"This Seems Crazy... Nothing's Wrong with Me." - Hypertension (Part I)

In the first episode of our hypertension series, our patient Taylor  joins us for a discussion on receiving and coming to terms with a diagnosis of high blood pressure.

Share your reactions and questions with us at  Speak Pipe . We might feature you on a future episode!

===  Outline ===
1. Introduction
2. Chapter 1: Taylor's Story/Hypertensive Urgency
3.  Chapter 2: Defining Hypertension
4. Chapter 3: Measuring Blood Pressure
5. Chapter 4: White Coat Hypertension
6. Conclusion

=== Learning Points ===

1. The ideal target for a patient’s blood pressure is based on their risk score for cardiovascular events and mortality in the long term. 
2. Measurement of blood pressure in an office setting is often performed in nonideal conditions.Out-of-office monitoring of blood pressure monitoring should be used whenever possible. 
3. The “white coat effect” refers to high blood pressure that is above a patient’s treatment goal in the office, but below their treatment goal at home. This effect is still clinically significant.

=== Our Expert(s) ===

Benjamin Gallagher, MD, FACP is an Assistant Professor of Clinical Medicine (General Medicine) at Yale School of Medicine.

=== References ===

1. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2018;71:e127-e248.
2. Ostchega Y, Fryar CD, Nwankwo T, Nguyen DT. Hypertension prevalence among adults aged 18 and over: United States, 2017–2018. NCHS Data Brief, no 364. Hyattsville, MD: National Center for Health Statistics. 2020.
3. SPRINT Research Group, Wright JT Jr, Williamson JD, Whelton PK, Snyder JK, Sink KM, et al. A randomized trial of intensive versus standard blood-pressure control. N Engl J Med 373(22):2103–16. 2015.
4. Powers BJ, Olsen MK, Smith VA, Woolson RF, Bosworth HB, Oddone EZ. Measuring blood pressure for decision making and quality reporting: where and how many measures? Ann Intern Med. 2011 Jun 21;154(12):781-8, W-289-90. doi: 10.7326/0003-4819-154-12-201106210-00005. PMID: 21690592.
5. de la Sierra A, Segura J, Banegas JR, Gorostidi M, de la Cruz JJ, Armario P, Oliveras A, Ruilope LM. Clinical features of 8295 patients with resistant hypertension classified on the basis of ambulatory blood pressure monitoring. Hypertension. 2011 May;57(5):898-902. doi: 10.1161/HYPERTENSIONAHA.110.168948. Epub 2011 Mar 28. PMID: 21444835.

=== About Us ===

The Primary Care Pearls (PCP) Podcast is created in collaboration with faculty, residents, and students from the Department of Internal Medicine at the Yale School of Medicine. The project aims to create accessible and informative podcasts for furthering the medical education of residents and clinicians in early stages of their careers. Building on the work of other medical education podcasts, Primary Care Pearls includes contributions from patients themselves, who have the autonomy to share their own experiences of how their primary care physician directly impacted the quality of their care.

Hosts: Josh Onyango, Maisie Orsillo
Producers: Helen Cai, Kevin Wheelock, Danish Zaidi
Logo and name: Eva Zimmerman
Theme music and Editing: Josh Onyango
Other background music: The Mini Vandals, Asher Fuller, Astron, Joel Cummins, penguinmusic, Unicorn heads, Dan Bodan, 

Instagram: @pcpearls
Twitter: @PCarePearls
Listen on most podcast platforms: linktr.ee/pcpearls

Transcript

Introduction

[00:00:00] Josh: hi, welcome to primary care pearls. A podcast made by learners for learners today. 

[00:00:05] Gallagher: Hypertension is a significant risk factor for cardiovascular disease and mortality. it's one of the major preventable causes of preventable morbidity and mortality in the U S yes all over the world. it's true. It is generally asymptomatic condition. It's very common, as I mentioned, it's 46% of us adults. Um, but it's very treatable and a significant risk factor for a lot of outcomes that we'd like to avoid. And so that's why we screen for it and measure i t at every okay. and really try to get people under control when they're found to have a blood pressure that's above threshold. 

[00:00:40] Josh: We're talking about hypertension during our discussion today, we'll be joined by Taylor.

[00:00:48] Taylor: Hi, my name is Taylor. I am a patient at the, um, hypertension clinic at Yale. 

[00:00:55] Josh: We'll learn more about her experience with receiving a diagnosis of hypertension. 

