Talk:White coat hypertension
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[edit] WCH and risk
The article currently seems fairly certain in promoting WCH as being benign. It cites from Pickering who seems to have written a large number of articles (according to PubMed search) unfortunately mostly to journals not abstracted by PubMed. There are several issues here both for WCH and home blood pressure recordings:
- Yes WCH might mean that the patient is not having a consistent high reading as determined in the clinic, over aggressive treatment would of course result in hypotension (low BP outside of the clinic).
- But how certain are we in reporting WCH as benign and not needing treatment - the fact that such patients can mount such a response to a stressful stimuli distinguishes them from those normotensives who despite being under enormous personal stress (eg bereavement, loss of job, or concerns for health) nether-the-less maintain a normal BP reading.
- It is generally true that home readings are 5-10mmHg lower than clinic readings for the majority of patients (i.e. excluding those with WCH). But the studies looking at the risks of higher blood pressures and hence the benefits of treating were established from clinic readings. So a patient seeming above treatment-instigation level of 150mmHg, with a clinic reading of 152mmHg, is merely confirming the need to start (gentle low-dose) therapy if their home readings are consistently around 148mHg.
- Ambulatory blood pressure reading (automated machine like a walkman personal player strapped to waist) that takes BP every 15-30min throughout the course of a day and night is often better than repeated single home readings. Some patients get stressed over what they will find their self-taken home readings will be, the ambulatory monitors do not display the reading obtained and the patient has little time to get stressed over having a single reading, and obviously even less so with the night time readings (although often a disturbed nights sleep for the duration of the test).
The following additional references may be helpful, the later ones in particular show debate not closed on WCH being innocent:
- Little P, Barnett J, Barnsley L, Marjoram J, Fitzgerald-Barron A, Mant D (2002). "Comparison of agreement between different measures of blood pressure in primary care and daytime ambulatory blood pressure.". BMJ 325 (7358): 254. PMID 12153923. - Ambulatory is better for diagnosing hypertension
- Kario K, Pickering T (1999). "Survey of white coat hypertension. Definition differs from others.". BMJ 318 (7182): 535. PMID 10024273. - defining WCH correspondence debate between Pickering and original paper's authors
- "White coat hypertension is associated with risk of left ventricular hypertrophy" (1998). BMJ 317 (7158): C. PMID 9721143. - commentary on:
Muscholl M, Hense H, BrÃckel U, DÃring A, Riegger G, Schunkert H (1998). "Changes in left ventricular structure and function in patients with white coat hypertension: cross sectional survey.". BMJ 317 (7158): 565-70. PMID 9721112. - Mancia G, Facchetti R, Bombelli M, Grassi G, Sega R (2006). "Long-term risk of mortality associated with selective and combined elevation in office, home, and ambulatory blood pressure.". Hypertension 47 (5): 846-53. PMID 16567588. - which concludes "white-coat hypertension and masked hypertension, both when identified by office and ambulatory or by office and home BPs, are not prognostically innocent. Indeed, each BP elevation (office, home, or ambulatory) carries an increase in risk mortality that adds to that of the other BP elevations."
For now I conclude with the title of another paper this year (sadly no abstract available in PbMed) : McLean M, Naidoo S (2006). "The white coat in clinical practice - the debate rages on!". S Afr Med J 96 (5): 402-6. PMID 16751911. David Ruben Talk 01:10, 13 June 2006 (UTC)
[edit] Size of the effect
There's no indication in the article about the possible size of this effect. Have there been any studies on this? Jammycakes 13:43, 10 July 2006 (UTC)
[edit] Ethical implications
If a doctor has a patient who smokes, or drinks coffee, or is a little bit overweight, and has elevated blood pressure, there are likely to advise them to improve their health and cut down on their bad habits rather than mention anything like white coat hypertension.
In fact it may be the single most useful placebo phenomenon in encouraging people to improve their general health, although depending on your definition of ethical such practices might be unethical.
