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| {{Infobox_Disease |
| | #REDIRECT[[Chronic hypertension differential diagnosis#White Coat Hypertension]] |
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| ==Overview==
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| '''[[White coat]] [[hypertension]]''', more commonly known as '''white coat syndrome''', is a phenomenon in which patients exhibit elevated [[blood pressure]] in a clinical setting but not in other settings.<ref name="urlHypertension: Overview - eMedicine">{{cite web |url=http://emedicine.medscape.com/article/889877-overview |title=Hypertension: Overview - eMedicine }}</ref> It is believed that this is due to the [[anxiety]] some people experience during a clinic visit.<ref name="healthminutes01">{{cite video |people=Swan, Norman |date=20 June 2010 |title=Health Minutes - Hypertension |url=http://www.youtube.com/watch?v=YQC9PYgZ_Zw |accessdate=27 August 2010}}</ref>
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| As the notion of "normal" is subjective and changes from individual to individual a reference measurement was necessary. As night-time and self measured values are often not subject to daily [[Stress (medicine)|stress]] and clinical values are subject to unusual [[anxiety]], daytime ambulatory blood pressure is used as a reference as it takes into account daily stress but not in excess. Due to specificity involved in diagnosis of white coat hypertension, many problems have been incurred in its [[medical diagnosis|diagnosis]] and treatment.
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| The term "masked hypertension" can be used to describe the contrasting phenomenon, where blood pressure is elevated during daily living, but not in an office setting.<ref name="pmid17664850">{{cite journal |author=Pickering TG, Eguchi K, Kario K |title=Masked hypertension: a review |journal=Hypertens. Res. |volume=30 |issue=6 |pages=479–88 |year=2007 |month=June |pmid=17664850 |doi= 10.1291/hypres.30.479|url=http://joi.jlc.jst.go.jp/JST.JSTAGE/hypres/30.479?from=PubMed |format= – <sup>[http://scholar.google.co.uk/scholar?hl=en&lr=&q=intitle%3AMasked+hypertension%3A+a+review&as_publication=Hypertens.+Res.&as_ylo=2007&as_yhi=2007&btnG=Search Scholar search]</sup>}} {{dead link|date=April 2009}}</ref>
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| ==Diagnosis==
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| In studies, white coat hypertension can be defined as the presence of a defined hypertensive average blood pressure in an office setting but not at home.<ref name="pmid18320786">{{cite journal |author=Ruxer J, Mozdzan M, Baranski M, Wozniak-Sosnowska U, Markuszewski L |title="White coat hypertension" in type 2 diabetic patients |journal=Pol. Arch. Med. Wewn. |volume=117 |issue=10 |pages=452–6 |year=2007 |month=October |pmid=18320786 |doi= |url=http://tip.org.pl/pamw/issue/search.html?lang=en&search=18320786}}</ref>
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| Diagnosis is made difficult as a result of the unreliable measures taken from the conventional methods of detection. These methods often involve an interface with health care professionals and frequently results are tarnished by a list of factors including variability in the individual’s blood pressure, technical inaccuracies, anxiety of the patient,<ref>{{cite journal|url=http://www.bpmonitoring.com/pt/re/bpm/abstract.00126097-200512000-00006.htm;jsessionid=LpvGzJN7PDC1yqJtnQj3ZWfmzgdnhWycyzsKybSHsr2FLx3hR1vh!1805002056!181195629!8091!-1 |author=Jhalani, Juhee a; Goyal, Tanya a; Clemow, Lynn a; Schwartz, Joseph E. b; Pickering, Thomas G. a; Gerin, William a|title=Anxiety and outcome expectations predict the white-coat effect. |volume=10 | issue = 6 |month= December | year=2005 |publisher= Lippincott Williams & Wilkins, Inc. |pages=pp317–319}}</ref> recent ingestion of [[pressor]] substances, and talking, amongst many other factors. The most common measure of blood pressure is taken from a noninvasive instrument called a [[sphygmomanometer]]. "A survey showed that 96% of primary care physicians habitually use a cuff size too small,"<ref name="Pickering1994">{{cite journal | author=Pickering T | title=Blood pressure measurement and detection of hypertension | journal=Lancet | volume=344 | issue=8914 | pages=31–5 | year=1994 | pmid=7912303 | doi=10.1016/S0140-6736(94)91053-7}}</ref> adding to the difficulty in making an informed diagnosis. For such reasons, white coat hypertension cannot be diagnosed with a standard clinical visit. It can be reduced (but not eliminated) with automated blood pressure measurements over 15 to 20 minutes in a quiet part of the office or clinic.