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WHITE COAT syn­drome

Does your blood pres­sure soar when you see a doc­tor? It could mean your op­er­a­tion is can­celled thanks to . . .

- By ADRIAN MONTI Health · Medicine · Health Conditions · Blood Disorders · Gillingham · Greece · Blood Pressure · Strood · Imperial College London · Gillingham

Tom macdon­ald would de­scribe him­self as pretty laid back — un­less, that is, he sees the doc­tor. Then, sud­denly, he starts to trem­ble and his blood pres­sure soars. ‘Be­fore I re­tired as a de­liv­ery driver’s as­sis­tant, I would be un­der pres­sure all day, cop­ing with traf­fic and long jour­neys to make sure we were on time,’ says Tom, 64, a grand­fa­ther of four. ‘But I never got stressed with work. Yet med­i­cal set­tings made me ex­tremely anx­ious.’

This didn’t pose a prob­lem un­til ten years ago when Tom de­vel­oped an um­bil­i­cal her­nia, where part of the bowel squeezes through a weak spot in the mus­cles of the ab­dom­i­nal wall, caus­ing a lump un­der the skin.

‘This lump came out of my belly but­ton and grew to the size of a ta­ble ten­nis ball,’ re­calls Tom, who is mar­ried to mar­garet and lives in Strood, Kent. ‘It wasn’t painful, but looked very ugly.’

His GP re­ferred Tom to a spe­cial­ist. although not con­sid­ered urgent, if left un­treated, a her­nia can cause com­pli­ca­tions, such as cut­ting off the blood sup­ply to part of the bowel.

Re­pair­ing a her­nia with mesh to strengthen the mus­cle wall is a rou­tine 30-minute pro­ce­dure per­formed un­der gen­eral anaes­thetic.

How­ever, Tom’s anx­i­ety cre­ated prob­lems. ‘When I had my blood pres­sure taken in hos­pi­tal, the con­sul­tant told me that I wouldn’t be able to have the surgery be­cause it was so high,’ he says. ‘There was a risk I could die in theatre.’

a nor­mal blood pres­sure read­ing is be­tween 90/60mmHg and 120/80mmHg.

High blood pres­sure, oth­er­wise known as hy­per­ten­sion, is a read­ing of 140/90 or higher. Tom’s read­ings were over 155/90.

Surgery for pa­tients with high blood pres­sure can be risky be­cause af­ter a pa­tient has been given an anaes­thetic, their blood pres­sure can dra­mat­i­cally rise be­fore crash­ing very low, de­pend­ing on the anaes­thetic used.

These rapid swings are closely mon­i­tored by the anaes­thetist, but for pa­tients with hy­per­ten­sion such swings are more likely to cause a heart at­tack or stroke.

But when Tom’s blood pres­sure was later taken by his GP, a doc­tor he had known for many years, the top num­ber (the pres­sure in the blood ves­sels when the heart con­tracts, known as the sys­tolic read­ing) fell to be­low 140 — high, but not high enough to pre­vent surgery.

on another visit, how­ever, he saw a locum GP — a stranger — and his blood pres­sure was recorded at just un­der 200.

‘I was told to go home, and if it hadn’t re­duced by the time I came back, I’d be ad­mit­ted to hos­pi­tal and given drugs to lower my blood pres­sure,’ says Tom. HE USED a DIY mon­i­tor he had pre­vi­ously bought to mea­sure his blood pres­sure at home, where it fell to a more ac­cept­able level.

‘Soon af­ter­wards, I saw my usual GP who di­ag­nosed me with “white coat syn­drome”. He ex­plained it’s when see­ing a doc­tor or be­ing in a hos­pi­tal causes your blood pres­sure to rise even if it is usu­ally nor­mal, or close to it.’

It can mean a pa­tient is wrongly di­ag­nosed with hy­per­ten­sion — or in Tom’s case, deemed un­suit­able for surgery.

In 2016, GPs were given new guide­lines in a bid to re­duce the 1 per cent of NHS op­er­a­tions can­celled at short no­tice due to hy­per­ten­sion.

The rec­om­men­da­tions said doc­tors should re­fer pa­tients for non- emer­gency surgery only if they have an av­er­age blood pres­sure read­ing of be­low 160/100 over the pre­vi­ous 12 months.

‘as many as one in four peo­ple may have white coat syn­drome,’ says Peter Sever, a pro­fes­sor of clin­i­cal phar­ma­col­ogy and ther­a­peu­tics at Im­pe­rial col­lege lon­don and for­mer pres­i­dent of the Bri­tish Hy­per­ten­sion So­ci­ety.

