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The misdiagnosis of hypertension: the role of patient anxiety - PubMed

  • ️Tue Jan 01 2008

The misdiagnosis of hypertension: the role of patient anxiety

Gbenga Ogedegbe et al. Arch Intern Med. 2008.

Abstract

Background: The white coat effect (defined as the difference between blood pressure [BP] measurements taken at the physician's office and those taken outside the office) is an important determinant of misdiagnosis of hypertension, but little is known about the mechanisms underlying this phenomenon. We tested the hypothesis that the white coat effect may be a conditioned response as opposed to a manifestation of general anxiety.

Methods: A total of 238 patients in a hypertension clinic wore ambulatory blood pressure monitors on 3 separate days 1 month apart. At each clinic visit, BP readings were manually triggered in the waiting area and the examination room (in the presence and absence of the physician) and were compared with the mercury sphygmomanometer readings taken by the physician in the examination room. Patients completed trait and state anxiety measures before and after each BP assessment.

Results: A total of 35% of the sample was normotensive, and 9%, 37%, and 19% had white coat, sustained, and masked hypertension, respectively. The diagnostic category was associated with the state anxiety measure (F(3,237) = 6.4, P < .001) but not with the trait anxiety measure. Patients with white coat hypertension had significantly higher state anxiety scores (t = 2.67, P < .01), with the greatest difference reported during the physician measurement. The same pattern was observed for BP changes, which generally paralleled the changes in state anxiety (t = 4.86, P < .002 for systolic BP; t = 3.51, P < .002 for diastolic BP).

Conclusions: These findings support our hypothesis that the white coat effect is a conditioned response. The BP measurements taken by physicians appear to exacerbate the white coat effect more than other means. This problem could be addressed with uniform use of automated BP devices in office settings.

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Figures

Figure 1
Figure 1

Schematic drawing of the hypothesized conditioning process that may lead to white coat hypertension. Upward arrow indicates increase.

Figure 2
Figure 2

Diagnostic categories and associated target organ damage, based on the joint assessment of clinic and ambulatory blood pressure (BP).

Figure 3
Figure 3

Study timeline. BP indicates blood pressure.

Figure 4
Figure 4

Mean visual analog scale scores before and after the physician’s entrance to the examination room for the 4 diagnostic categories. BP indicates blood pressure.

Figure 5
Figure 5

Mean systolic blood pressure (BP) before and after the physician’s entrance to the examination room and before and after the physician’s exit from the examination room for the 4 diagnostic categories. Error bars indicate standard errors.

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