White Coat Syndrome Research Articles

An overlooked cause of resistant hypertension: upper airway resistance syndrome - preliminary results

OBJECTIVE:Upper airway resistance syndrome is a sleep-disordered breathing syndrome that is characterized by repetitive arousals resulting in sympathetic overactivity. We aimed to determine whether upper airway resistance syndrome was associated with poorly controlled hypertension.METHODS:A total of 40 patients with resistant hypertension were enrolled in the study. All of the patients underwent polysomnographic examinations and 24-hour ambulatory blood pressure monitoring to exclude white coat syndrome and to monitor treatment efficiency. Among 14 upper airway resistance syndrome patients, 2 patients had surgically correctable upper airway pathologies, while 12 patients were given positive airway pressure therapy.RESULTS:All patients underwent polysomnographic examinations; 22 patients (55%) were diagnosed with obstructive sleep apnea and 14 patients (35%) were diagnosed with upper airway resistance syndrome, according to American Sleep Disorders Association criteria. The patients with upper airway resistance syndrome were younger and had a lower body mass index compared with other patients, while there were no difference between the blood pressure levels and the number of antihypertensive drugs. The arousal index was positively correlated with systolic blood pressure level (p = 0.034; rs = 0.746), while the Epworth score and AHI were independent of disease severity (p = 0.435, rs = 0.323 and p = 0.819, rs = -0.097, respectively). Eight patients were treated with positive airway pressure treatment and blood pressure control was achieved in all of them, whereas no pressure reduction was observed in four untreated patients.CONCLUSIONS:We conclude that upper airway resistance syndrome is a possible secondary cause of resistant hypertension and that its proper treatment could result in dramatic blood pressure control.

The "tremor diary": a useful tool in the management of patients with tremor.

When caring for patients with essential tremor (ET) and other action tremors in the outpatient setting, a challenge for the clinician is to assess interval changes in tremor severity, particularly if such changes are subtle. Patients are often asked to report whether their tremor has worsened between visits or whether they have experienced an improvement in the setting of a therapeutic challenge with a new medication or an increase in dosage of an existing medication. Conversely, patients may be asked to report whether their tremor has worsened in the setting of a reduction in dosage. In these various settings, patients often have difficulty assessing whether their tremor has changed or improved, and this is made more challenging by the presence of normal day-to-day fluctuations in tremor severity that patients often experience. The patient’s level of anxiety or mood may further affect their ability to objectively assess the severity of their tremor. The tremor on the day of their clinical visit may be influenced by their psychological state or level of fatigue, confounding the neurological examination. In addition, “white coat syndrome” might influence the amount of tremor observed in the office. For several years, one of us (E.D.L.) has used a simple clinical aid to help assess response to medication change. To our knowledge, this method has not been published elsewhere. The goal of this brief report is to share this method with the larger community of movement disorder neurologists and discuss its benefits.

Secondary Peak Detection of PPG Signal for Continuous Cuffless Arterial Blood Pressure Measurement

The arterial blood pressure (ABP) is one of the most important physiological parameters for health monitoring. Most of the blood measurement devices in the market determine the ABP through the inflation and the deflation of a cuff controlled by a bladder. This method is very uncomfortable for most of the users and may even cause anxiety, which in turn can affect the blood pressure (BP) (white coat syndrome). This paper investigates a cuffless nonintrusive approach to estimate the BP. The main idea is to measure the pulse transit time (PTT), i.e., the delay between the R-peak of the electrocardiogram (ECG) signal and the following peak of the finger photoplethysmograph (PPG) signal. The main problem of this approach is that when the dicrotic notch of the PPG signal is unobservable, the position and the amplitude of the main peak of the PPG signal will be changed. As a result, the correlation between the BP and the PTT can be affected. To overcome this problem, three types of secondary peak detection methods are designed to reveal the secondary peak from the original PPG signal. Actual ECG, PPG, and the BP measurements extracted from the Multiparameter Intelligent Monitoring in Intensive Care II database that contains clinical signal data reflecting real measurements are used. The results verify that the proposed detection methods improve the correlation relationship between the BP and the PTT, and demonstrate that the adjusted PTT can be used as an indicator of the ABP by removing the dicrotic notch impact on the PPG signal.

