Review Question - QID 103301

The patient is found to be very anxious with elevated blood pressure readings may be experiencing white coat hypertension. Ambulatory monitoring would help in determining if white coat hypertension is the cause of this patient's elevated blood pressure.

White coat hypertension occurs when a patient's blood pressure elevated transiently secondary to anxiety provoked by a clinical setting. The patient's blood pressure is at a lower average outside of this setting. Ambulatory blood pressure monitoring, which measures a patient's blood pressure throughout the day, can be used to identify patients with white coat hypertension.

Viera and Hinderliter discuss the evaluation and treatment of patients with resistant hypertension, including white coat hypertension. Resistant hypertension was defined as an elevated blood pressure above the therapeutic goal in the setting of at least three optimally dosed antihypertensive medications of separate classes (one being a diuretic). They report that a recent study found that approximately 40% of patients who were taking one to two antihypertensive medications and approximately 30% of those taking three antihypertensives who had elevated blood pressures over 140/90 mm Hg in the office were found to have well controlled blood pressures under ambulatory monitoring.

Kobos et al. review recent studies on white-coat hypertension. They report that improving the patient-physician relationship and utilization of effective communication can help to alleviate patient's anxiety in a clinical setting and thus can have an impact on the occurrence of white-coat hypertension. They also state that white coat hypertension can have an impact on a patient's health and can lead to end-organ damage. Specifically, they report an association between white coat hypertension with both carotid atherosclerosis and increased left ventricular mass when compared to relation to non-hypertensive patients.

Incorrect answers:
Answer 1 and 3: While hyperparathyroidism and renal disease can lead to hypertension, this patient's presentation is consistent with white coat hypertension and should be evaluated with ambulatory blood pressure monitoring.
Answer 2: This patient has already had two elevated blood pressure readings in the office and would benefit from ambulatory blood pressure monitoring to determine if they are experiencing white coat hypertension.
Answer 5: An EKG would not be necessary at this time, this patient's presentation is consistent with white coat hypertension and should be evaluated with ambulatory blood pressure monitoring.