<ref name='Pickering2005p146'>{{cite journal|title=Recommendations for blood pressure measurement in humans and experimental animals: Part 1: blood pressure measurement in humans: a statement for professionals from the Subcommittee of Professional and Public Education of the American Heart Association Council on High Blood Pressure Research |journal=Hypertension |year=2005|first1=TG |last1=Pickering |first2=JE |last2=Hall |first3=LJ |last3=Appel |first4=BE |last4=Falkner |first5=J |last5=Graves |first6=MN |last6=Hill |first7=DW |last7=Jones |first8=T |last8=Kurtz |author9=Sheps, SG; Roccella, EJ |display-authors=3|volume=45|issue=5|pages=142–61|pmid=15611362 |doi=10.1161/01.HYP.0000150859.47929.8e |url=http://hyper.ahajournals.org/cgi/content/full/45/1/142|format=|accessdate=2009-10-01| ref=harv}} See p. 146, ''Masked Hypertension or Isolated Ambulatory Hypertension''.</ref>
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| Patients with white coat hypertension do not exhibit the signs indicative of trepidation and their increased blood pressure is often not accompanied by [[tachycardia]].<ref name="Pickering1988">{{cite journal | author=Pickering T, James G, Boddie C, Harshfield G, Blank S, Laragh J | title=How common is white coat hypertension? | journal=JAMA | volume=259 | issue=2 | pages=225–8 | year=1988 | pmid=3336140 | doi=10.1001/jama.259.2.225}}</ref> This is supported by studies that repeatedly indicate that 15%–30% of those thought to have mild hypertension as a result of clinic or office recordings display normal blood pressure and no unusual response to pressure stimulus. These persons did not show any specific characteristics such as age that may be indicative of a higher susceptibility to white coat hypertension.<ref>{{cite journal | author=McGrath B | title=Is white-coat hypertension innocent? | journal=Lancet | volume=348 | issue=9028 | pages=630 | year=1996 | pmid=8782749 | doi=10.1016/S0140-6736(05)65069-6}} - commenatry on:<br>{{cite journal | author=Glen S, Elliott H, Curzio J, Lees K, Reid J | title=White-coat hypertension as a cause of cardiovascular dysfunction | journal=Lancet | volume=348 | issue=9028 | pages=654–7 | year=1996 | pmid=8782756 | doi=10.1016/S0140-6736(96)02303-3}}</ref>
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| [[Ambulatory blood pressure monitoring]] and patient self-measurement using a [[home blood pressure monitoring]] device is being increasingly used to differentiate those with white coat hypertension or experiencing the white coat effect from those with chronic hypertension. This does not mean that these methods are without fault. Daytime ambulatory values, despite taking into account stresses of everyday life when taken during the patient's daily routine, are still susceptible to the effects of daily variables such as physical activity, stress and duration of sleep. Ambulatory monitoring has been found to be the more practical and reliable method in detecting patients with white coat hypertension and for the prediction of target organ damage. Even as such, the diagnosis and treatment of white coat hypertension remains controversial.
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| Recent studies showed that [[home blood pressure monitoring]] is as accurate as a 24-hour ambulatory monitoring in determining blood pressure levels.<ref name="pmid16647616">{{cite journal |author=Niiranen TJ, Kantola IM, Vesalainen R, Johansson J, Ruuska MJ |title=A comparison of home measurement and ambulatory monitoring of blood pressure in the adjustment of antihypertensive treatment |journal=Am. J. Hypertens. |volume=19 |issue=5 |pages=468–74 |year=2006 |month=May |pmid=16647616 |doi=10.1016/j.amjhyper.2005.10.017}}</ref> Researchers at the [[University of Turku]], [[Finland]] studied 98 patients with untreated hypertension. They compared patients using a home blood pressure device and those wearing a 24-hour ambulatory monitor. Researcher Dr. Niiranen said that "home blood pressure measurement can be used effectively for guiding [[anti-hypertensive]] treatment". Dr. Stergiou added that home tracking of blood pressure "is more convenient and also less costly than ambulatory monitoring."
