Patients who have a high blood pressure reading during a provider visit but a normal reading outside the office may suffer from white coat syndrome (also known as white coat hypertension). With this condition, a patient’s blood pressure spikes in a provider’s office, which can result in an inaccurate diagnosis.

White coat syndrome, so named for the white coats often worn by providers in a clinical setting, is thought to be triggered by patient anxiety over a medical appointment, as well as a reaction to the application and inflation of the blood pressure cuff. The actual cause of white coat syndrome is unclear, but patients most prone to the condition may be those with a history of anxiety disorders and/or those who generally feel anxious about their health, have had negative experiences in the medical system, are elderly, and do not visit their primary care provider regularly.

White coat syndrome or hypertension?

Distinguishing white coat syndrome from hypertension can be challenging since it is difficult to capture an accurate blood pressure reading for these patients in a clinical setting. According to the Cleveland Clinic, white coat syndrome affects 15 to 30 percent of adults who have high blood pressure. However, those without high blood pressure can experience it as well. Each year, 5 percent of patients with white coat syndrome receive a hypertension diagnosis.

Studies suggest that adults with white coat syndrome may be at higher risk for developing sustained hypertension over time compared to those with normal blood pressure. Therefore, the American Heart Association recommends closely monitoring those diagnosed with white coat syndrome.

Taking multiple readings, both at the patient’s preventive care visits and at home, to get a reliable baseline is helpful. Patients can use at-home or ambulatory blood pressure monitors that provide regular measurements over a 24-hour period. This maps overall blood pressure levels and offers a more complete picture of the patient’s condition.

Note: It’s imperative that blood pressures are measured using validated blood pressure monitors and appropriate technique.

Why it Matters

Poorly controlled hypertension is a major contributor to many other chronic conditions, disability and death in senior patients: heart attack, heart failure, and stroke. The latest guidelines from the American College of Cardiology and the American Heart Association (ACC/AHA) define normal blood pressure and high blood pressure using the same ranges for all adults, regardless of age or gender.

The ACC/AHA guideline recommends treatment to a BP target of <130/80 mm Hg for many patients. According to the AHA, a systolic blood pressure reading of 130-139/80-89 mm Hg is considered stage 1 hypertension, and a reading of > 140/90 mm Hg is considered stage 2 hypertension. ^[1]

^[1] 2023 ESH Hypertension Guideline Update: Bringing Us Closer Together Across the Pond – American College of Cardiology (acc.org)

Reducing risk

Current recommendations on the management of white coat syndrome include intensive lifestyle modifications and cardiovascular risk reduction, including moderate salt restriction, weight reduction, regular exercise, and smoking cessation. Monitoring and managing comorbid conditions such as diabetes and hyperlipidemia, if present, are essential aspects of overall cardiovascular risk reduction as well.

Educating patients about the nature of white coat syndrome and the importance of regular monitoring can alleviate anxiety and improve adherence to monitoring protocols. Also, addressing underlying anxiety and providing strategies such as relaxation techniques may help reduce the frequency and severity of white coat syndrome episodes.

Coverage for self-measured blood pressure

Cigna Healthcare^SM coverage policies were recently updated to include patients self-monitoring their blood pressure. Providers whose plan of care includes patients monitoring their blood pressure at home can now submit claims for self-measured blood pressure patient education, device calibration, and monitoring. 

Resources

Following are several resources to educate you and your patients about white coat syndrome:

• Learn more about best practices for controlling hypertension, accurate coding and documentation, and common billing codes on the Controlling High Blood Pressure resource page on the Cigna for Health Care Professionals website (CignaforHCP.com).
• Access the updated Preventive Care Services coverage policy at CignaforHCP.com.
• Patient education is available on the Wellness Library page at Cigna.com.
• Access blood pressure education, webinars, and more on the Target: BP website, a national initiative created by the American Heart Association and the American Medical Association that focuses on blood pressure improvement, self-measured blood pressure, patient education, and data collection.

1 White Coat Syndrome (ClevelandClinic.org)

2 Measurement of Blood Pressure in Humans: A Scientific Statement From the American Heart Association (National Library of Medicine)

3 White-coat hypertension (National Library of Medicine)