breathe in and out through your nose.

New Numbers for Hypertension

In November 2017, high blood pressure was redefined by medical experts, including the American Heart Association (AHA) and the American College of Cardiology. It is now defined as readings of 130 mm Hg and over for systolic blood pressure and 80 or higher for diastolic (lower number). The previous standard was 140/90. In addition, they eliminated “prehypertension” as a category.

The AHA stated: “Damage to blood vessels begins soon after blood pressure is elevated. The guidelines stress the importance of home blood-pressure monitoring using validated devices and appropriate training of healthcare providers to reveal ‘white coat hypertension.’ “

“People with white coat hypertension do not seem to have the same elevation in risk as someone with true sustained high blood pressure,” says Paul K. Whelton, M.B., M.D., M.Sc., lead author of the guidelines.


Blood Pressure Chart: Where Do Your Numbers Fit?
UHN Blog: What’s the Right Blood Pressure for You? It Depends
13 Cardinal Rules for Getting Accurate Blood Pressure Readings at Home

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Cindy Foley

Cindy Foley is the editor of several health reports, including Managing Your Cholesterol, Core Fitness, and Brain Power & Nutrition, among others. Foley has worked in the private medical practice field … Read More

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