We'll also be joined by Dr. Ben Gallagher, a faculty expert from the Yale school of medicine

[00:01:08] Gallagher: Ben Gallagher, I am a general internist. I also work at the Yale school of medicine and I primarily work in the outpatient setting, um, in a primary care clinic in new Haven where a lot of the internal medicine residents at Yale also practice. Um, and I have a special interest in hypertension, both in diagnosis and management.

[00:01:29] Josh: with the conversation facilitated by our resident interviewer, Dr. Kevin Wheelock

[00:01:35] Kevin: My name is Kevin Wheelock. I'm a second year internal medicine residents at the Yale school of medicine.

[00:01:42] Josh: and our medical student interviewer Helen Cai 

[00:01:45] Helen: hello, my name is Helen and I'm a first-year medical student here at the Yale school of medicine.

[00:01:50] Josh: This discussion will be part one of a three-part series that will explore the diagnosis of hypertension or high blood pressure.

My name is Joshua I'm a third year primary care internal medicine resident at Yale. 

[00:02:05] Maisie: And my name is Dr. Macy Orsillo, and I'm a second year primary care internal medicine resident at Yale and I'll be your co-host for this episode. We hope that through this discussion, you'll be able to empathize with a patient receiving a diagnosis of hypertension, and come to understand the necessary steps that should be taken to ensure we provide an accurate diagnosis. 

[00:02:26] Josh: Before we get started, please know that this content is made to be for learning and entertainment purposes only, and should not be used to serve as medical advice. If you, or a loved one is suffering from anything discussed in today's episode, please be sure to discuss it with a medical expert. Now onto the show.

Chapter 1: Taylor's Story/Hypertensive Urgency

[00:02:45] Helen: So let's maybe start to get to know you a little bit better. Um, why don't you just tell me about yourself?

[00:02:51] Taylor: I am from this area actually. Um, I am 32 years old. I work as a property manager in apartment building in a downtown.

I have a pet. That's basically my whole life right there. 

[00:03:05] Helen: Wow. What's the rabbit's name? 

[00:03:07] Taylor: His name is peaches. Yeah. 

[00:03:10] Helen: I love that. How do you like your work?

[00:03:12] Taylor: I actually really like it a lot. It can be really stressful. Um, basically an adult babysitter that does a lot of Excel reports, but it's, um, generally a pretty good time and met some really cool people doing it.

[00:03:24] Helen: so what kind of prompted you to head to doctor to get Gallagher in the first one? 

[00:03:28] Taylor: this whole thing started, uh, about an April.

I had a really bad cough that had been going on for a couple months and it started just getting annoying because people kept being like, it's definitely COVID. And I was like, it's not COVID I've been tested a million times. Um, I told a bunch of friends about it. Again, people that live at the building, I work at a lot of them are residents at the hospital.

And, uh, she was like, I think you, I didn't have a primary doctor also. So she's like, I really think you should probably see like a doctor. I kept just going to like walk in and clinics and like, you know, CVS and whatever. Not that they're. Um, knowledgeable, but  

It's like a different person every time though. So you don't really get like that personal kind of relationship with them. It's someone, you know, flipping through my actual chart or my chart or whatever. And they're just like, oh yeah, it says here, you know, 2012, this happened whatever. And they don't actually know you at all.

So it was. Um, and while I was there, I was like, can you just test me for everything? Because I need to just keep telling people, like, it's not, COVID, it's not strap. It's not whatever. And they checked everything and they were like, um, I mean, honestly like seem fine, not totally sure where the cough is coming from. Probably just some kind of infection it'll go away on its own. Um, however, your blood pressure is like alarmingly high and they're like, we're gonna, um, They checked it like three times already. And like before they had said anything and I knew something was up. Cause it was kind of weird. Um, since she's like, I'm going to have someone else come in, are you okay with that?

I was like, yeah, of course, whatever. And they're like, are you nervous? I'm like, no, not at all. And they like kept asking me like, are you like, did something happen at work today? And I'm like, I don't know, like what are we getting at right now? Um, so the second person that came in, they checked it and then they all looked at each other like eyes like extremely wide and like walked out of the room.

And I still was kind of like, I don't like, I feel fine, nothing's wrong, whatever. And they come back with someone else and they check it again. And they're like, so do you have anybody with you? And I'm like, no. And they're like, well, you shouldn't have to call someone because we really think you should maybe go to the emergency room.