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| Use of breathing patterns has been proposed as a technique for identifying white coat hypertension.<ref name="pmid19009177">{{cite journal |author=Thalenberg JM, Póvoa RM, Bombig MT, de Sá GA, Atallah AN, Luna Filho B |title=Slow breathing test increases the suspicion of white-coat hypertension in the office |journal=Arq. Bras. Cardiol. |volume=91 |issue=4 |pages=243–9, 267–73 |year=2008 |month=October |pmid=19009177 |doi= |url=http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0066-782X2008001600010&lng=en&nrm=iso&tlng=en}}</ref>
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| In one Turkish study of 438 consecutive patients, 38% were normotensive, 43% had white coat hypertension, 2% had masked hypertension, and 15% had sustained hypertension. Even patients taking medication for sustained hypertension who are normotensive at home may exhibit white coat hypertension in the office setting.<ref name="pmid16778338">{{cite journal |author=Helvaci MR, Seyhanli M |title=What a high prevalence of white coat hypertension in society! |journal=Intern. Med. |volume=45 |issue=10 |pages=671–4 |year=2006 |pmid=16778338 |doi= 10.2169/internalmedicine.45.1650|url=http://joi.jlc.jst.go.jp/JST.JSTAGE/internalmedicine/45.1650?from=PubMed |format= – <sup>[http://scholar.google.co.uk/scholar?hl=en&lr=&q=intitle%3AWhat+a+high+prevalence+of+white+coat+hypertension+in+society%21&as_publication=Intern.+Med.&as_ylo=2006&as_yhi=2006&btnG=Search Scholar search]</sup>}} {{dead link|date=April 2009}}</ref>
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| ==Implications for treatment==
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| In general, individuals with white coat hypertension have lower morbidity than patients with sustained hypertension, but higher morbidity than the clinically normotensive.<ref name="pmid17435652">{{cite journal |author=Khan TV, Khan SS, Akhondi A, Khan TW |title=White coat hypertension: relevance to clinical and emergency medical services personnel |journal=MedGenMed |volume=9 |issue=1 |pages=52 |year=2007 |pmid=17435652 |pmc=1924974 |doi= |url=http://www.medscape.com/viewarticle/552593}}</ref>
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| However, it should be remembered that all the established published trials on the consequences of high blood pressure and the benefits of treating are based on one-time measurement in clinical settings rather than the generally slightly lower readings obtained from ambulatory recordings.
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| The debate and conflicting ideas revolve around whether or not it would be feasible to treat white coat hypertension, as there still is no conclusive evidence that a temporary rise in blood pressure during office visits has an adverse effect on health.
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| In fact, many cross sectional studies have shown that "[[target-organ damage]] (as exemplified by [[left ventricular hypertrophy]]) is less in white-coat hypertensive [patients] than in sustained hypertensive [patients] even after the allowance has been made for differences in clinic pressure".<ref name="Pickering1994"/> Many believe that patients with "white coat" hypertension do not require even very small doses of antihypertensive therapy as it may result in [[hypotension]], but must still be careful as patients may show signs of vascular changes and may eventually develop hypertension.
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| ==See also==
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| {{wiktionary}}
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| * [[Blood pressure]]
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| * [[Hypertension]]
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| * [[Home blood pressure monitoring]]
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| ==References==
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| {{Reflist|2}}
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| [http://www.facmedicine.com/?p=104 Faculty Of Medicine : White Coat Syndrome]
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| {{Vascular_diseases}}
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| [[ca:Efecte « bata blanca »]]
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| [[de:Weißkittelhypertonie]]
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| [[es:Hipertensión de bata blanca]]
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| [[fr:Effet « blouse blanche »]]
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| [[hi:ह्वाईट कोट हाईपरटेंशन]]
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| [[he:תסמונת החלוק הלבן]]
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| [[ja:白衣高血圧]]
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| [[pl:Efekt białego fartucha]]
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| [[ru:Гипертензия белых халатов]]
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| [[zh:白大衣高血壓]]
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| [[Category:Hypertension]]
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| [[Category:Cardiology]]
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| [[Category:Up-To-Date cardiology]]
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