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.
