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Resistant hypertension diagnosis may mask actual condition: research shows that many patients diagnosed with resistant hypertension may actually have "white coat hypertension.".

If you have been diagnosed with resistant hypertension you instead might be suffering from "white-coat hypertension."

A study published online March 28 in Hypertension examined 8,295 patients who were identified with resistant hypertension, which occurs when blood pressure remains high--above 140/90 mm HG--despite taking at least three different antihypertensive medications. The University of Barcelona researchers who led the study discovered that 37.5 percent of this group actually suffered from white coat hypertension, a condition where stress and/or anxiety related to doctor office visits temporarily raises blood pressure to high levels.

The study was conducted using ambulatory blood pressure monitoring (ABPM) where patients' BP was routinely measured and recorded outside the doctor's office during a 24-hour period. This approach gives a clearer picture of one's actual blood pressure when not influenced by office visit stress or other related stimuli.

The white coat group originally classified as resistant had a mean blood pressure in the office of 161/88 mm HG, but the ABPM recorded their average blood pressure at actually 134/75 mm HG, which confirmed improved control.

Among the group classified as true resistant hypertension, these patients tended to be male with a longer duration of hypertension, and a worse cardiovascular risk profile. They included larger proportions of smokers, diabetics, and target organ damage, such as left ventricular hypertrophy (thickening of the muscle tissue that makes up the wall of your heart's main pumping chamber), impaired kidney function, and previously diagnosed cardiovascular disease.

But as the study demonstrated, people initially diagnosed with resistant hypertension may suffer from white coat hypertension and not even realize it. Or they may be conscious of doctor office anxiety, but not understand how it may interfere with blood pressure readings. "It is actually quite common for patients' blood pressure to be elevated during a visit, especially if you are meeting a new doctor for the first time," says Curtis Rimmerman, MD, cardiologist and Gus P. Karos Chair of Clinical Cardiovascular Medicine at the Sydell and Arnold Miller Family Heart & Vascular Institute at Cleveland Clinic.

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Understanding the differences

To help differentiate true blood pressure elevation from white coat hypertension ask to have your blood pressure taken at the end of the exam after you have had ample time to relax and adjust to your surroundings. "Sitting on the exam table waiting for the door to open is when your stress levels may be highest," says Dr. Rimmerman.

If your appointment is at a new facility, conduct a trial run to determine travel distance and ease of locating the office. Research the facility online for other day-of suggestions to make your initial visit go smoothly, and arrive 30 minutes early on exam day. "When you take out the unknowns, you take out the extra stress," he adds.

When seeing a new physician, send your medical records ahead of time so your doctor can review your medical history beforehand. This way you can spend less time covering old information, which may make you feel anxious or uncomfortable, and instead focus on the present.

Investigating hypertension

If your in-office BP reading is still high, inquire about using an ambulatory blood pressure monitor. An ABPM is a small machine, about the size of a portable radio, which you wear on your belt, and is attached to a blood pressure cuff. The cuff is typically concealed under your clothes. The monitor automatically measures your blood pressure every 15 minutes when awake and every 30 minutes during sleeping hours. During a 24-hour period you can record approximately 80 to 90 measurements.

"While you will probably experience some sensation and anticipation the first few times it inflates there are enough distractions during the day that you will become less mindful of the procedure in action," says Dr. Rimmerman. You also will be asked to keep a diary of that day's activities, so your doctor will know when you were active and at rest. After wearing it for a day, the information is given to your physician who compares it to previous BP tests.

If white coat hypertension has been excluded and you still struggle with resistant hypertension examine your lifestyle more closely.

First, you should conduct a thorough review of your diet. Dr. Rimmerman recommends seeing a registered dietitian to identify foods, especially those high in salt, or other ingredients, such as caffeine and herbal supplements, which can trigger high blood pressure. "Keep a detailed food log for two weeks," he says. "Note every single food you consume along with specific amounts and calories, if possible, and give to the dietitian to help create a clear picture of your diet in order to pinpoint possible trouble spots."

You should also re-exam your current weight. While obesity is a strong factor for hypertension even the slightest increase above your normal weight--even as little as five pounds--can cause BP to rise.

Another commonly overlooked contribution to hypertension is sleep apnea, which is characterized by exaggerated snoring and frequent pauses in breathing during sleep. A relatively common condition, sleep apnea is most notably in overweight individuals, but research has shown that moderate levels of this disorder can increase your risk of high pressure. (If you believe you might suffer from sleep apnea, consult with your primary care doctor who can provide advice.)

If theses new approaches do not help manage your resistant hypertension, then you should consult a hypertension specialist. He or she will explore secondary issues on a physiological level that may be the source of your hypertension, such as thyroid or adrenal problems or blood flow restriction to the kidneys.
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Publication:Heart Advisor
Date:Jun 1, 2011
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