What is white coat hypertension? How do you overcome it?

If you’ve ever been a little anxious about a visit to your doctor, you’re not alone. Some people, however, get more than just a little nervous when they enter the exam room: Their blood pressure rises at the doctor’s office, even though it was normal at home. This spike in a medical setting is known as white coat hypertension or white coat syndrome. As many as 1 in 3 people who have a high blood pressure reading at their doctor’s office might be affected, according to the Centers for Disease Control and Prevention (CDC). 

But it might not just be a little pre-exam jitters. Learn what causes this rise in blood pressure, what to do about it, and find out if you should be concerned about the implications. 

What is hypertension?

According to the American Heart Association, normal blood pressure is 120/80. That is, you should have a systolic blood pressure of 120 mmHg or less, and a diastolic blood pressure of 80 mmHg or less.

If the top number hovers between 120 and 129 and the bottom number stays under 80, you have elevated blood pressure. When you have a blood pressure of 130-139 over 80-89, you  enter the realm of hypertension, or hypertension stage 1. If your blood pressure is 140/90 or greater, that’s hypertension stage 2. If you wind up in the 180/120 range, that’s a full-blown hypertensive crisis and you need immediate care.

RELATED: What are normal blood pressure levels?

What is white coat hypertension?

White coat hypertension describes the phenomenon that occurs when the nurse or medical assistant straps the blood pressure cuff around your upper arm and detects a higher-than-normal reading when at home it is normal. The name alludes to the white lab coats that many healthcare professionals wear on the job. Some patients state that they like coming to the doctor’s office and that they do not feel any anxiety and yet they can still have this condition. 

It’s more common than you might realize. Experts estimate the prevalence of the white coat effect is 10% to 15% in the general population. White coat hypertension is highest in children, older adults, women, and those whose blood pressure is just above the normal range.

If you get a doctor’s office blood pressure reading that is higher than expected, don’t panic. If you have normal blood pressure at home, but your blood pressure is high in the doctor’s office, there are several possible causes, according to the CDC:

• If you are talking
• How you are sitting
• What you ate, drank, or did before the reading

“I make it a point to review with my staff who take my patients’ blood pressure to ensure that the patient is sitting relaxed for at least five minutes without talking and with their back supported on their chair, both feet flat on the ground, and their arm at heart level with a blood pressure cuff that fits their arm,” says Anna Askari, MD, a family physician practicing in Rancho Mirage, California.  

It’s also a good idea to avoid smoking, exercising, and drinking caffeine or alcohol before heading to your appointment—especially within 30 minutes of your blood pressure reading. 

Should high blood pressure be treated? 

First, you need more information to determine if it’s really white coat hypertension, or actual hypertension. “Anytime a patient has high blood pressure, it is important to keep an eye,” says Mariea Snell, DNP, APRN, FNP-C, the assistant director of the Online Doctor of Nursing Practice program at Maryville University in Missouri. Those with family history of hypertension or cardiovascular disease should be especially diligent.

Home blood pressure monitoring is a good follow-up plan. Your healthcare provider can provide guidance to you to make sure you’re measuring your blood pressure correctly on your own when using a home blood pressure monitor. Your physician might also suggest that you wear an ambulatory blood pressure monitor. An ambulatory blood pressure monitor tracks blood pressure readings over the course of 24 hours. These out-of-office readings provide a better sense of what your blood pressure is really doing.

If your blood pressure is normal at home…

For many years, doctors shrugged off the in-office spike in blood pressure to nerves. But, recent research suggests that white coat hypertension may be a sign that you’re at a higher risk for developing sustained high blood pressure—and may be at increased risk for cardiovascular events like heart attack and stroke. Those with white coat hypertension have a three-to-fourfold increased risk of developing hypertension within 10 years compared to normotensive (normal blood pressured) patients.  

