Skip to main content
PMC home page
CMAJ : Canadian Medical Association Journal logoLink to CMAJ : Canadian Medical Association Journal
. 1999 Aug 10;161(3):265–269.

Prevalence and predictors of white-coat response in patients with treated hypertension

M B MacDonald 1, G P Laing 1, M P Wilson 1, T W Wilson 1
PMCID: PMC1230502  PMID: 10463047

Abstract

BACKGROUND: White-coat response, defined as higher office blood pressure readings than ambulatory readings, is common. Few studies have estimated its prevalence among subjects with treated hypertension, and almost none have defined its determinants. The objective of this study was to estimate the prevalence of white-coat response among subjects with treated hypertension and to determine whether the phenomenon could be predicted using clinical and psychometric data. METHODS: A total of 103 treated patients (55 men and 48 women) with uncontrolled hypertension who attended a hypertension outpatient clinic in Saskatoon between September 1993 and December 1995 were entered into the study. Patients had at least 2 clinic blood pressure readings of 140/90 mm Hg or higher, had no target organ damage or left ventricular hypertrophy, and had been prescribed 2 or more classes of antihypertensive drugs. Patients had blood pressure measured in the supine position in the clinic, were placed on 24-hour ambulatory blood pressure monitoring and then completed questionnaires before returning to the clinic. Patients were classified as exhibiting a white-coat response if their mean daytime ambulatory systolic/diastolic blood pressure was 139/89 mm Hg (both) or less, or if the systolic/diastolic pressure was at least 20/15 mm Hg (both) lower than the clinic reading. RESULTS: Eleven men (20%, 95% confidence interval [CI] 10%-33%) and 26 women (54%, 95% CI 39%-69%) showed white-coat response. Logistic regression modelling showed that determinants such as stress had significantly different effects among men and women. Separate models were therefore created for men and women. For women, perceived level of stress was the most important predictor of white-coat response (odds ratio [OR] per unit 7.0, 95% CI 1.3-36.0), followed by time since diagnosis. For men, depression was a weak predictor, with higher depression scores predicting sustained hypertension (OR per unit 1.2, 95% CI 1.01-1.5). INTERPRETATION: Sex is an important factor in white-coat response. Attempts to predict white-coat response from psychometric variables should take sex differences into account. Clinical variables were not effective as predictors of white-coat response.

Full Text

The Full Text of this article is available as a PDF (139.2 KB).

Selected References

These references are in PubMed. This may not be the complete list of references from this article.