And I'm like, I'm sorry, what? Like why? Um, and they like showing me my blood pressure and I'm like, I don't know what this means. Like, what is this supposed to be? What does that mean? And they're like, um, you're like really high risk for having a stroke. What are you talking about? Um, anyway, I was like, I'm not going to go the hospital.

This seems crazy. Nothing's wrong with me? Like, I'm fine. 

I was like, I don't know. Um, anyway, so the next morning. I had run into, um, Tom Bell's, his ex wife actually. And she, I didn't even say anything to her. She looked at me and she's like, what's wrong with you? Something's wrong. And it was like, I didn't even know where that well, um, and she's like some what, like what's going on?

And then I told her like, kinda what was happening. And she's like, she had like a thing with her and we checked it and she was like, no, she called Dr. Gallagher's office. And I actually went over there. Um, That first day 

[00:06:25] Gallagher: yeah, so the kind of dangerous own blood pressures. Um, generally speaking are systolic that's over 180 and a diastolic that's over one 10 or a one 20. And so patients with that blood pressure, um, if they have no symptoms of hypertensive end organ damage, I that's called a hypertensive urgency. Whereas if they do have symptoms or signs or evidence of hypertensive end organ damage, And acute EMI or an aortic dissection or a stroke, um, injury, that's a hypertensive emergency. Most of what you're going to see is going to be hypertensive urgency

[00:07:09] Helen: as I'm listening to that first initial story, it sounds like everyone around you is freaking out about your blood pressure except for you 

[00:07:15] Taylor: basically. Yeah. 

[00:07:16] Helen: How did that make you feel? 

[00:07:19] Taylor: I don't know, I guess like a couple of points. It was a little scary just thinking about that. I was like, wait, why do I feel fine? Like, cause this, this like can't be normal. And every time it would get checked, like, you know, the, whoever was checking a cab will kind of like they would check it.

It'd be really high. And then they would leave me alone for a while. And I knew that. Thinking that like, I was probably nervous and then I would calm down and they check it again. It'd be fine. They would check it again and it would still be really high. And then they'd be like, Hmm. Um, and they'd call someone else in.

But it was also like, what, like, why are we doing this? I feel totally fine. 

[00:07:50] Gallagher: I'll say at the outset that there is accumulating data that hypertensive urgency may not be a clinically important entity in the sense that in studies, where you look at patients with hypertensive urgency that were sent home and managed as an outpatient sent to the emergency room, there's no term difference cardiovascular outcomes or mortality.

 It may be that a hypertensive urgency is just as severe manifestation of uncontrolled hypertension. And you often see this in patients with a new diagnosis who, um, were asymptomatic and they went to their dentist's office say, and their blood pressure was really high. And everyone got really nervous. Those blood pressures do alarm me , but, there's probably hypertensive urgencies in my clinic every day.

[00:08:44] Maisie: Wow. So as we can see, our patient was experienced what we call hypertensive urgency, a condition that occurs when a patient's blood pressure is severely elevated, but is not causing any immediate symptoms or consequences. In my experience, diagnosing patients with high blood pressure, I've encountered similar situations where patients have no symptoms and have difficulty believing that anything is even wrong. Have you had any experiences like that? 

[00:09:10] Josh: I have, and I think it's really common to see patients who are told that they have hypertension rather than feel that they have it. And many times they get that news from us, once we measure them, but they've never really felt anything. Um, so I think it probably is a very common experience for other patients as well. And I think Dr. Gallagher did a really nice job contextualizing how to think about a patient like Taylor. Who's really struggling with getting this initial diagnosis of hypertension or high blood pressure. 

[00:09:43] Maisie: Yeah, no, I think hearing her experiences is really valuable in understanding how that feels at that age to receive the diagnosis of high blood pressure. 

Chapter 2: Defining Hypertension

[00:09:52] Helen: Had you heard anything about like high blood pressure or the word hypertension before it came up in these visits? 

[00:09:58] Taylor: Not really. Other than, um, my dad had high blood pressure and I know, I like knew it had started a long time ago. I didn't really ever think about it too much before to be honest.

Um, I feel like that's all I talk about now, but, uh, before that now, honestly, I didn't even know the hypertension was high blood pressure. Figured that out pretty quick. 

[00:10:18] Kevin: What is high blood pressure and sort of what are our Def what is our definition of that? Or I think more recently is as guidelines have changed, you know, what are some definitions of high blood pressure?

[00:10:31] Gallagher: the simple answer is that high blood pressure, his blood pressure that is above normal, the moving target is what is considered normal. And so compared to other kind of biological parameters, we don't really define. Uh, I'm normal blood pressure based on what's the average or the median in the general population.