Explode and die! A fat woman's perspective on prenatal care and the fat panic epidemic.

Explode and Die!A Fat Woman’s Perspective on Prenatal Care and the Fat Panic Epidemic Jennifer Hansen Classifying obesity as a disease provides more ammunition for the “war on obesity.” I gather that this is supposed to be a good thing. The problem is that obesity isn’t a germ or a crime; it’s a word applied to a particular kind of body—and thus to the person inhabiting it. From a fat person’s perspective, the “war on obesity” is a war on fat people. It’s a license to bully, shame, and ostracize fat people and deny us employment, medical care, and even ordinary family life because we don’t look right. Fat people, proclaimed by medical authority to be the enemy and identifiable on sight as outsiders, are made into targets for all kinds of free–floating anger. For example, I am apparently sucking away people’s tax dollars via my fat, and it’s also my fault that men expecting to fantasize about every woman they see on the street encounter my distasteful fatness instead. But no matter how many times we get told that we are wrong just for existing, we go on existing, in public even. How dare we? The answer, obviously, is to keep at us. If we would just admit that we have no right to exist, then we would all either vanish or become socially acceptably thin, and then the whole world would be unicorns and butterflies and everyone would be rich and nobody would get old. Or something like that. If obesity is a disease, then phrenology is a science. Of course, we get a lot of well–meaning flak along with the bullying; after all, concentrating on weight loss can only be good for us, because fat people are always about to explode and die. This assumption has definitely affected my relationship with the only medical practice I can reach that’s in my network. During the 20–plus years since I became visibly obese, I have gotten used to the constant drone of “You’re fat, you’re fat, you’re about to explode and die, we don’t care about what you actually came in for because it’s vitally important that we bug you yet again about your pants size,” but some things can still shock me. For example, during all three of my pregnancies, I never had a result that was even borderline for gestational diabetes (GD). And yet, some time after my last baby was born, someone wrote “HISTORY OF GESTATIONAL DIABETES” in my file. I first heard about it during my annual checkup, when the doctor referred to it when talking about my increased risk of Type 2 diabetes due to age (unavoidable), my first–ever non–whitecoat–syndrome borderline blood pressure (BP) reading (taken with a standard cuff, gee how could it possibly have been inaccurate), and GD (gosh, I felt so safe and supported at this fine reality–based practice). And of course my weight. Whoever wrote that felt free to make things up because I’m fat. To repeat, somebody with access to my file at my only source for affordable health care felt free to write things in it that were completely contradicted by the facts just a few sheets below. There’s no need to fact–check your assumptions when you can tell by looking at her that she’s F–A–T, and everybody knows what they are. They’ll explode and die, every last one of them. Better medicate them now before they inevitably break down! Speaking of which, there’s a particular OB at the practice who I’ll call Doctor Eeyore. At every appointment, Doctor Eeyore would take measurements, stare, and say, “Hmm … tch.” If I asked him to tell me what he had found, he would say, “Too big,” or, “Too small,” or indicate some other inadequacy in his glum, word–miserly way. He only bothered to produce complete sentences when he enthusiastically told me that I would die if I didn’t give birth with an IV in place to administer the life–saving drugs for my inevitable cardiac event...

OP-346 An Overlooked Cause of Resistant Hypertension; Upper Airway Resistance Syndrome

