Journal of Clinical and
Basic Cardiology
An Independent International Scientific Journal
Journal of Clinical and Basic Cardiology 2011; 14 (1-4), 23-24
White-Coat Hypertension and
Socio-Interactive Dynamics: A Case Report
Gasser S, Zunko S, Kraigher-Krainer E, Gasser R
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ORIGINAL PAPERS, BASIC CARDIOLOGY
White-Coat Hypertension and Sociointeractive Dynamics: A Case Report J Clin Basic Cardiol 2011; 14 (online): 23
White-Coat Hypertension and Socio-Interactive Dynamics:
A Case Report
S. Gasser, S. Zunko, E. Kraigher-Krainer, R. Gasser
From the Department of Cardiology, Medical University of Graz, Austria
W hite-coat hypertension is defined as high blood pres-
sure on clinical assessment but normal BP elsewhere or
on ambulatory measurement [1]. The nature of this phenom-
Cycle Ergometer Stress Testing
Maximum 125 Watt (25 Watt intervals), maximal frequency:
180 bpm, maximal BP 193/88 (159/114 at rest; noteworthy:
enon, which involves autonomic nervous dysregulation as automatically assessed, not by nurse or physician), reason for
well as psychological factors, is not completely understood. discontinuation: weakness of legs and heart rate.
Data show that it tends to co-exist with metabolic risk and The patient was asked to perform BP measurements at
overall prevalence is higher among older adults, females, and home at regular intervals.
non-smokers [2]. White-coat hypertension can already be Blood pressure during self-measurements was regularly
seen in children [3] and later predicts total and cardiovascu- around 110/70 mmHg at rest, however, when emotionally
lar mortality during long-term follow-up [4]. In white-coat distressed, it was reportedly higher (up to 160/100). At the
hypertensives, we find a difference between BP values mea- office, we noted a BP of 225/120 mmHg when assessed by
sured at home, ambulatory BP (note “reversed white-coat” the “professor” of internal medicine, however, 160/100 when
condition), BP assessed by a nurse, and BP measured by a treated by a nurse. The patient reported reproducibly dif-
physician [1, 5, 6]. ferent BP levels when assessed by different persons (self-
We describe a case of a 58-year-old woman with a history measurement < daughter < mother < pharmacist < nurse
of transient hysterical anopia who presented with an office < GP < professor of internal medicine; Figure 1).
BP of 225/115 mmHg measured by the clinical professor and So far, we have not observed a similar case of socio-emo-
normal BP at home. The case was unusual since measured tional correlation between blood pressure and the person
BP reproducibly showed graded values which were nor- who performs the BP measurements.
mal under self-measurement and increased with the type of
person performing the measurement in the following man-
ner: herself < daughter < mother < husband < pharmacist
< general practitioner < professor of internal medicine.
Case
A 58-year-old woman (62 kg, 161 cm) presented with an-
gina-like retrosternal pressure and arterial hypertension of
225/110 mmHg gat rest. She reported mild symptoms of diz-
ziness, occasional retrosternal pressure, and headache, espe-
cially in stressful situations. Her social anamnesis was nor-
mal: happily married, one daughter, academic profession.
She reported that throughout her life she had been “hypoten-
sive”. Once, during childhood, she had suffered from a)
pyelonephritis without later renal dysfunction. At the age of
9, she had a “near-death experience” during tonsillectomy
under full anesthesia. This experience was traumatic and she
later had recurrent episodes of hysterical sensorimotor loss
and anopia, which disappeared after her 40th birthday. She
has, however, remained somewhat “phobic” of hospitals and
physicians. Cardiovascular risk factors: hyperlipidemia, hyper-
uricemia, and moderate adiposity.
Routine laboratory
Renal, cardiac, and hepatic functional parameters, electrolytes,
proteins, BCC, thyroid hormones within the normal range,
total cholesterol slightly elevated.
b)
ECG
Sinus rhythm, 73 bpm, left-type electrical position, positive Figure 1. (a) Systolic blood pressure in mmHg; (b) Diastolic blood
Sokolov Index. pressure in mmHg; Sample: BP assessment by different persons:
measurement by patient (1), daughter (2), mother (3), pharmacist
(4), GP (5), and professor of internal medicine (6). One can see the
Echocardiography reproducible socio-emotional dynamics of both systolic and diastolic
Moderate left ventricular hypertrophy, mild diastolic dys- blood pressures in this patient. Number of measurements for each
function, minimal mitral insufficiency, LVEF 70 %. sample: 5.
For personal use only. Not to be reproduced without permission of Krause & Pachernegg GmbH.
ORIGINAL PAPERS, BASIC CARDIOLOGY
J Clin Basic Cardiol 2011; 14 (online): 24 White-Coat Hypertension and Sociointeractive Dynamics: A Case Report
Conclusion 3. Sorof JM, Poffenbarger T, Franco K, et al. Evaluation of white coat hyperten-
sion in children: importance of the definitions of normal ambulatory blood
pressure and severity of casual hypertension. Am J Hypertension 2001; 14:
We conclude that measured BP values may vary within a 8855–60.
large range, depending on the socio-emotional interaction 4. Strandberg TE, Salomaa V. White coat effect, blood pressure and mortality in
men. A prospective cohort study. Eur Heart J 2000; 21: 1647–8.
between patient and observer. There are known differences 5. Tsai PS. Determinants of the white-coat effect in normotensives and never-
between BP assessed by a nurse and a physician, but this phe- treated hypertensives. Clin Exp Hypertens 2003; 25: 443–54.
nomenon can also occur among a patient’s family members. 6. Stergiou GS, Efstthiou SP, Argyraki CK, et al. White coat effect in treated versus
The observed case gives rise to the question in how far psy- untreated hypertensive individuals: a case-control study using ambulatory and
home blood pressure monitoring. Am J Hypertens 2004; 17: 124–8.
chotherapeutic measures should support standard antihyper-
tensive therapy and to which extent alternative definitions
instead of “white-coat phenomenon” could be more suitable.
Correspondence to:
References: Prof. Robert Gasser, MD PhD (Oxford UK)
1. Bombelli M, Sega R, Faccetti R, et al. Prevalence and clinical significance of a Department of Cardiology
greater ambulatory versus office blood pressure (‘Reversed white coat’ condi- Medical University of Graz
tion) in a general population. J Hypertens 2005; 23: 513–20.
2. Dolan E, Stanton A, Atkins N, et al. Determinants of white-coat hypertension.
A-8036 Graz, Auenbruggerplatz 15
Blood Press Monit 2004; 9: 307–9. e-mail: [Link]@[Link]
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