  1. Bidlingmeyer I., Burnier M., Bidlingmeyer M., Waeber B., Brunner H. R. Isolated office hypertension: a prehypertensive state? J Hypertens. 1996 Mar;14(3):327–332. doi: 10.1097/00004872-199603000-00009. [DOI] [PubMed] [Google Scholar]
  2. Bottini P. B., Carr A. A., Rhoades R. B., Prisant L. M. Variability of indirect methods used to determine blood pressure. Office vs mean 24-hour automated blood pressures. Arch Intern Med. 1992 Jan;152(1):139–144. [PubMed] [Google Scholar]
  3. Cardillo C., De Felice F., Campia U., Folli G. Psychophysiological reactivity and cardiac end-organ changes in white coat hypertension. Hypertension. 1993 Jun;21(6 Pt 1):836–844. doi: 10.1161/01.hyp.21.6.836. [DOI] [PubMed] [Google Scholar]
  4. Cavallini M. C., Roman M. J., Pickering T. G., Schwartz J. E., Pini R., Devereux R. B. Is white coat hypertension associated with arterial disease or left ventricular hypertrophy? Hypertension. 1995 Sep;26(3):413–419. doi: 10.1161/01.hyp.26.3.413. [DOI] [PubMed] [Google Scholar]
  5. Cerasola G., Cottone S., Nardi E., D'Ignoto G., Volpe V., Mulé G., Carollo C. White-coat hypertension and cardiovascular risk. J Cardiovasc Risk. 1995 Dec;2(6):545–549. [PubMed] [Google Scholar]
  6. Cohen S., Kamarck T., Mermelstein R. A global measure of perceived stress. J Health Soc Behav. 1983 Dec;24(4):385–396. [PubMed] [Google Scholar]
  7. Gosse P., Promax H., Durandet P., Clementy J. 'White coat' hypertension. No harm for the heart. Hypertension. 1993 Nov;22(5):766–770. doi: 10.1161/01.hyp.22.5.766. [DOI] [PubMed] [Google Scholar]
  8. Haynes R. B., Lacourcière Y., Rabkin S. W., Leenen F. H., Logan A. G., Wright N., Evans C. E. Report of the Canadian Hypertension Society Consensus Conference: 2. Diagnosis of hypertension in adults. CMAJ. 1993 Aug 15;149(4):409–418. [PMC free article] [PubMed] [Google Scholar]
  9. Julius S., Mejia A., Jones K., Krause L., Schork N., van de Ven C., Johnson E., Petrin J., Sekkarie M. A., Kjeldsen S. E. "White coat" versus "sustained" borderline hypertension in Tecumseh, Michigan. Hypertension. 1990 Dec;16(6):617–623. doi: 10.1161/01.hyp.16.6.617. [DOI] [PubMed] [Google Scholar]
  10. Kuwajima I., Suzuki Y., Fujisawa A., Kuramoto K. Is white coat hypertension innocent? Structure and function of the heart in the elderly. Hypertension. 1993 Dec;22(6):826–831. doi: 10.1161/01.hyp.22.6.826. [DOI] [PubMed] [Google Scholar]
  11. Lerman C. E., Brody D. S., Hui T., Lazaro C., Smith D. G., Blum M. J. The white-coat hypertension response: prevalence and predictors. J Gen Intern Med. 1989 May-Jun;4(3):226–231. doi: 10.1007/BF02599528. [DOI] [PubMed] [Google Scholar]
  12. MacDonald M. B., Sawatzky J. E., Wilson T. W., Laing G. P. Lifestyle profiles of hypertensives. Can J Cardiovasc Nurs. 1991 Sep;2(2):3–8. [PubMed] [Google Scholar]
  13. MacDonald M. B., Sawatzky J. E., Wilson T. W., Laing G. P. Predicting success in antihypertensive drug therapy: the importance of nondrug variables. Can J Cardiol. 1991 Jan-Feb;7(1):19–23. [PubMed] [Google Scholar]
  14. MacDonald M., Spink K. S., Faulkner R. The effect of testing anxiety on blood pressure. Can J Cardiovasc Nurs. 1993;4(3-4):3–6. [PubMed] [Google Scholar]
  15. Mancia G., Bertinieri G., Grassi G., Parati G., Pomidossi G., Ferrari A., Gregorini L., Zanchetti A. Effects of blood-pressure measurement by the doctor on patient's blood pressure and heart rate. Lancet. 1983 Sep 24;2(8352):695–698. doi: 10.1016/s0140-6736(83)92244-4. [DOI] [PubMed] [Google Scholar]
  16. Mancia G., Parati G. Clinical significance of "white coat" hypertension. Hypertension. 1990 Dec;16(6):624–626. doi: 10.1161/01.hyp.16.6.624. [DOI] [PubMed] [Google Scholar]
  17. Mancia G., Sega R., Bravi C., De Vito G., Valagussa F., Cesana G., Zanchetti A. Ambulatory blood pressure normality: results from the PAMELA study. J Hypertens. 1995 Dec;13(12 Pt 1):1377–1390. [PubMed] [Google Scholar]
  18. Mansoor G. A., McCabe E. J., White W. B. Determinants of the white-coat effect in hypertensive subjects. J Hum Hypertens. 1996 Feb;10(2):87–92. [PubMed] [Google Scholar]
  19. Melamed S. Emotional reactivity and elevated blood pressure. Psychosom Med. 1987 May-Jun;49(3):217–225. doi: 10.1097/00006842-198705000-00001. [DOI] [PubMed] [Google Scholar]
  20. Myers M. G., Reeves R. A. White coat effect in treated hypertensive patients: sex differences. J Hum Hypertens. 1995 Sep;9(9):729–733. [PubMed] [Google Scholar]
  21. Myers M. G., Reeves R. A. White coat phenomenon in patients receiving antihypertensive therapy. Am J Hypertens. 1991 Oct;4(10 Pt 1):844–849. doi: 10.1093/ajh/4.10.844. [DOI] [PubMed] [Google Scholar]
  22. Pickering T. G., Devereux R. B., Gerin W., James G. D., Pieper C., Schlussel Y. R., Schnall P. L. The role of behavioral factors in white coat and sustained hypertension. J Hypertens Suppl. 1990 Dec;8(7):S141–S147. [PubMed] [Google Scholar]
  23. Pickering T. G., James G. D., Boddie C., Harshfield G. A., Blank S., Laragh J. H. How common is white coat hypertension? JAMA. 1988 Jan 8;259(2):225–228. [PubMed] [Google Scholar]
  24. Pierdomenico S. D., Lapenna D., Guglielmi M. D., Antidormi T., Schiavone C., Cuccurullo F., Mezzetti A. Target organ status and serum lipids in patients with white coat hypertension. Hypertension. 1995 Nov;26(5):801–807. doi: 10.1161/01.hyp.26.5.801. [DOI] [PubMed] [Google Scholar]
  25. Pierdomenico S. D., Mezzetti A., Lapenna D., Guglielmi M. D., Mancini M., Salvatore L., Antidormi T., Costantini F., Cuccurullo F. 'White-coat' hypertension in patients with newly diagnosed hypertension: evaluation of prevalence by ambulatory monitoring and impact on cost of health care. Eur Heart J. 1995 May;16(5):692–697. doi: 10.1093/oxfordjournals.eurheartj.a060975. [DOI] [PubMed] [Google Scholar]
  26. Schneider R. H., Egan B. M., Johnson E. H., Drobny H., Julius S. Anger and anxiety in borderline hypertension. Psychosom Med. 1986 Mar-Apr;48(3-4):242–248. doi: 10.1097/00006842-198603000-00009. [DOI] [PubMed] [Google Scholar]
  27. Siegel W. C., Blumenthal J. A., Divine G. W. Physiological, psychological, and behavioral factors and white coat hypertension. Hypertension. 1990 Aug;16(2):140–146. doi: 10.1161/01.hyp.16.2.140. [DOI] [PubMed] [Google Scholar]
  28. Verdecchia P., Schillaci G., Boldrini F., Zampi I., Porcellati C. Variability between current definitions of 'normal' ambulatory blood pressure. Implications in the assessment of white coat hypertension. Hypertension. 1992 Oct;20(4):555–562. doi: 10.1161/01.hyp.20.4.555. [DOI] [PubMed] [Google Scholar]
  29. Verdecchia P., Schillaci G., Borgioni C., Ciucci A., Porcellati C. Prognostic significance of the white coat effect. Hypertension. 1997 Jun;29(6):1218–1224. doi: 10.1161/01.hyp.29.6.1218. [DOI] [PubMed] [Google Scholar]

Articles from CMAJ: Canadian Medical Association Journal are provided here courtesy of Canadian Medical Association

RESOURCES