This is more of a rant. I have this problem where everytime I go to the doctor to get my BP checked, its always high even when I am on meds. It was 160/96 when I last went in. At home it always around 125/70 which isn't perfect but is good for me. This has caused problems, the nurses always accuse me of not taking my meds, and they always end up taking my blood pressure 4-5 times. They hide the the BP monitor from me and tell me to relax thinking that if I don't see the result it will make my blood pressure lower, but it has the opposite effect.

The problem is that while I am sitting in the waiting room I become very anxious and impatient, sometimes the wait is more than an hour and by then my blood pressure is already up. The absolute worst was when a nurse accused me of taking illegal drugs because my blood pressure was so high, he told me never to come back (I think I could have gotten this guy fired but I did nothing + I switched hospitals).

I really don't want to take anxiety medication as I am already taking 3 BP meds (they added an extra one after this last visit metoprolol + benaepril + norvasc).

I empathize with you. I never had "white coat" until last year when I went back to the doctor after having been off BP meds for six months without her previous "permission." I had been getting an average of 125/75 or so without them at home, so why continue on meds after my lifestyle changes? Anyway, I knew she would be upset that I hadn't asked her first, and since my BP is highly affected by stress, my initial BP was 161/something when the nurse first took it. And by the time I got done talking to the doctor, it was 181/something or thereabouts! Of course, they tried to tell me that it was my monitor that was off, but I bought a new one and still get similar readings at home. Anyway, ever since then, I've had white coat bad.

But my attitude is the doctor is working for me. I'm the manager of my own health; the doctor is merely the paid consultant. And just like a business manager, I can choose to go along with what the consultant recommends, but since I know more about my business than she does, I can also reject her recommendations. And I have. I haven't yet told her in so many words, but my attitude is "I will make the decisions based upon my home readings regardless of what readings you get in the office." Some day I might even tell her to forget about taking office readings, as they are worthless to me when I get upset. I do, however, take a record of my home readings with me when I go to the appointments. If she doesn't want to believe them, tough.

ofacto,

My experience as a long term white coater: there is NO drug combo that will beat my white coat unless it's something like demerol to render me unconscious.

Best you can do is to get a thorough record of BP's at home and tell your doctor where to stick his sphygmomanometer.

Trying to medicate so a doctor sees good numbers is ultimately a silly way to go.

If your doctor won't believe your chart, find another.

What amazes me most about having white coat hypertension is
the reaction from most doctors when you try to tell them. They look
at you with disbelief, like they are hearing this for the first time.
Then you feel guilty because you think you are the only one he or she
has seen with this in a long time.

In reality, your doctor probably sees patients with sky high office-only
readings all throughout the week. If they would only tell you they
understand, believe you and will work with you, the next visits would probably be less stressful. But in many cases the threat of more meds because of the high office readings and the raised eyebrows of the nurse or doctor taking your bp is enough to keep one in a contineous white coat state.

Autumn,

The reaction is sort of "Of course, White Coat EXISTS BUUUUTTTTTT."
Then they go on with the stupid argument, "Well, if it's high in this office when ELSE is it high."
An then the non-sequitor "Do I make you NERVOUS?"

The answer to that last question, and I've actually used it is: "No, but you certainly are making me p*****d off!"

What will shut them up is to ask them to define hypertension...they stammer a lot. And they LOVE when you add "But doctor, you forgot 'sitting comfortably, relaxed, without legs dangling and NEVER on an examining table in a cold room!"" They always smile in appreciation to relearn that little item from med school.

What do you guys compare your office visit BP measurement with, in order to know your BP really isn't that high? I had a pharmacist to tell me that I was a tad nervous the other day, after a high reading (158/100). I said yeah, ok, but knew that I had forgot to take my Lasix. I got home, took my Lasix and my BP returned to normal.

Why do you think BP medicines should stop the "white coat syndrome"?

Brad,

I just go by my home monitor. I'm retired and home most of the time, so home readings represent the majority of my time.

I've taken hundreds of readings, so I have a very good idea of what my BP does under different circumstances. My "white coat" readings range from a level I would normally get after light activity to those I get only after climbing seven flights of stairs at home - and I'm out of shape. I got one "white coat" reading comparable to what I've had at home only after a death in the family, so I know very well that that is not anywhere near my normal BP. Also, when I went to my doctor's other office (different town) where there is a different nurse who doesn't upset me, I had a normal reading - 118/something.

My BP is highly variable. Today, for example, I took seven readings and they ranged from 97/66 to 164/83. But the high one was when I first got up, and another reading two minutes later was 145/78. I have postprandial hypotension, so as long as I keep eating all day, my BP will be down. (Sure glad I'm thin and can do it.)