ObjectiveUpper airway resistance syndrome is a sleep disordered breathing syndrome characterized by repetetive arousals resulting in sympathetic overactivity. We aimed to determine whether upper airway resistance syndrome is related to resistant hypertension.MethodsFourty patients with resistant hypertension were enrolled in the study. All patients underwent polysomnographic examination. All patients underwent 24 hours ambulatory blood pressure monitoring in order to rule out white coat syndrome and to monitor treatment efficiency.ResultsTwenty-two patients (55%) were diagnosed with obstructive sleep apnoea and 14 patients (35%) were diagnosed with upper airway resistance syndrome according to American Sleep Disorders Association criteria. Upper airway resistance syndrome patients were younger and had a lower BMI when compared to other patients while there were no difference between the blood pressure levels and the number of antihypertensive drugs. Arousal index was determined to be positively correlated with systolic blood pressure level (p=0.034; r=0.746 ) while epword score and apnea-hypopnea index were independent of disease severity (p=0.435, r=0.323 and p=0.819, r= -0.097 respectively). Eight patients were treated with positive airway pressure treatment and blood pressure control was achieved in all whereas no pressure reduction was observed in 4 untreated patients.ConclusionsWe concluded that upper airway resistance syndrome is a possible secondary cause of resistant hypertension and its proper treatment can result in dramatic blood pressure control. ObjectiveUpper airway resistance syndrome is a sleep disordered breathing syndrome characterized by repetetive arousals resulting in sympathetic overactivity. We aimed to determine whether upper airway resistance syndrome is related to resistant hypertension. Upper airway resistance syndrome is a sleep disordered breathing syndrome characterized by repetetive arousals resulting in sympathetic overactivity. We aimed to determine whether upper airway resistance syndrome is related to resistant hypertension. MethodsFourty patients with resistant hypertension were enrolled in the study. All patients underwent polysomnographic examination. All patients underwent 24 hours ambulatory blood pressure monitoring in order to rule out white coat syndrome and to monitor treatment efficiency. Fourty patients with resistant hypertension were enrolled in the study. All patients underwent polysomnographic examination. All patients underwent 24 hours ambulatory blood pressure monitoring in order to rule out white coat syndrome and to monitor treatment efficiency. ResultsTwenty-two patients (55%) were diagnosed with obstructive sleep apnoea and 14 patients (35%) were diagnosed with upper airway resistance syndrome according to American Sleep Disorders Association criteria. Upper airway resistance syndrome patients were younger and had a lower BMI when compared to other patients while there were no difference between the blood pressure levels and the number of antihypertensive drugs. Arousal index was determined to be positively correlated with systolic blood pressure level (p=0.034; r=0.746 ) while epword score and apnea-hypopnea index were independent of disease severity (p=0.435, r=0.323 and p=0.819, r= -0.097 respectively). Eight patients were treated with positive airway pressure treatment and blood pressure control was achieved in all whereas no pressure reduction was observed in 4 untreated patients. Twenty-two patients (55%) were diagnosed with obstructive sleep apnoea and 14 patients (35%) were diagnosed with upper airway resistance syndrome according to American Sleep Disorders Association criteria. Upper airway resistance syndrome patients were younger and had a lower BMI when compared to other patients while there were no difference between the blood pressure levels and the number of antihypertensive drugs. Arousal index was determined to be positively correlated with systolic blood pressure level (p=0.034; r=0.746 ) while epword score and apnea-hypopnea index were independent of disease severity (p=0.435, r=0.323 and p=0.819, r= -0.097 respectively). Eight patients were treated with positive airway pressure treatment and blood pressure control was achieved in all whereas no pressure reduction was observed in 4 untreated patients. ConclusionsWe concluded that upper airway resistance syndrome is a possible secondary cause of resistant hypertension and its proper treatment can result in dramatic blood pressure control. We concluded that upper airway resistance syndrome is a possible secondary cause of resistant hypertension and its proper treatment can result in dramatic blood pressure control.

White coat syndrome: Learning from mistakes in laboratory research

White coat syndrome: Learning from mistakes in laboratory research

Occupational white coat syndrome

Some doctors seem to have entered the profession because of an attraction to its external trappings, without considering the day to day work entailed. Caroline Elton looks at this occupational white coat syndrome