And then say, if you're a certain number of standard deviations above or below that, then you have it on normal blood pressure. We really define the normal based on what we think is optimal in terms of preventing cardiovascular disease and mortality in the longterm. And so you'll recognize in a moment when I go through the numbers that the vast majority of, um, or rather a significant number of people, uh, Mo almost a half of adults in the U S are considered hypertensive based on our most recent guidelines.

And that's not because those are quote unquote abnormal in the sense that they are very far from the average, but that they're abnormal in the sense that they, um, uh, it could be there's room for improvement because having a lower blood pressure?

then that could prevent cardiovascular disease and mortality, uh, in the long run.

Um, uh, the move in the, the normal value also is kind of a moving target based on, uh, changing research over time, evolving, uh, research studies, uh, and it tends to have gotten lower as time has gone on we've understood from different randomized controlled trials of treatment of hypertension.

in many cases I going lower is better, understanding that there are different guidelines in other countries and international guidelines, but the American guidelines that are the ones that I'm most familiar with. Um, so the 2017 g uidelines basically create four categories of blood pressure.

So less than a blood pressure of one 20 over 80 is considered normal. Uh, blood pressure between one 20 and 1 29 systolic and less than 80 diastolic is called pre hypertension. A blood pressure of one 30 to 1 39 systolic over 80 to 89. Diastolic is considered stage one hypertension and a blood pressure of one 40 over 90 or greater is considered a stage two hypertension.

[00:12:52] Taylor: And then it was like, oh my God. Then it started to get like, almost annoying. So I was like, what is it like, why is this happening? Like, I don't do anything. Like, I don't know. I'm basically just sitting here and very calm. I don't know. So yeah. It's it was good because I like felt like people cared. Like they were like, no, we're going to like, make sure you're fine.

[00:13:11] Helen: have there been any, like reactions from your friends or family? 

[00:13:15] Taylor: Um, I mean, people like constantly just asking me, like, if I'm okay, if I'm feeling okay. Um, my mom is like, just constantly concerned about what my numbers are and I'm like, do you even know like when she does, but, um, Yeah, my sister's a nurse.

So I feel like, and like I said, a lot of people that I work, uh, or that live at the building I work at are in the medical field somehow. It's like, I feel like a lot of people knew about it. Um, and they constantly are asking me and they want to check it all the time and they find it like interesting. Um, I think.

Some people kind of think it's funny. Cause there, I mean, you know, it is what it is I guess, but they're like, it's only funny because they're like, that only happens to like old people and I'm like, well, I've learned you're very wrong on that. But um, you know, I think most people just more so like my like immediate family were just a little more concerned.

Yeah. That, and they yell at me. If I do try to eat fries, like they're all like, you're not supposed to eat that. And I'm like, I know you're right. Fine.

[00:14:17] Gallagher: So the patient in mind that you interviewed is very young and most of the patients that we see that have a diagnosis of hypertension tend to be older. You know, it's 46% of the general adult population. But that prevalence increases with age and a rough rule of thumb is that, uh, at every decade, we're starting at age 50 for every decade.

Your risk of hypertension is about equal to that decade in percentage. So 50 year olds have a 50% risk of hypertension, 60 year old, 60%, et cetera, et cetera. So most of the patients that I take care of with hypertension are 50 and older. Um, and many of them have, uh, kind of underlying risk factors that I mentioned briefly, the family history, obesity, uh, and a sedentary lifestyle and, and a high salt diet.

And those are pretty common and often modifiable. But even when those things are modified, many of them will continue to have high blood pressure. And I would say that there are many of them are not surprised because they know that it's a very common condition and they will have had a number of friends and family that had.

But I don't tend to find that to be an impediment to them wanting to get it under control because likewise, they also have a lot of friends and family who have had heart attacks or strokes, or who have been on dialysis and things like that. And so they recognize the relationship between blood pressure and their, uh, health.

[00:15:49] Taylor: I know I used to have a lot of headaches. Um, and honestly, once I started taking this medications, they stopped, which I just never even considered, uh, My a lot of people in my family have migraines pretty consistently. So I kind of, I mean, I've had like an actual migraine before, like I can't see anything killing it late, but it always was just so nervous that that was like what was coming from me that it was like, cause they get them really bad.

Um, then we realized that, uh, probably a lot of these headaches I was having was because of the high blood pressure. So that's been really cool. Cause I felt like for years I just like constantly had attic. It was always like pretty mild, but. I like have not had headaches since, and that's actually been like the craziest thing.