My mom had the same problem with elevated blood pressure at doctor's visits. She ended up taking her home monitor in to the doctor's to ensure the readings were correct. At all of her future visits, she just took in her home log for the doctor to make his medical decisions by. They stopped taking her blood pressure at the doctor's office because the readings were so far off. This method has worked for her and her internist for many years.

I just want all of you to realize that you need to be sure of your BP. If it is high and you do not realize it, it will hurt you. I in no way doubt the syndrome. I just hope all are making competent dicisions based on semi-scientific comparisions :)

Most doctor's knee jerk reactions to borderline hypertension and to high office readings is to medicate. I doubt very much that many PCPs would bother to inquire about the possibility of postprandial hypotension (PPH) and unless they had done an ambulatory BP on the patient, they wouldn't know it exists. Yet it is estimated that about one-third of patients over age 65 have it, so we are talking about a sizeable number of people. And there is a very real possibility that medicating so the pressure goes too low might be just as big a problem as pressures that go too high in this population. Present BP medications to lower the highs typically also lower the lows.

Here are a few quotes from an research article titled Postprandial Hypotension Predicts All-Cause Mortality in Older, Low-Level Care Residents on which I base my concern. Emphasis mine.There was a dose–response relationship between postprandial fall in SBP and mortality rates. Absolute postprandial SBP of 120 mmHg or less was also significantly associated with total mortalityConclusion: In older low-level-care residents, PPH is an independent predictor of all-cause mortality with no added predictive value explained by other BP indices: OH, hypertension, PP, MAP.
I already have postprandial falls to below SBP 120 mgHg. Though I don't check it that often, two of those readings in the past month were to 93 and 97. Under the circumstances, I'm not about the accept a script for BP meds to lower my pressure more based upon some inflated white coat readings. I know that before this is over, I'm going to need to do a lot more study on this and may even need to see a hypertension specialist.

I encourage others, also, to study their own specific situation so they can evaluate their doctor's conclusions, which are often based upon only a few minutes time with the patient.

Uff-Da

I surely understand your concern with over-medication. I found the study you are quoting from. It was a very small number of people involved in the study., I believe 147, in Australia. They do not mention the various causes of death, ie, heart attack, stroke, etc. After looking at some of the possible causes of Postprandial Hypotension, high BP is one, and malfunctions in the autonomic nervous system, which constrict arteries after a meal, in order to send lots of extra blood to the stomach and intestines, can cause PH. So my question is whether the low BP after a meal is causing these mortalities, or the autonomic nervous system and diseases that affect it like, Parkinsons and diabetes?

Postprandial hypotension occurs in up to one third of older people but virtually never occurs in younger people. It is more likely to occur in people who have high blood pressure or disorders that impair the brain centers controlling the autonomic nervous system (which regulates internal body processes). Examples of such disorders are Parkinson's disease, multiple systems atrophy (Shy-Drager syndrome), and diabetes.

The intestines require a large amount of blood for digestion. When blood flows to the intestines after a meal, the heart rate increases and blood vessels in other parts of the body constrict to help maintain blood pressure. However, in some older people, such mechanisms may be inadequate. Blood flows normally to the intestines, but the heart rate does not increase adequately and blood vessels do not constrict enough to maintain blood pressure. As a result, blood pressure falls.

Postprandial hypotension can cause dizziness, light-headedness, faintness, and falls. If an older person experiences these symptoms after eating, doctors measure blood pressure before and after meals to determine if postprandial hypotension is the cause.

People who have symptoms of postprandial hypotension should not take antihypertensive drugs before meals and should lie down after meals. Taking a smaller dose of the antihypertensive drugs and eating small, low-carbohydrate meals more frequently may help reduce the effects of this disorder. For some people, walking after a meal helps improve blood flow, but blood pressure may fall when they stop walking.

Taking certain drugs before a meal may help. For example, nonsteroidal anti-inflammatory drugs (NSAIDs) (see Pain: Nonsteroidal Anti-Inflammatory Drugs) cause salt to be retained and thus increase blood volume.

Some Trade Names

Octreotide
SANDOSTATIN
reduces the amount of blood flowing to the intestines. Caffeine, with or without dihydroergotamine
D.H.E. 45
MIGRANAL
causes blood vessels to constrict. Caffeine should be taken only before breakfast so that sleep is not affected and the person does not become tolerant of caffeine's effects

Recently there has been 2 prominent Cardiologist/Thoractic surgeons on a day time talk show. They are on the cutting edge of technology, it seems. They stated that high BP is the leading cause of heart disease, not cholesterol, diabetes etc. I have had a heart attack and a stroke, so I have to keep my BP as low to normal as I can. I am in the process of changing my BP medication. What fun (not, lol).

I would like to emphasize again, that no one should believe that they have the white coat syndrome without proper studies. That is the only point I was trying to make earlier. High BP kills. I am afraid that some people do not have the ability to cross reference their office BP, with their BP taken at home.

