hypertension

High Blood Pressure: a new twist on the white coat syndrome

by Barry Bittman, MD

What you don’t know can kill you!

One of the most devastating silent killers of our era is high blood pressure, or hypertension. It occurs in more than 50 million Americans, and remains undiagnosed in one third of affected individuals despite the fact that it is easily detected.

In addition to self-help and prevention strategies, there may be another key factor to consider that could actually save your life. A recent study published in the New England Journal of Medicine (December 31, 1998) disclosed that “many physicians are not aggressive enough in their approach to hypertension.”

Researcher, Dan Berlowitz, MD and his colleagues studied 800 elderly men with high blood pressure over 2 years at 5 Veterans Affairs Hospitals in New England. Their focus was not on identifying individuals who avoided the system. Instead, they studied patients who were actually being treated on a regular basis.

Their analysis disclosed that 40 percent of patients had blood pressures greater than 160/90, despite the fact that these individuals averaged more than 6 blood pressure related medical visits per year. During follow-up visits, only 25.6 percent of patients with elevated blood pressure received a medication change. One could argue that a single measurement of increased blood pressure does not justify an increase or change in medication. However, the researchers found that over 2 years, the decisions to make therapeutic changes were repeatedly delayed. In effect, treatment was inadequate!

As physicians, patients are often blamed for non-compliance, or the failure to take medication on a regular basis. The system is also attacked, citing reduced access to health care as the basis for increasing illness. Yet, this study clearly demonstrates that despite more than 6 follow-ups per year for blood pressure control, medication management was not instituted appropriately in a significant number of cases.

The “White Coat Syndrome” is also explained as a reason for not increasing or changing blood pressure medicines in a timely fashion. It refers to the anxiety an individual experiences when dealing with a health care professional, who in days past, typically wore a white lab coat.

Patients argue that their blood pressures rise whenever they see a physician, and health care providers often accept that position without delving further into the situation. I challenge the presumption, especially when a favorable physician-patient relationship exists. It is logical to assume that if your blood pressure rises in my office, it is bound to occur many more times in multiple situations each day.

The question that remains is simple¾ what can we do to ensure the best care possible when it comes to our blood pressure? Consider the following:

· Know your blood pressure. Optimally, it should be around 120/80. High normal is considered 130-139 over 85-89. Pressures above 139/89 require attention. Keep a log of your blood pressures, and discuss it with your physician. Ask the nurse at work to check it regularly, or consider a home blood pressure device (bring it to your check-up to verify its accuracy).

· Do not fall back on the “White Coat Syndrome” as a means of avoiding treatment. If elevated, ask your doctor or nurse to take your blood pressure again, before you leave the office. If you’re still not convinced, ask your health care provider about an ambulatory blood pressure monitor. Dr. Zelen, our community’s hypertension specialist, has one in his office. It is a device that one wears for recording blood pressures over 24 hours.

· Strive for a healthy body weight, exercise regularly, practice relaxation techniques, and limit your salt intake (do not add table salt to your meals, and always read food labels).

Since there is no doubt that effectively controlling blood pressure can substantially prevent heart disease, stroke and kidney failure, why not take better care of yourself? Insist on developing a working relationship with your physician, and never settle for poorly-controlled blood pressure. Becoming an informed medical consumer can prevent a great deal of suffering in the future¾ Mind Over Matter!