‘The dif­fer­ence be­tween a doc­tor or nurse record­ing blood pres­sure com­pared to a pa­tient do­ing it at home can be as much as 40 or 50mmHg — and that can make a huge dif­fer­ence. The main dif­fi­culty with white coat syn­drome is it only oc­curs in a clin­i­cal set­ting, which means you can’t re­ally treat it,’ adds Pro­fes­sor Sever.

‘You can’t send a pa­tient away with tablets be­cause once they get home and take them, their blood pres­sure is go­ing to fall through the floor. It is a big prob­lem when it leads to op­er­a­tions be­ing can­celled, cost­ing time and money to the NHS.’

He said sep­a­rate guide­lines for anaes­thetists also al­low pa­tients to have surgery if their ‘real’ blood pres­sure is be­low 160/100.

The good news is that many peo­ple do gain con­trol over the syn­drome; knowl­edge can make a dif­fer­ence. ‘ With some peo­ple, if they know they have it, they do seem to be able to take some con­trol over it and it can im­prove,’ says Pro­fes­sor Sever.

‘If white coat hy­per­ten­sion is sus­pected, we leave a pa­tient in a quiet room for 15-20 min­utes, dur­ing which time their blood pres­sure is au­to­mat­i­cally mon­i­tored.

‘This helps to iden­tify pa­tients whose blood pres­sure goes up in the pres­ence of doc­tors and nurses.’

many hospi­tals now have strate­gies to tackle the prob­lem of white coat syn­drome by deal­ing with pa­tient anx­i­ety. They in­clude the Will adams NHS Treat­ment cen­tre in Gilling­ham, Kent, where Tom fi­nally had his her­nia re­paired ear­lier this year.

Pre­vi­ously, both an NHS and pri­vate sur­geon had said his blood pres­sure was too high and, thus, too risky to un­dergo surgery.

‘I’d ap­proached a pri­vate hos­pi­tal about hav­ing the op­er­a­tion four years ago, but de­spite los­ing 5st to help more gen­er­ally with my blood pres­sure, I was again told it was too high for me to un­dergo surgery,’ says Tom.

‘I was dis­ap­pointed, as I was be­com­ing more aware of the lump stick­ing out from my tummy.’

af­ter a friend sug­gested he try the Will adams hos­pi­tal, he con­tacted them ear­lier this year.

‘un­like at the other two hospi­tals, they tried to help me stop be­ing so anx­ious.’

one of the sur­geons at the hos­pi­tal, nu­rul ahad, says: ‘We ac­cept no one re­ally likes com­ing into hos­pi­tal. So we ar­range an ex­act time slot for their ap­point­ment with­out much de­lay, in­vite them to wait in a more pri­vate wait­ing room and see the same faces at each ap­point­ment rather than lots of dif­fer­ent med­i­cal staff.

‘Be­ing dealt with by the same staff rather than lots of dif­fer­ent faces seems to help.

‘We tell them what they need to know, but do not linger on the po­ten­tial com­pli­ca­tions, which again might make them anx­ious.

‘We fo­cus on tak­ing away what is caus­ing the anx­i­ety with lit­tle things we can con­trol.’ SUC­CESS isn’t guar­an­teed, he ad­mits. ‘I did have one pa­tient re­cently who was very re­sis­tant to ev­ery­thing we tried, and we re­luc­tantly had to can­cel her elec­tive surgery twice. But usu­ally, man­ag­ing the anx­i­ety is ef­fec­tive.’

In June, Tom’s GP surgery lent him a 24-hour mon­i­tor­ing de­vice to use at home. His blood pres­sure read­ing was of­ten be­low 140, mean­ing he was safe to be op­er­ated on. ‘ The first record­ing at home was 153/93, but dur­ing that day they were mostly in the 130s,’ says Tom. ‘ my low­est read­ing was 126/83.’

The con­clu­sion was that white coat syn­drome had been the cause of his read­ings, so surgery was pos­si­ble.

on the day of his op­er­a­tion in July, he says he felt calm.

‘I asked my con­sul­tant not to give me any de­tails of how the op­er­a­tion is done. and one of my fears was of be­ing wheeled into the op­er­at­ing theatre, so in­stead I walked in, which helped. my blood pres­sure was slightly raised, but safe be­fore I had the anaes­thetic.’

The surgery was suc­cess­ful and Tom went home later the same day. life has im­proved as a re­sult. ‘I’ve been on hol­i­day to Greece and felt much bet­ter by the pool — not em­bar­rassed,’ he says.

‘I now un­der­stand what was mak­ing my blood pres­sure rise, which has helped. I can’t say if I have to­tally over­come my fears, but it’s a huge relief know­ing how to ease my anx­i­ety.’

 ?? Pic­ture: ALAMY ??
Pic­ture: ALAMY

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