My very conservative family doc let me go to long with high BP, before sending me to a cardiologist. The reference ranges were also different back then, so I really can't blame my doc.

Do you check your BP before and after a meal? Have you any ways (other medicines, etc) to help you deal with your PH? I sure hope so.

Brad:

I agree that one needs to look carefully at the extent to which "white coat" readings do, in fact, represent stress levels at other times as well, and for many people that could make the difference between medicate or not medicate. I know for certain that if I were still teaching high school, I'd have to be on meds, not only because of the stresses when students act out, etc., but just being around other people raises my SBP around 20 points above resting BP. But I also know that my "white coat" is mild compared to what some others have. I'm sure there are others who are fine at work, even though the doctor freaks them out. But yes, they should check.

I've read dozens of research articles on postprandial hypotension (PPH), as well as on blood pressure variability, and will probably be reading dozens more before I next see my doctor. From what I've read, it seems there is a lot about it they simply don't know at this point. They don't even seem to know yet whether the PPH causes the associated brain lesions or vice versa, though my personal guess is the latter.

I have a high deductible ($1500) on my insurance which I've hardly touched yet, and since I'll be eligible for Medicare in August, I'm holding off seeing my doctor until after that, in case she recommends expensive testing. Hopefully it will be covered. Several months ago I inquired about having an ambulatory BP test, since though I can take enough BP readings during the day to know what is happening, I have no idea what is happening at night. Unfortunately, that test is not available in my small rural community. Not even the hospital has such equipment. But in the meantime I'm studying my situation with many BP readings under different circumstances, pre- and postprandial, different foods, early morning, when I wake up during the night, etc., so I'll have as much information as I can when I do see the doctor.

At this point my average resting SBP before breakfast is around 128, but since my BP shoots up about 20 points with the slightest activity, even just walking to the refrigerator and back, I'd expect my BP to be in the low hypertensive range quite often if I didn't eat. But by eating something every few hours, my average BP stays within the normal range part of the time and within the prehypertensive range most of the time during the day and the fall isn't so great after each meal. If I can just treat the problem with food, that sounds like a better alternative than with medicine. But I've only been able to get a few readings when I wake up in the night so far and have no idea what's happening while I actually sleep. I seriously believe that that is going to be the difference between medicate or not medicate. Because I also have a serious sleep problem, I suspect a sleep study may be ahead of me, and I may find out about my night-time BP then.

I read one article in which highly variable BP was treated with Klonopin instead of with BP meds. Since my BP is so easily affected by stress, that might be something to consider if I were able to cut down the highs just on the more stressful days and not take anything the rest of the time. It wouldn't lower the lows like BP meds. Since I feel far too lethargic when my BP is lower than 115, I really don't want to lower the lows and spend more time in that BP range.

A stroke is my biggest fear. Since my father had his first stroke at 69, I am soon to be 65, and I have PPH which is strongly associated with brain lesions even when asymptomatic, I definitely plan to follow up on this. But I don't want to be a zombie on meds, either.

Uff-Da

I can surely sympathize with your predicament. I have had 2 strokes and 1 heart attack. I still get around, but was forced to retire from my work. I have small vessel disease (SVD) and it caused 2 blockages of blood supply to 2 separate areas of my brain, which died. I have plaque in my brain as well as in my heart. I also have "white matter disease" that is also involved with MS, but in a different way.

I replied earlier in regard to the test you quoted. Now I would like to ask if you realize how are BP is actually, physically regulated? As we age, our arteries lose a fair amount of elasticity. Arteries, not veins, expand and contract with the beat and rest of our heart. The more elasticity an artery has, the more it can expand and limit the peak punch delivered by our left ventricle (the big pumper). When the heart rests, the arteries contract to "hold up our BP, to keep it from going so low. The aorta usually is not real pretty when we get into our later years. Calcium deposits in the aorta and other arteries like the carotid, coronary, etc, become more brittle and less flexable. Blockages also form, and the arteries themselves deform due to arteriosclerosis from age. It is a natural occurrence.

The ability to chemically regulate our BP comes from the brain and other glands, hormones, etc, BUT the arteries have to help out. Your PH could be caused by an autonomic system disorder that does not increase your heart rate after you have ate, as it should because you need the extra blood circulation to digest your food, or your heart rate could be doing what it thinks is right, pacewise, but your arteries are not expanding to allow flow to areas other than your stomach. Remember, gravity can carry blood to your stomach and intestines. The heart has to lift and push it to your brain, arms (brachial artery). I wonder if your pulse rate increases after a meal, as it should?

Brad,

My white coat readings are quite scientific and I know this because I consistently get white coat readings of +40 systolic and +20 diastolic in a doctors office even ON MY OWN TESTER (talk ablout lack of LOYALTY:rolleyes: .)