Prevalence of white-coat syndrome in Saudi hypertensive patients

White-coat hypertension (WCHT) is a persistently increased blood pressure in the medical office compared with home (or better) 24-h ambulatory blood pressure monitoring (ABPM). Studies in the West have demonstrated that 31–32% of patients with established hypertension experience WCHT. To date, no similar studies have been carried out in this region. The primary objective of this study was to explore the prevalence of WCHT in Saudi patients with established hypertension, attending a nurse-led clinic at King Abdulaziz Medical City (KAMC). This retrospective, descriptive study included 50 patients with hypertension attending a nurse-led clinic in KAMC, from January to October, 2011. Patients had, at minimum, 2 clinic blood pressure readings of 140/90 mmHg or higher and ABPM. Analysis was performed using SPSS Advanced Statistics for Windows, version 18. Of the total population ( n = 50), 60% were male, mean age was 61.4 ± 12.6 WCHT was found in 48% of patients; 66.6% males. There were no significant clinical differences between the 2 groups as both had equal distribution of co-morbidities There is a high prevalence of WCHT in patients with established hypertension, followed up in a nurse led clinic with a higher prevalence in males. These figures are significantly higher than Western data. All patients with established hypertension should have at least one ABPM in order to guide the clinician in diagnosis and appropriate management.

The 2012 Canadian Hypertension Education Program Recommendations for the Management of Hypertension: Blood Pressure Measurement, Diagnosis, Assessment of Risk, and Therapy

We updated the evidence-based recommendations for the diagnosis, assessment, prevention, and treatment of hypertension in adults for 2012. The new recommendations are: (1) use of home blood pressure monitoring to confirm a diagnosis of white coat syndrome; (2) mineralocorticoid receptor antagonists may be used in selected patients with hypertension and systolic heart failure; (3) a history of atrial fibrillation in patients with hypertension should not be a factor in deciding to prescribe an angiotensin-receptor blocker for the treatment of hypertension; and (4) the blood pressure target for patients with nondiabetic chronic kidney disease has now been changed to < 140/90 mm Hg from < 130/80 mm Hg. We also reviewed the recent evidence on blood pressure targets for patients with hypertension and diabetes and continue to recommend a blood pressure target of less than 130/80 mm Hg.

Measuring blood pressure in primary care: identifying ‘white coat syndrome’ and blood pressure device comparison

Hypertension is a major risk factor for cardiovascular disease, especially in the presence of other risk factors.1 Accurate identification of hypertension is challenging largely due to blood pressure variability in an office or clinic where most GP consultations take place. Blood pressure can be affected by several factors including measurement technique and observer bias.2 Ambulatory blood pressure monitoring (ABPM) and self-monitoring, two methods used to detect ‘white coat syndrome’ (the phenomenon whereby blood pressure measured by medical personnel is elevated above usual levels), have been shown to be more accurate in predicting end-organ damage than office readings.3,4 However, thresholds for diagnosis of hypertension with ABPM vary and guidelines recommend its use in specific circumstances only.5 The use of self-monitoring in diagnosis is unclear in terms of the number of blood pressure readings required.6 Furthermore, current cardiovascular risk assessment charts are based on office blood pressure readings, so when calculating cardiovascular risk clinicians need a reliable method of measuring office blood pressure. In this month's issue of the BJGP two articles focus on blood pressure measurement. Scherpbier-de Haan and colleagues examine …

Comparative Assessment of Four Blood Pressure Measurement Methods in Hypertensives

Introduction Discordance between blood pressure (BP) measurement methods can occur and create ambiguity. New automated office BP monitors (AOBPs) are widely available, but their role is presently unclear. The objectives of this study are to quantify concordance among BP measurement methods and to define the diagnostic sensitivity, specificity, and predictive value of AOBPs in a population of hypertensive patients. Methods The office mercury sphygmomanometer, the AOBP, an ambulatory BP monitor (ABPM), and home self-measurement with an automatic device were compared in a randomized, crossover study. BP averages and achievement of therapeutic goals were defined. Comparisons and agreement tests were performed. Diagnostic indices were calculated for the AOBP. Results A total of 101 patients were enrolled. Average BP results were similar between measurement methods with the exception of daytime ABPM, which was significantly higher; figures are mean ± standard deviation (SD): sphygmomanometer, 129.9 ± 13.7/80.9 ± 9.3 mm Hg; AOBP, 128.4 ± 13.9/80.0 ± 9.4 mm Hg; 24-hour ABPM, 131.4 ± 11.7/78.7 ± 9.7 mm Hg; day ABPM, 135.5 ± 11.4/82.0 ± 11.9 mm Hg; home self-measurement, 131.0 ± 14.3/82.5 ± 8.2 mm Hg. Discordance in the achievement of therapeutic goals was observed in 58 patients, with only 26 cases being explained by masked hypertension or “white coat syndrome” according to all measurements. Disagreement was greater when office methods were compared with ambulatory methods. Conclusions This study shows that the 4 measurement strategies provide similar average BP estimates but generate many discordant results. The AOBP device can be very valuable as a replacement for the sphygmomanometer.

