What is white coat syndrome?

It’s common to feel a little nervous before a doctor’s appointment. You may even experience blood pressure spikes at the doctor’s office.

But if your blood pressure is only high in a healthcare setting, you could have a condition called white coat syndrome.

Here, I’ll break down white coat syndrome and how it can affect your heart health, and I’ll give you tips on how to manage it.

What is white coat syndrome?

White coat syndrome is also called white coat hypertension.

Hypertension is the medical term for high blood pressure. When you get your blood pressure taken, the results yield two numbers: a systolic (top or first) number and a diastolic (bottom or second) number. You have hypertension when your blood pressure is 130/80 mm Hg or higher on more than one reading.

To diagnose hypertension, we look at whether you’ve had multiple high readings in different settings – like your home and a doctor’s office. This is because blood pressure changes regularly.

The setting is also part of the criteria that differentiates hypertension from white coat hypertension. White coat hypertension is when your blood pressure is only high in a clinical setting, like a doctor’s office, and normal in any other setting. “White coat” refers to the white coats often worn by doctors.

Your doctor may use ambulatory blood pressure monitoring or self-measured blood pressure readings at home to help diagnose white coat hypertension.

Ambulatory blood pressure monitoring is when you wear a portable device outside of the doctor’s office. It regularly tracks your blood pressure over a set amount of time – usually 24 to 48 hours.

Self-measured readings are used more often because they are convenient. You will use a home blood pressure cuff to check readings at least twice a day – in the morning and evening.

Both of these approaches to home blood pressure monitoring can confirm that your blood pressure is normal outside of a healthcare setting.   

What causes white coat syndrome?

The most common cause of white coat syndrome is not being in your normal setting. Being in a clinical setting, especially if you’re getting scans, bloodwork or other tests done, can cause stress and anxiety. This can raise your blood pressure.    

Sometimes, a high blood pressure reading at your doctor’s office can be due to measurement error, such as the cuff fitting incorrectly or being the wrong size. It’s important to get accurate readings to correctly diagnose white coat syndrome.

What happens in my body when my blood pressure is high?

Blood pressure is regulated by two competing nervous systems in your body: the sympathetic and the parasympathetic nervous systems.

The sympathetic nervous system drives your “fight or flight” response. In perceived harmful or stressful situations, it tells your blood vessels to clamp down and for your heart to beat quickly with more force to increase the amount of blood flow going through your body. This raises your blood pressure.

The parasympathetic nervous system does the exact opposite. It controls the “rest and digest” response. It tells your body to slow down, calm down and relax. Your blood vessels open up and your heart rate slows down, which lowers your blood pressure.

These nervous systems are always in some sort of equilibrium. So, as one goes up, the other goes down. Our goal in clinic is to measure your blood pressure when you’re in a “rest and digest” state. But stress can cause patients to be in “fight or flight” mode.  

How is white coat syndrome treated?

Your doctor might recommend lifestyle changes to help you manage white coat hypertension. These are also good for cardiovascular health in general.

Diet

Following a healthy diet low in sodium, such as the DASH (Dietary Approaches to Stop Hypertension) diet, is good for heart health. It includes eating foods with nutrients that help regulate blood pressure and restricting sodium, which reduces water in your bloodstream.  

Exercise

Regular physical activity, particularly aerobic exercise, helps your heart pump blood more efficiently. This can help lower your blood pressure.

Weight loss

Evidence-based studies have shown that for every kilogram of weight you lose, you’re likely to drop your systolic blood pressure by one mm Hg.

Tobacco control

Smoking can affect your blood pressure, as well as increase your risk for heart disease and cancer. If you use any kind of tobacco, talk to your doctor about resources to help you quit.

Wellness activities

There is some evidence suggesting that mindfulness, yoga and meditation can help lower blood pressure. But this is not as well-studied.

Remember: white coat hypertension is not the same as hypertension. We typically treat hypertension with medication and lifestyle changes.

Is white coat syndrome serious?

White coat hypertension can increase your risk for developing hypertension. Studies have shown that people with white coat hypertension are 3 to 4 times more likely to develop true hypertension within 10 years.

Some therapies used in cancer treatment – like certain chemotherapy, immunotherapy and targeted therapy drugs – can raise your blood pressure.

So, it’s important to talk to your doctor if your blood pressure is consistently high in healthcare settings. They can get to the bottom of it and recommend lifestyle changes to help reverse the condition before it develops into hypertension.

Does white coat syndrome ever go away?

With proper management, white coat syndrome can definitely improve and resolve.

How can I calm down before a blood pressure test at the doctor’s office?

We generally recommend that you don’t exercise for at least 30 minutes before your blood pressure is checked. You should also empty your bladder.

If you feel anxious in the clinic or doctor’s office, try the following to calm your nerves:

• Sit in a chair for at least five minutes before your blood pressure is taken.
• Do not talk or use your phone.
• Take slow, deep breaths.

When possible, the healthcare provider checking your blood pressure should make sure that:

• Both of your feet are rested on the floor
• Your legs are uncrossed
• Your arm rests on a surface level to your heart
• The blood pressure cuff is just on your skin, not your clothes
• The blood pressure cuff fits snugly around your arm, but not too tight

Communicate with your healthcare provider

Healthcare professionals can do a better job at times of making sure you’re calm and settled before taking your blood pressure. Or, if you get a high reading, they can try taking your blood pressure again later in the appointment once you’re more settled. Unfortunately, this doesn’t always happen due to time or clinical constraints.

But it is very reasonable to ask your provider, “If there’s time, would you mind checking my blood pressure again in a few minutes or at the end of my appointment?”

That can give you time to practice self-regulation or calming techniques.

Single high readings can be misleading. So, your provider may also ask you to check your blood pressure at home – usually twice a day, once in the morning and once in the evening – for a week or so, to identify trends. That can provide them more insight into whether it could be white coat syndrome or something else.

Your relationship with your healthcare provider is very important. You should feel comfortable communicating any questions or concerns. We’re here to make sure you get the best care possible.

Carl Zehner, M.D., is a cardiologist at UT MD Anderson.

Request an appointment at UT MD Anderson online or call 1-877-632-6789.