My tester even switches automatically to the next range, inflates to 200 in a doctor's office, when at home it ALWAYS stays in the low inflation zone (to 160.)
My heart always sinks when I hear that "extra" inflation kick in.

To Lenin:

My last doctors visit I took my OMRON bp machine with me so they could check it. I have one of the manual kits with the stethoscope and I took that to the doctor last year and they said it was accurate. I have measured the atuomatic one against that one and they are pretty close. Anyway I was very nervous and when I tried to use it I first got an error reading and I tried it again and the reading was something like 200/100. The doctor told me not to use it. When I got home I used the manual one and then I tried this one again and my readings were good on both. 125/80.. I know I have the White coat problem also and I get that alert reaction everytime the nurse checks it. For some reason I feel more comfortable with the doctor and the readings are always lower when he checks it again before I leave. Last time I went the nurse checked it and it was 144/82. The doctor checked it again before the visit was ending and this time it was 128/80.. He said as long as my readings are below 140/90 at home than I am fine..

Lenny,

I do believe FOR SURE in the white coat syndrome. I just think that the results may be somewhat subjective. Resting BP for some, and probably many, changes every few seconds for many reasons, as you know. Have you ever tried to ask the nurse, or doc to leave the room, after thay have checked your BP with their equipment, then after a few minutes check yours with your home monitor? Here is another way. After you leave the doc's office, go to a park (need a battery) or to a friends house nearby the doc's office, and check it within maybe 10 minutes?

Aren't you a big city guy, lol? I am from a very small town. No traffic hassles. I wonder how many big ole city dwellers have the white coat syndrome? Take NYC....Ride a subway to a doc's office????? I have been there many times. The cursing from all the cabbies can get me riled when I hit the streets, lol. I don't know where I got the idea you were from NYC.....It must be my small vessel disease :)

My background is in engineering. I have worked with many highly sophisticated instruments and pumping systems (ah that sounds so egotistical I know, and must apologize). Imagine an electric, motor driven pump (with a state of the art feedback system), that cannot maintain a constant pressure, due to changes in flow demand and flow resistance within the closed circulating system. Now look at all the "thangs" that have to come together within your body, to maintain a steady resting heart rate, ESPECIALLY as we age.

5 days ago, I forgot to take Lasix. I went by a hometown pharmacy to pick up a prescript for corticosteroids. I felt really bad, so I asked the nurse that works there to check my BP, while waiting. It was 158/105, or close to that. She went to the pharmacist and said shouldn't he get his BP down before he takes this medicine? The pharmacist said no, that he believed hat I was uncomfortable. I went home and checked my BP on my omron 870, and it matched exactly. I monitored it as it fell, after taking my Lasix. I also take atenolol. This pharmacist gave me very bad information, but I knew it was bad. I just fear that some of you will get bad info also and treat yourselves accordingly.

I despise BP and heart disease meds, but I am on the conservative side when I try to take my meds and treat it. I would rather have side affects than another stroke or heart attack. I will give up the soapbox to you and George, lol.

Good day to all :)

P.S. Steroids have increased my BP for sure!

:wave: great idea. I tell any doctor office I go to that I monitor my bp at home and that allowing them to take it is bad for my health ;) If it wasn't for a numbskull doctor I would never have had this problem, its a long story but since then I have the problem. Even thinking about someone taking my bp makes me nervous and frankly I have to force myself to take it at home occasionally as that also causes me alot of initial stress and worry but as long as I get under 140/80 I don't worry about it. I am in my late 60's and I keep my weight down, exercise and eat a vegetarian diet :p
anneh

tell your doctor where to stick his sphygmomanometer.

Trying to medicate so a doctor sees good numbers is ultimately a silly way to go.

If your doctor won't believe your chart, find another.[/QUOTE]

I have the same problem as you. My readings are always higher in the doctor's office and they drop 10 to 20 points as soon as I get home from my appointment. I record my readings regularly on my digital BP cuff at home and they are good (I am on Toprol XL and Maxide). I've also used my dad's digital monitor and the readings are good on his also. The Toprol makes me drowsy sometimes. When I went to the doctor the last time, he read my chart and said "that's two high readings in a row (around 150/98) - I'm going to up your dose of Toprol. Just what I need - to be a walking zombie. I told him there was no way I was going on a higher dose of meds when my readings are good at home. He wanted me to wear a 24 BP monitor. I told him if I know it's on, I will be anxious about it the whole time. I feel his doesn't trust what I'm telling him and I wish I could find somebody who would work with me better. I have to go back in November and I DON'T WANT TO GO!!! I think I'll try to find some holistic healer instead. Just kidding but it DOES get ridiculous.