The Misdiagnosis of Hypertension The Role of Patient Anxiety
ABSTRACT The white coat effect (defined as the difference between blood pressure [BP] measurements taken at the physician's office and those taken outside the office) is an important determinant of misdiagnosis of hypertension, but little is known about the mechanisms underlying this phenomenon. We tested the hypothesis that the white coat effect may be a conditioned response as opposed to a manifestation of general anxiety.
A total of 238 patients in a hypertension clinic wore ambulatory blood pressure monitors on 3 separate days 1 month apart. At each clinic visit, BP readings were manually triggered in the waiting area and the examination room (in the presence and absence of the physician) and were compared with the mercury sphygmomanometer readings taken by the physician in the examination room. Patients completed trait and state anxiety measures before and after each BP assessment.
A total of 35% of the sample was normotensive, and 9%, 37%, and 19% had white coat, sustained, and masked hypertension, respectively. The diagnostic category was associated with the state anxiety measure (F(3,237) = 6.4, P < .001) but not with the trait anxiety measure. Patients with white coat hypertension had significantly higher state anxiety scores (t = 2.67, P < .01), with the greatest difference reported during the physician measurement. The same pattern was observed for BP changes, which generally paralleled the changes in state anxiety (t = 4.86, P < .002 for systolic BP; t = 3.51, P < .002 for diastolic BP).
These findings support our hypothesis that the white coat effect is a conditioned response. The BP measurements taken by physicians appear to exacerbate the white coat effect more than other means. This problem could be addressed with uniform use of automated BP devices in office settings.
SourceAvailable from: Magdy Darwish[Show abstract] [Hide abstract]
ABSTRACT: Many guidelines adopt static numeric thresholds as a basis for identification, classification and management of hypertension. In real life and clinical practice blood pressure may be elevated in many situations in absence of hypertension. On the other hand, other situations in which the patient may be hypertensive meanwhile having normal or merely high normal static blood pressure measurement. Challenges with numeric diagnosis include – phenomena of false negative e.g. masked hypertension and phenomena of false positive e.g. white coat hypertension. False positive and false negative labeling of patients may have grave consequences. Many challenges exist with current guidelines and tools: Normal biologic variations and responses of blood pressure, inaccurate measurement which may occur due to variety of causes: patient, observer or technique factors in addition to labile, masked and paroxysmal hypertension. Abnormal patterns of blood pressure which are not considered in current guidelines e.g. Loss of nocturnal Blood Pressure dipping, Visit to visit variability of blood pressure, Exaggerated response to exercise and mental stress, Widened pulse pressure, Salt sensitivity and Postural hypertension may all have great diagnostic and/or prognostic significance with or without elevated static blood pressure measurements. All these call to look at hypertension as a syndrome – not just numerical definition and make effort to develop strategies for earlier diagnosis of this syndrome considering blood pressure value as only one of several cardiovascular markers of this syndrome.Life Science Journal 01/2013; 1010:1072-1082. · 0.17 Impact Factor
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ABSTRACT: Aim. White coat hypertension (WCH) is hard to differentiate from sustained hypertension without the use of 24-h ambulatory blood pressure monitoring (ABPM). This invaluable procedure is nevertheless cumbersome and expensive. A simple test of deep breathing over 30 s (DBT) was proposed as a method to unveil WCH. Methods. Two hundred and fourteen outpatients referred for the evaluation of uncontrolled hypertension (blood pressure, BP > 140/90 mmHg despite therapy) were enrolled in a controlled clinical trial. The examinees were randomly divided in two groups: control (n = 108; sequential standard BP measurement only) and intervention (n = 106; the same+DBT), using ABPM as the reference standard. Results. The relative decrease in BP was significantly larger in the intervention group than in the control group, by 15/4 mmHg (p = 0.005). The best detection of WCH was obtained at ≥ 15% systolic BP reduction following DBT, with a positive predictive value of 94.0% (95% CI 72.0-100.0). BP reduction of ≤ 8% may rule WCH out with a negative predictive value of 78.4% (95% CI 64.0 - 85.9). Conclusion. DBT is a reliable, inexpensive and fast test for the detection of WCH in primary care.
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ABSTRACT: In the USA, hypertension affects one in three adults, and anxiety disorders are the most commonly diagnosed mental health disorders. Both hypertension and anxiety have been studied extensively. Yet, a full understanding of anxiety's relationship to hypertension has been elusive. In this review, we discuss the spectrum of anxiety disorders. In addition, we consider the evidence for acute and long-term effects of anxiety on blood pressure. We review the effect on blood pressure of several "real-world" stressors, such as natural disasters. In addition, we review the effect of anxiety treatments on blood pressure. We explain the American Heart Association's recent recommendations regarding meditation and other relaxation methods in the management of hypertension. We conclude that novel research methods are needed in order to better elucidate many aspects of how anxiety relates to hypertension.Current Hypertension Reports 10/2014; 16(10):486. DOI:10.1007/s11906-014-0486-0 · 3.90 Impact Factor