[00:16:31] Gallagher: And I would also say that many of them, uh, attribute symptoms that they may be having to their high blood pressure, even though statistically that's unlikely. Um, but sometimes it's sort of a motivating factor for them to get things under control. 

[00:16:45] Maisie: You know, it really hit me when Dr. Gallagher said that almost 50% of adults living in the U S have high blood pressure based on recent guidelines. That's a huge portion of our population. And that likely only incorporates patients who are actually coming in and getting routine medical care and getting their blood pressure checked in a standardized way in the office. So imagine how many people are out in the community living with undiagnosed high blood pressure.

[00:17:11] Josh: Yeah, that's such a good point. I think even in trying to define what a normal blood pressure is, I think is really interesting because unlike other lab values where we're actually looking at the median of the general population and how an individual person might stack up to that median, Blood pressure is really informed more so by the number that's needed to prevent long-term , complications from uncontrolled hypertension.

[00:17:37] Maisie: You know, it's really great to hear Taylor's point about how her headaches improved after starting antihypertensive therapy. It really demonstrates how we can positively impact. 

patient's lives by screening for, and having early conversations about high blood pressure 

[00:17:54] Josh: Recent guidelines do a really nice job of providing us very clear numerical valleys to follow when we're trying to make the diagnosis of hypertension. But as we're about to see a diagnosis of hypertension really is only as good as the quality of the blood pressure measurement that you're able to obtain from the patient. 

Chapter 3: Measuring Blood Pressure

[00:18:13] Taylor: My parents have a machine at home. That's my dad. I said blood pressure. So I went home after work. Cause I told my mom, of course she's like panicking and she wanted me to check it again and checked it again. And it was still really high all night.

Um, so they're like, you're just nervous and I'm like, I mean, I'm not, but okay. Um, Whatever I, you know, kinda was like talked her into letting me just like, can I just like check it again in the morning, checked it in the morning. It was still like really high at this point. It was just going up and up. And then I started to get like, oh my God, am I going to have a stroke?

[00:18:44] Kevin: You have a patient that comes into your clinic you get the knock on the door, you get your, you know, your vital sheets or you look in the computer, how, you know, however it's set up and you see that their blood pressure is 1 45 over 82 how do you approach talking about that number with them, you know, for a patient who doesn't have a diagnosis of hypertension?

[00:19:05] Gallagher: So I think the first thing to say is that measurement, especially in the office, uh, is key. um,

and that you don't want to declare a person to be hypertensive or not hypertensive based on a single measurement. And you especially don't want to do that. If you're not confident that the measurement technique being used is appropriate.

So I don't think we're going to go into this in detail, but the technique for proper office blood pressure measurement is quite intricate. It's the technique that you guys have all learned in medical school. Um, but it's rarely adhered to in everyday practice. And that has mostly to do with the fact that it's hard to accomplish in a brief period of time.

And in fact, waiting three to five minutes as part of the process and in primary care, the, uh, in the U S in many settings, the, uh, operative, uh, um, or the, the name of the game is kind of high throughput and getting people in and out and doing as many visits as possible. And so that technique is one of the first thing that goes by the wayside and the medical assistants and in my office.

And I'm sure in many other offices in that kind of rooming process are tasked with answer asking screening questions, reconciling medications, Um, you know, getting updated, uh, demographic and contact information, and they're expected to do all of that while checking the patient's blood pressure, which something you're should not be doing, and the patient should be resting and not talking while their blood pressures being nothing just, uh, measured.

And those are just a few of the things that we're supposed to be adhering to. And yet we're still complaining to them that they're not rooming patients fast enough so that we can move on with our day. So, uh, what I would say is that I take any individual blood pressure measurements in the office. that's where I'm not sure of how it was measured. And I kind of assume that there probably were some gaps in or, or deficiencies in how it was measured. I take that with a big grain of salt and I almost treat it as a screening test. So in other words, someone whose blood pressure is below even the prehypertensive range, you know, their blood pressure is one 15 over 75.

Maybe the way that it was measured was not perfect, but it's unlikely that they have, you know, significantly uncontrolled hypertension, right? And by the same token, someone whose blood pressure is 1 65, over 105 may, it may not be truly that high if you measured accurately or if you measured outside the office, but they probably are above what their goal is.

And so I treat anything in between is where I want to get kind of more data, but, um, you know, except for those extremes, I take any individual measurement with a big grain of salt. So, you know, within, uh, individual visit taking multiple measurements uh, doing um, accurately and using the technique that we're taught to use is key.