Effect of Soy Protein on Blood Pressure in Prehypertensive/Stage 1 Hypertensive Adults

Research is mixed on the BP lowering effect of soy protein. However, even if such effects are modest, reductions in hypertension‐related mortality and morbidity in the population could be significant. Thus, the aims were to determine if daily intake of soy milk made from whole soy beans (WSB) or soy protein isolate (SPI) for 8 weeks reduces BP compared to cow's milk (CM) and if the nature of soymilk, WSB (Silk) or SPI (8th Continent) has a bearing on the degree of effect in pre‐/Stage I hypertensives. Participants (n=68) consumed the randomly assigned beverage equal to 21 g of protein/d in this single‐blind study. BP was measured in‐house using the recommended office assessment and with a 24‐hr ambulatory BP monitor at baseline, 4 and 8 weeks. Data analysis shows that while baseline BP did not differ across groups, responses to treatment differed based on the method used to assess BP. In‐house data showed significant improvements in systolic BP (SBP) for all groups and in diastolic BP (DBP) for only the CM group. Ambulatory data showed a significant improvement in DBP for only the CM group. Ambulatory BP likely provides more insight about overall BP because 1) measures are taken every 15 min for 24 h and 2) it also overcomes “whitecoat syndrome” (inflation of BP due to testing environment). Overall, soy protein did not have a greater effect in lowering BP compared to milk protein, and no difference between WSB and SPI was noted.

Poster 209: The Other White Coat Syndrome: Somatic Dysfunctions in Medical Students Wearing White Coats (A Case Series)

Poster 209: The Other White Coat Syndrome: Somatic Dysfunctions in Medical Students Wearing White Coats (A Case Series)

Young Children's Perceptions of Physicians Wearing Standard Precautions Versus Customary Attire

The aim of the study was to determine if young children have a preference regarding whether physicians wear standard precautions attire. One hundred ninety-seven children, aged 4 to 8 years, and their parents were recruited from the pediatric emergency department of a tertiary care center. Two sets of 4 photographs-the same man in formal attire, a white coat, greens, and severe acute respiratory syndrome (SARS) standard precautions attire, and the same woman in formal attire, a white coat, greens, and SARS standard precautions attire-were shown to the children and their caregiver. Both were asked which physician's attire he or she liked the most and which he or she liked the least. Parents filled out a questionnaire regarding their experiences in the pediatric emergency department during the SARS epidemic. The children selected the physician in SARS standard precautions attire as most liked 17.5% of the time and least liked 53.3% of the time. The parents selected the physician in SARS standard precautions attire as most liked 0% of the time and least liked 94.8% of the time. Physicians wearing standard precautions attire while working in the pediatric emergency department need to be aware that this attire may negatively impact their relationship with pediatric patients 4 to 8 years of age.

Que valores devem ser adotados como limites de normalidade na monitorização ambulatorial de pressão arterial e na monitorização residencial de pressão arterial?

