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    Michael L. Aaronson, MD
    Kidney Doctor and High Blood Pressure Specialist
    7401 O Street Lincoln, NE 68510
    Phone: 402-484-5600

    Sunday, January 27, 2019

    White coat hypertension: the Importance of Correlating the Blood Pressure Cuff

    As a high blood pressure specialist, I get referrals to help patients get to their target blood pressure goals. Sometimes there is a discrepancy between the blood pressure recorded in the nephrologist's office and the patient's blood pressure at home. I commonly hear from the patients I serve the following: "I have white coat hypertension Doctor Aaronson. My blood pressure is high in the office, but it is normal at home. I just get nervous in the office and my pressure increases." And many times this statement made by the patient is spot-on correct. The prevalence of white coat hypertension is common in the population and ranges from 13 to 35 percent.

    What's important to find out is whether or not the blood pressure is really lower at home. Is the home cuff reading calibrated correctly? If the numbers are accurate we can can rest-assured that we are evaluating the situation correctly. 

    Let's talk about measuring blood pressure outside of the office. There are essentially two ways to do it. There are machines called 24 hour ambulatory blood pressure monitors (abpm) that record blood pressure every 30 minutes while awake and 1 hour while asleep that give insight as to whether or not a person has white coat hypertension. They are helpful but can be a burden to wear for the 24 hour period and can be expensive. The alternative is the traditional automated home blood pressure cuff, as shown in the figure above. To make sure the home monitor is accurately reading: correlate your home blood pressure monitor with the office reading. This approach helps the kidney doctor feel comfortable that your device is reading your blood pressure correctly. That's the key - an accurate measurement.

    Once we know that the home device is correctly calibrated to the office device, the home cuff can be used in the right setting as a surrogate for office blood pressure readings. Why is this so important? Our goal is to achieve target blood pressure and not overtreat. We don't want to treat a normal blood pressure and make a person hypotensive, causing unnecessary side effects.

    That said, caution must be used with this strategy. As people age or get heavier they usually transition from white coat hypertension to having truly elevated blood pressure. Many of these people require blood pressure medication or more blood pressure medicine. The conversion of patients with white coat hypertension to true hypertension requiring treatment is 1 to 5 per cent per year. So we cannot be complacent. We need to follow blood pressure closely. We need to treat when necessary to decrease cardiovascular disease and promote health.

    Some questions answered:

    What is the goal blood pressure? Recent cardiac guidelines suggest a target blood pressure of less than 130/80 millimeters of mercury (mm Hg) rather than 140/90 mm Hg. Ask your doctor for your goal blood pressure. Different patients have different goal blood pressures.

    What if you are not sure whether or not to treat with antihypertensive medication (blood pressure medicine)? Some might suggest a cardiac echocardiogram to assess for left ventricular hypertrophy, defined as thickening or enlargement of the wall of the left heart caused by the heart muscle having to exert extra effort against an elevated blood pressure. If present, some doctors would suggest treatment to decrease the strain on the heart.

    What is the downside of using home blood pressure monitoring? Nothing! Just remember to correlate the cuff so that you know that the reading is right. Patients with bona fide hypertension use this technique to see how they are doing on their medication over time.

    In sum, white coat hypertension is a real phenomenon. Consider correlating your home cuff with the office cuff to get accurate readings.

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