Um, and the guidelines suggest that we do. Blood pressure measurements on at least three different occasions that are separated by at least a few days or a week each, um, to make a diagnosis of hypertension. Uh, and in fact that three visits may be a compromise because when you look at. Uh, kind of population data, the intra patient variants in blood pressure over different visits.

It doesn't really level off until you get to four or five or six visits. So to get a real, uh, trend of, uh, blood pressure, uh, you know, status for an individual patient, you may need four or five or six visits to really. Tell you, are they truly hypertensive or, or not. And that is kind of where a out of office blood pressure monitoring comes in.

And there are several ways to do that, but those methods have been found to have a stronger correlation with cardiovascular disease and mortality as, uh, uh, compared to, uh, office standard office based measurements. And so the guidelines now recommend using some type of, out of office measurement to both diagnose hypertension and to monitor response to treatment of hypertension.

And so we try to use that as much as possible, but there are some significant barriers to getting that done. 

[00:23:28] Kevin: even to get the three in visit blood pressure measurements, um, if it's someone who's otherwise doing okay, you know, those three visits could be over the course of like a year or multiple years, you know, depending on when they come back.

So I'm curious how you, how you've managed that, uh, 

[00:23:44] Gallagher: Yeah. I would say that if hypertension is a problem that you're going to be treating seriously, that you should try everything that you can to do some type of out-of-office monitoring because of those limitations of the office blood pressure that I mentioned earlier, that having been said, you need to kind of think about the patient and whether that makes sense for them, uh, given what else is going on with their health or in their life, or maybe this now is not the right time to be doing this.

[00:24:13] Helen: How often do you check your blood pressure throughout the day? 

[00:24:15] Taylor: Um, I've stopped doing it like as much as I was, but for while I was doing it in the morning, I would try to do like a middle of the day and then also in the evening. And now I try to do it like, I mean, probably once a day and we mostly in the morning.

[00:24:33] Gallagher: Is hypertension, no problem. One of one on their problem list or one of 10. And if it's one of 10, how are those other nine problems doing? You know, I use the example all the time of some people with hypertension and diabetes, right? If they're diabetic and hypertensive and their A1C is 10, and now you have them on taking insulin and multiple other medications for diabetes, And they're checking their finger sticks once a day or multiple times a day, and have other kinds of, uh, lifestyle modifications and dietary changes exercise improvements that they're working on now is not the time ask them to check their blood pressure twice a day for a few weeks and then have frequent visits for that. so have to kind of think about who is the patient. For someone who's, let's say who is diabetic okay. they're high risk, for some other reason, let's say they're working on smoking cessation and that by virtue of that they're high risk. And maybe now is not the time really push the out of office monitoring.

But at the same time, all, you never know when people are going to come back, right? And so you maybe you'd like them to come every two weeks or every month for whatever issue that you're dealing with them, they may not come back ever. Or they may not come back until next year. 

We saw that happen a lot during the pandemic, even with. Excuse me, access to telemedicine. And so in that situation, if you have someone who's kind of high risk, you have to think about, well, what are the, um, what are the consequences of kind of losing this person to follow up and potentially having their hypertension untreated?

And so maybe those are people who I'm not going to be doing out of office monitoring. I'm going to have a slightly lower threshold to treat them because I'm kind of hedging my bets on, you know, the epidemiology and statistically, how likely are they to have a truly normal blood pressure at home?

Uh, you know, how, how, um, confident they might've. Did they have that pure white coat hypertension, you know, before, for example, starting them on a medication or intensifying their treatment. Right. Um, so I guess the summary is that I think we should be trying to do this as much as possible, but it's not always available and it's not always the right patient or the right time for that patient.

Uh, and so I kind of, um, try to make patient centered decisions along those.

[00:26:47] Maisie: you know, one of my most valuable outpatient experiences has actually been time spent learning and seeing patients at our hypertension clinic. I don't know how you feel about hypertension clinic, but I think it's been super valuable to just focus on it and learn more about how to best manage.

Uh, and one of the biggest things I learned is how key proper blood pressure measurement is. I've seen all sorts of ways to check a blood pressure, and it really makes a difference when you have appropriately measured pressures in how you then interpret that data. So it really is critical to make sure that the cough is properly calibrated, especially if it's one of those old school wall cuffs with the mercury in them, like you see in some offices, you got to make sure that's calibrated and that the correct size cuff is used, uh, that the patient is seated with feet flat on the floor. I think it's common that a lot of times patients are up on an exam table. So feet flat on the floor and their back supported at really after they've been sitting for about five, those are like some of the key measurement points that I've taken away from hypertension clinic. And if those things can't be assured, then taking the measurement with a grain of salt as Dr. Gallagher suggested is is important to consider. 