New methods to evaluate blood pressure – such as ambulatory blood pressure monitoring (ABPM) and home monitoring of blood pressure (HMBP), have been increasingly more used in clinical practice as key source of additional information to the traditional evaluation of blood pressure measuring at the doctor’s office. There is a growing body of evidence available to show that both methods are strong predictors of both substitute or intermediate cardiovascular outcomes such as cardiovascular morbidity and mortality1. In addition, both methods can also evaluate conditions so far under less extensive research, such as the white coat syndrome, blood pressure behavior during sleep, masked hypertension, and early morning surge.2

Comments on the New AHA Recommendations for Blood Pressure Measurement

Comments on the New AHA Recommendations for Blood Pressure Measurement

Variaciones de la prevalencia y el perfil del paciente con fenómeno de bata blanca, según su definición con automedida de presión arterial domiciliaria (AMPA)

To calculate the prevalence of white-coat syndrome (WCS) in patients with hypertension, comparing the two most common definitions and their effect on the profile of the patient with WCS. Cross-sectional, descriptive study.Setting. Urban health centre.Patients. Hypertense patients selected by simple randomised sampling from among those included in the hypertension programme. Clinical blood pressure (CBP) from the previous year was collected. Home blood pressure (HBP) was measured by the patient with an electronic sphygmomanometer. Age, sex, further tests (analysis and electrocardiogram) and other clinical features were also recorded. WCS was defined as when CBP was above/equal to 140/90 mmHg and HBP was under 135/85 mmHg or when the difference between CBP and HBP was more than/equal to 20 mmHg systolic and/or 10 mmHg diastolic pressure. In 154 hypertense patients (60.4% women) between 38 and 92 years old, mean CBP (141.1/85.3) was higher than mean HBP (136.8/79.8). WCS prevalence varied (p = 0.001), depending on the definition used (20.1% and 36.4%). The systolic and diastolic mean CBP of the last year were higher in those patients with WCS (p < 0.001 for diastolic pressure). The profile of hypertense patients with WCS varied according to the definition used. WCS is common in hypertense patients treated in Primary Care and may condition an inadequate assessment of the degree of blood pressure monitoring. As the way of defining WCS conditions its prevalence, its profile and clinical decision-taking, it is essential to agree a uniform definition for practical use.

Why ambulatory blood pressure monitoring?

Factors that affect the reliability and accuracy of blood pressure measurements are reviewed, and new technologies for measuring blood pressure are discussed. Blood pressure measurements obtained in an office, hospital, or clinic are subject to variation and error. Reasons for variations include the wrong cuff size, improper inflation or deflation technique, and patient apprehension ("white-coat syndrome"). Ambulatory blood pressure monitoring (ABPM) involves the use of a fully automated standard arm cuff that is inflated at predetermined intervals by a small battery-powered pump unit. The most reliable ABPM method is the oscillometric method, which detects subtle changes in air pressure within the cuff system caused by fluctuations of the brachial artery. The process for interpreting 24-hour ABPM data is still evolving. Twenty-four-hour ABPM has been shown to eliminate white-coat hypertension and is also useful for assessing patients whose blood pressure is inappropriately high in the absence of end organ damage, monitoring persons at risk of developing hypertension because of their race or family history, determining a medication's 24-hour effect on blood pressure, and assessing the early-morning rapid rise in blood pressure, which has been linked to an increased risk of nonembolic stroke and myocardial infarction. ABPM enables identification of patients whose blood pressure is elevated in the office but normal at home, allows more appropriate screening of patients for clinical trials, gives reproducible values, and enables evaluation of drug duration and action.

Clinical Applications of Ambulatory Blood Pressure Monitoring

The estimation of an individual's true blood pressure by conventional clinical measurement is subject to a number of errors, stemming partly from the inherent variability of blood pressure, and also from the white coat syndrome, which is an elevation of blood pressure limited to the clinic setting. This may occur in about 20% of patients with mild hypertension, and is hypothesized to be a learned or conditioned response. Ambulatory monitoring may help to identify such patients. Other potential clinical applications of the technique include evaluation of patients with resistant hypertension, with excessively labile blood pressure, or with autonomic insufficiency, which may be characterized not only by hypotensive episodes, but also by hypertensive episodes during the night. An unresolved question is the definition of the upper limit of normal ambulatory pressure, which is required before ambulatory monitoring finds wide clinical acceptance.

The white coat syndrome

The white coat syndrome