Set It and Forget It: My Successful First Use of Ambulatory Blood Pressure Monitoring

Fritz Daum kept bringing in erratic and disappointing blood pressure logs, always too high but never the same. His office readings were the same way. He was clearly worried and also quite probably disappointed in my therapeutic skills; most medications I prescribed did little for his blood pressure control, and many had unpleasant side effects.

We got access to continuous blood pressure monitoring two years ago, but I hadn’t ordered it before. I made Fritz my first patient to use it. The result was illuminating. The first and last two hours’ readings were high. In fact, the tracing started high and gradually normalized over a couple of hours, and the last two hours before the monitor was removed showed a steady rise in his blood pressure.

It seems Fritz gradually stopped thinking about his blood pressure, since the machine was doing it for him. Then, as he got ready to drive to the clinic to have the leads removed and the monitor disconnected, he probably started wondering what the recording would show.

So, now I know what he has: not white coat hypertension, but anticipatory hypertension. White coat hypertension has been re-evaluated and my medical school teaching disproven, see below, but what do we know about anticipatory hypertension?

I found a few articles about this. A 1996 article in Hypertension looked at blood pressure seated on an exercise bicycle just before starting a session, compared with at rest one week earlier. It showed that “men showing systolic responses greater than or equal to 30 mm Hg or diastolic responses greater than 15 mm Hg [had] nearly four times the risk of becoming hypertensive.”

A 2018 article in the Journal of Hypertension describes an anticipatory rise in blood pressure before self measurement “that remains present after multiple BP readings”.

I’m not sure whether anything needs to be done with Fritz, my frequent checker. My inclination is not to prescribe more medications, including for blood pressure anxiety, but to see where his office readings land if I can get him to stop checking his own blood pressure at home for a while.

A Country Doctor Reads: August 10, 2019 – High Blood Pressure is High Blood Pressure, No Matter Where or When

Patient: “Another Doctor Said Keto Was Bad For Diabetics” – Me: “Let Me Tell You the Story of the Flex Fuel Man”

“There is confusion and disagreement about diet, or should we say FOOD CHOICES, when you have Type 2 Diabetes”, I admitted. “But I’ve done my reading. I have had my own experience losing weight giving up being a vegetarian. And I have over 40 years of experience with diabetic patients – and curing some.”

These numbers illustrate what happened 2016-2017 when a diabetic patient of mine took my Flex Fuel talk to heart and drastically cut the carbs in his diet. We did not change his medications during this time – it was all because of his food choices.

A Flex Fuel Man

Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.



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