[00:28:01] Josh: I think you make a really important point about the importance of how the patient is seated and all of those different things to really make sure that we're getting an accurate blood pressure reading when the patient is in the office in front of us. But before we actually make the diagnosis, I think it's also really important to make sure that we have at least two or three separate in office blood pressure readings, to make the, the diagnosis.

And as we learned about I think several elevated readings on home measurements can actually be a really important and sometimes more accurate indicator of cardiovascular disease risk or mortality down the road. 

[00:28:38] Maisie: definitely. And another point that I really appreciated, was when Dr. Gallagher was talking about prioritizing patient health concerns with regard to the presence of multiple medical problems. I think we can all appreciate in primary care, the complexity of humans in general, right? There's a lot going on and a lot of things they want to discuss. And I appreciated that he, uh, talked about picking an appropriate time to measure blood pressure.

Maybe at least starting out with ambulatory blood pressure measurements, helping a patient, get an accurate cuff that they can use to then measure at home. But also bringing up hypertension, if it really is noted to be a problem for a patient at a time when their other medical conditions are a little more settled, right. So that they're in the right space to really process that information and feel like they can tackle the condition. Um, but also not miss the chance to talk about high blood pressure, you know? It's that balance. I think that he brought up, that's really important to think about. 

Chapter 4: White Coat Hypertension

[00:29:45] Josh: So how often in your experience have you encountered white coat hypertension? 

[00:29:53] Maisie: I think a fair amount. I think some patients are quick to say that they have white coat hypertension, but I also think that it's real for sure. And I think that the way we approach measurement like we were talking about earlier is very important.

[00:30:08] Gallagher: you know, yes, the out of office blood pressure measurement is crucial, but people who have a blood pressure greater than a one 60 over a hundred are very unlikely to have pure white coat hypertension.

In other words, their blood pressure at home may be lower than what you're getting in the office. Um, but it's probably still above threshold. Even there might be a 10 or 20 point difference, but it's probably still there, whatever there is blood pressure is at home is probably going to be higher than their threshold, their sort of target blood pressure at, at home.

[00:30:38] Kevin: You said the magic words. They're white coat hypertension. I have to ask you more about this. 

[00:30:44] Gallagher: Yeah, sure. 

[00:30:45] Kevin: it comes up. So much in terms of patients bringing it up is like the reason their blood pressure is 

[00:30:50] Gallagher: Yeah. 

[00:30:51] Kevin: Tell us a little bit about you, how you think about white coat hypertension and how that, you know, may or may not play a role in like the numbers that you're getting in the 

[00:30:59] Gallagher: Yeah. Sure. So, um, in white coat hypertension, just in terms of definitions is simply a blood pressure that is, uh, elevated in the office, but below threshold or below target at home. Uh, and just, um, for the sake of nomenclature, that's white coat hypertension. So those are people who are not treated for hypertension and there's various terms that are used in the literature.

But the one that I see most commonly patients who are treated is a white coat effect. So those are people who are, have a blood pressure it's above their treatment goal in the office, but below their treatment goal at home. So that's why is it's very common. It's prevalent and probably about 10 to 25% of the general population.

Um, and what I would say is that. Blood pressure in the office.

That's elevated because you didn't measure using the recommended technique is not like what hypertension, right? That is. I don't think there's a term for that, but That's not going up. Attention is white coat. Hypertension is when you are measuring your blood pressure in a stringent way the office and getting multiple values over time.

And yet that is still higher than the threshold, whereas their blood pressure at home is below threshold. So, you know, I mentioned before the kind of one 60 over a hundred or greater unlikely to be pure white coat hypertension. Um, and then I think in terms of what else to do about it, um, other kinds of clues are that people who have no hypertension mediated end organ damage like retinopathy or left ventricular hypertrophy or.

Uh, renal insufficiency or, uh, proteinuria, uh, and yet their blood pressure is high. So it's not as a rule. It's not that everyone with hypertension develop those things, but if they don't have those things and their blood pressure in the office is so high, you might wonder, are they really hypertensive at home?

