A discussion of White Coat Syndrome on another blog.

“The magnitude of white coat effect was 50 +/- 17 (8-84) mm Hg for systolic blood pressure and 18 +/- 11 (-9 +/- 41) mm Hg for diastolic blood pressure. A marked white coat effect (> 40 mm Hg) was observed in 78% of our hypertensive patients. In elderly people (> 60 years), this difference was greater (50 +/- 15 vs 45 +/- 21 mm Hg) though not significantly”

I have a fairly radical view of hypertension, which is that as a risk factor we have been not able to treat it effectively. As a result, patients continue to die while taking expensive medications. I question the viability of blood pressure as a diagnosis in older patients. I base these radical statements in part on the following:

https://www.ncbi.nlm.nih.gov/pubmed/14576382   “Lowering blood pressure or treating hypertension with a variety of antihypertensive agents reduced stroke; No effect was seen on vascular or all-cause mortality” (Stroke 2003 Nov;34(11):2741-8)

While lowering blood pressure does decrease other, lesser events, another study from 2016 found: “However, more intensive treatment had no clear effects on heart failure (15% [95% CI -11 to 34]), cardiovascular death (9% [-11 to 26]), total mortality (9% [-3 to 19]), or end-stage kidney disease (10% [-6 to 23])”  https://www.ncbi.nlm.nih.gov/pubmed/26559744 

Patients experienced fewer strokes but died at the same rate.

“In spite of its importance in causing cardiovascular disease blood pressure is a poor predictor of cardiovascular events; persons in the top 10% of the distribution of systolic blood pressure experienced only 21% of all ischaemic heart disease events and 28% of all strokes at a given age.. the term hypertension should be avoided because it is not a disease and it implies another category (normotensives) who would not benefit from lowering blood pressure (Health Technol Assess. 2003;7(31):1-94)

These experts recommend hypertension drugs for everyone. “To evaluate the effect of antihypertensive treatment on secondary prevention of CVD events and all-cause mortality among persons without clinically defined hypertension….Among patients with clinical history of CVD but without hypertension, antihypertensive treatment was associated with decreased risk of stroke, CHF, composite CVD events, and all-cause mortality” https://www.ncbi.nlm.nih.gov/pubmed/21364140  So we had better outcomes using blood pressure medications to treat heart disease even if the person didn’t have high blood pressure. Since this is the only study to show a decrease in overall mortality, shouldn’t we change the definition of what we’re doing?


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