In fact, a 2019 meta-analysis of 27 studies in the Annals of Internal Medicine found that people who had untreated white coat hypertension were at increased risk for developing heart disease. People with untreated white coat hypertension were also twice as likely to die from heart disease when compared to normotensive people—that is, people who have normal blood pressure.

In other words, white coat hypertension is not innocent. It can predict long-term health, according to a 2017 study in the Journal of Hypertension. Maintaining close follow-up with a physician can help you stay in optimal health.

Your healthcare provider may not recommend treatment with medication yet,  

but still want to monitor you, though, because of the increased risk of developing sustained hypertension in the future.

If blood pressure is high at home…

Interestingly, there’s another phenomenon that’s the opposite of white coat hypertension–but it’s still concerning. It’s called masked hypertension. If you have masked hypertension, your blood pressure reading at the doctor’s office looks just fine, but you’ll experience increases in blood pressure at other times and in other locations. Mental stress, alcohol use, and smoking are all believed to contribute.

People who have certain other health conditions like diabetes, chronic kidney disease, metabolic syndrome, shortened sleep time, or obstructive sleep apnea, may be more likely to have higher blood pressure readings at night but not in the doctor’s office, so ambulatory blood pressure monitoring can come in handy for getting more detailed information that may lead to a diagnosis.

If you’re measuring your blood pressure at home and consistently experiencing elevated blood pressure readings outside the doctor’s office, you’ll likely need to go ahead and start treatment.

Treatment for high blood pressure typically includes blood pressure medication. According to the American Heart Association, the different classes of antihypertensive medications include:

• ACE inhibitors
• Alpha blockers
• Alpha-2 receptor agonists
• Angiotensin II receptor blockers
• Beta blockers
• Calcium channel blockers
• Central agonists
• Combined alpha and beta blockers
• Diuretics
• Peripheral adrenergic inhibitors
• Vasodilators

Exercise and diet are also key to maintaining your blood pressure at healthy levels. Dr. Askari recommends the DASH diet, which includes fruits, vegetables, complex carbohydrates, lean protein, low-fat dairy products, and limited sodium (less than 2500 mg per day).

How to overcome white coat syndrome 

Still worried that you’re going to get a high blood pressure measurement at your next doctor’s appointment? 

If you know that you don’t normally have high blood pressure—that is, if you measure your blood pressure at home or in a nearby pharmacy and haven’t noticed an increase—you might try these strategies:

• Prepare in advance. You might try some visualization exercises in which you mentally walk through the process of visiting your doctor and having your blood pressure measured.
• Take someone with you. You might feel calmer with a trusted friend or family member by your side.
• Do some deep breathing exercises. A few minutes of mindfulness meditation or even just some deep breathing can help you calm down and feel more centered.
• Bring a log of home blood pressure readings. Sit quietly for three minutes before taking the blood pressure. Have the blood pressure cuff at the level of your heart. Take your blood pressure three times back to back.  Average the top number (systolic) and average the bottom number (diastolic). Write this averaged blood pressure down. Take your blood pressure twice a week at differing times of day.
• Acknowledge your anxiety. Let the nurse or office staff know that you’re nervous. They might be able to help you out, or perhaps delay taking your vital signs until later in the visit when you may feel calmer. Or it might just make you feel less anxious to share this information with them.

“I would recommend going into the office as relaxed as you can,” says Snell. “Know that no procedures will happen without your consent. Talk to your provider about your concerns so they can help you feel more comfortable.”

It’s useful to know if you have any other risk factors that might raise your cardiovascular risk. And it’s a good idea to think about how you can make some positive changes that could lower your blood pressure, especially if you know you’re at increased risk for cardiovascular disease.

The CDC recommends these strategies to help keep your blood pressure within healthy limits:

• Eat a heart-healthy diet.
• Exercise regularly.
• Stop smoking.
• Get enough sleep.
• Reduce your alcohol consumption to, on average, less than 1 serving per day for women and less than 2 servings per day for men.

All of these behaviors can help you improve your health, regardless of whether you have white coat hypertension or not.