Um, there is kind of debate about whether or not it is associated with cardiovascular risk. Um, but there are certainly not randomized controlled trial data saying that treating white coat hypertension per se, is something that has benefits to patients. And so we tend not to treat it the only kind of extra point that I'd add is that people with white coat hypertension are not people that you want to kind of say, or sort of exonerates like your blood pressure is normal at home. I don't need to see you for another year or ever, right? Because they have a higher risk than the general population of normotensive people of progressing to sustained hypertension, meaning blood pressure, that's high in the office and at home. And that risk is about one to 5% per year. And so the U S guidelines recommend that you do some type of, out of office measurement in those patients about once a year to catch the people who you think are progressing to sustain hypertension.

[00:33:56] Josh: You know, it's interesting. Cause a lot of patients bring up that they might have white coat hypertension.

And maybe like in our heads we might think like, okay, you know, is this really as common as some patients are making it out to be, but surprisingly, it is actually quite common among the general population up to 10 to 15% of folks in the general population might have white coat hypertension. Now, granted with a caveat that it's only diagnosed if the blood pressure is being measured accurately, we're talked about what that accurate measurement looks like earlier.

Um, so I, I think it's also important to know that once someone's diagnosed with white coat hypertension, accurately, Off the hook, just because their blood pressure is fine at home. You know, these are folks that are at higher risk of actually progressing to regular hypertension, which then puts them at higher risk of developing, cardiovascular events, and increased mortality in the future. So it's very important that we keep a close eye on these folks.

Outro

[00:34:54] Maisie: in medicine we often make sure that we're doing our best to treat the whole patient by reminding ourselves to not just treat abnormal lab values or other Uh, really interpreted things in the context of an individual circumstance, uh, knowing that people are multidimensional their stressors and various other things in their lives that are behind those numbers that they really should be thought about in the broader clinical context.

[00:35:19] Josh: For sure. Hypertension presents a really unique opportunity because we talk a lot in medicine about how it's so important to treat the whole person and it really is. Hypertension is a little unique in that it's one of the areas where we're really are just treating a number, um, it ends up being so important to get that number, right. Uh, obviously we're still taking into account other things like the patient's age, you know, what other medical conditions they might have that might affect 

their blood pressure or their ability to tolerate certain medications, um, But for the most part, our goal is really trying to bring a number down into a goal to try to help our patients stay as healthy as possible for as long as possible.

So that's why getting these accurate measurements is so, so critical. And if you're going to start a medication for a patient, it's really important to know that the data you're basing that decision on is accurate.

[00:36:15] Maisie: my gosh, all this talk about high blood pressure has me a little overwhelmed. I hope I'm measuring blood pressure the right way and making accurate diagnoses.

[00:36:25] Josh: It's okay. Maisie. I mean, given how prevalent high blood pressure is, I think it's good that you're always keeping this in mind when thinking about a patient's care. Since we've covered a few important things, let's recap some of these learning points, so it doesn't feel so overwhelming. What can we take away from this episode?

So using the ACC aha 2017 guidelines for the diagnosis of hypertension can be a helpful way to categorize patients into either normal pre hypertension stage one or stage two hypertension. 

It's also important to be able to recognize hypertensive urgency in the clinic and know how to triage appropriately. As we have learned, if patients have no signs of end organ damage, this is often something that can be treated in the outpatient setting without need for ER visits. It is a critical time for primary care based intervention that can provide long lasting benefits for patients. 

Measuring blood pressure correctly is a key part in making the diagnosis of hypertension. It can involve both in visit and at home blood pressure readings in order to clarify the diagnosis and to help recognize other entities such as white coat hypertension.

Be sure to tune in next time, to catch part two in our three part series, where we'll introduce you to methods of treating high blood pressure, such as lifestyle changes and medications. 

[00:37:48] Maisie: And that concludes our episode for today. We hope you enjoyed this episode, which was made possible by contributions from our patient tailor Dr. Kevin Wheelock, who served as our resident interviewer And Dr. Ben Gallagher, who served as our faculty expert and provided peer review for the project special, thanks to our producers, Madison Swallow August Allocco, Helen Cai and Dr. Joshua Onyango, as well as our faculty advisor, Dr. Katie Gielissen be sure to follow us at PC pearls on Instagram, where you can expect to get sneak, peeks, additional learning content and the most up-to-date details on show release times. 

If you enjoyed this episode, please share with others who are excited about primary care or friends. Who'd like to learn more about the health conditions we discussed today. Thank you for joining us farewell from all of us at the primary care pearls podcast. We'll catch you in the next one.