EFFECTS OF BLOOD-PRESSURE MEASUREMENT BY THE DOCTOR ON PATIENT'S BLOOD PRESSURE AND HEART RATE

doi:10.1016/S0140-6736(83)92244-4

The Lancet

Volume 322, Issue 8352, 24 September 1983, Pages 695-698

https://doi.org/10.1016/S0140-6736(83)92244-4 Get rights and content

Abstract

Changes in blood pressure in 10 or 15 min periods during which a doctor repeatedly measured blood pressure by the cuff method were monitored by a continuous intra-arterial recorder. In almost all the 48 normotensive and hypertensive subjects tested the doctor's arrival at the bedside induced immediate rises in systolic and diastolic blood pressures peaking within 1 to 4 min (mean 26·7±2·3 mm Hg and 14·9±1·6 mm Hg above pre-visit values). There were large differences between individuals in the peak response (range, 4-75 mm Hg systolic and 1-36 mm Hg diastolic) unrelated to age, sex, baseline blood pressure, or blood-pressure variability. There was concomitant tachycardia (average peak response 15·9±1·5 beats/min, range 4-45 beats/min) which was only slightly correlated with the blood-pressure rise. After the peak response blood pressure declined and at the end ofthe visit was only slightly above the pre-visit level. A second visit by the same doctor did not change the average size of the early pressor response or the slope of its subsequent decline.

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Cited by (755)

Effet blouse blanche résiduel: un outil pertinent en soins premiers?
2024, Annales de Cardiologie et d'Angeiologie
White coat effect (WCE) and white coat hypertension (WCH) are hardly both compared in primary care.
To assess the usefulness of repeated measures of systolic blood pressure (SBP) to dissociate various forms of white-coat interactions.
An open cross-sectional study on consecutive patients treated or not for high blood pressure was made in family physicians’ offices. SBP was measured 5 times by an electronic device. Measurements were performed before (SBP1) and after (SBP5) the office visit by a lay assistant and at the beginning (SBP2), middle (SBP3) and end (SBP4) of visit, by the family physician. Home BP (HBPM) was measured from 3 consecutive days by the patient. WCE and office WCE tail (OWCET) were defined, respectively, as a 10 mmHg SBP increase or decrease between SBP2-SBP1 or SBP4-SBP2. WCH was considered when HBPM was normal (SBP < 135 mmHg) at home and high during the SBP2 office visit.
Two hundred five patients (134 women versus 71 men, ratio 1.9, aged 59.8±15.7 years) were recruited. In categorical terms, there were 51 patients (25%) who presented with WCE, OWCET was seen in 121 patients (62%) and 47 patients (23%) had WCH. Only 36 patients (18%) presented both OWCET and WCE and 32 (16%) had both OWCET and WCH. The receiver operating characteristic curves (ROCs) of OWCET in diagnosing WCE or WCH were respectively 0.67 (p<0.0001) and 0.53 (NS).
Thus, OWCET was predictive of WCE and not of WCH and it is worthwhile to be measured in the family physician office.
L'effet blouse blanche (EBB) et l'hypertension blouse blanche (HBB) sont rarement comparés en soins premiers.
Étudier l'utilité de mesures répétées de pression artérielle systolique (PAS) afin de dissocier les différentes formes d'EBB.
Une étude transversale, ouverte, sur des patients consécutifs, traités ou non pour une hypertension artérielle a été réalisée au sein de plusieurs cabinets de médecine générale. La PAS a été mesurée à 5 reprises par un tensiomètre électronique. Les mesures ont été réalisées avant (PAS1) et après (PAS5) la consultation par un assistant ainsi qu'au début (PAS2), au milieu (PAS3) et à la fin (PAS4) de la consultation, par le médecin généraliste. Des automesures tensionnelles (AMT) ont été réalisées durant 3 jours consécutifs pour chaque patient. L'EBB et l'effet blouse blanche résiduel (EBBR) ont été définis, respectivement, comme une augmentation ou une diminution de 10 mmHg de PAS entre PAS2–PAS1 ou PAS4–PAS2. L'HBB a été considérée lorsque les AMT étaient normales (PAS < 135 mmHg) à domicile et élevée lors de la PAS2 de la consultation.
Deux cent cinq patients (134 femmes versus 71 hommes, ratio 1,9, âge 59,8 ± 15,7 ans) ont été inclus. Il y avait 51 patients (25 %) qui présentaient un EBB, un EBBR a été constaté chez 121 patients (62 %) et 47 patients (23 %) avaient une HBB. Seulement 36 patients (18 %) présentaient un EBBR et un EBB et 32 (16 %) avaient à la fois un EBBR et une HBB. Les courbes ROC de l'EBBR pour le diagnostic de l'EBB et de l'HBB étaient respectivement de 0,67 (p<0,0001) et 0,53 (NS).
L'EBBR était prédictif de l'EBB mais pas de l'HBB. Il doit être systématiquement mesuré en soins premiers.
Noninvasive assessment of pressure distribution and fractional flow in middle cerebral artery using microbubbles and plane wave in vitro
2024, Ultrasonics
Fractional flow has been proposed for quantifying the degree of functional stenosis in cerebral arteries. Herein, subharmonic aided pressure estimation (SHAPE) combined with plane wave (PW) transmission was employed to noninvasively estimate the pressure distribution and fractional flow in the middle cerebral artery (MCA) in vitro. Consequently, the effects of incident sound pressure (peak negative pressures of 86–653 kPa), pulse repetition frequency (PRF), number of pulses, and blood flow rate on the subharmonic pressure relationship were investigated. The radio frequency data were stored and beamformed offline, and the subharmonic amplitude over a 0.4 MHz bandwidth was extracted using a 12-cycle PW at 4 MHz. The optimal incident sound pressure was 217 kPa without skull (sensitivity = 0.09 dB/mmHg; r² = 0.997) and 410 kPa with skull (median sensitivity = 0.06 dB/mmHg; median r² = 0.981). The optimal PRF was 500 Hz, as this value affords the highest sensitivity (0.09 dB/mmHg; r² = 0.976) and temporal resolution. In addition, the blood flow rate exhibited a lesser effect on the subharmonic pressure relationship in our experimental setup. Using the optimized parameters, the blood pressure distribution and fractional flow (FF_s) were measured. As such, the FF_s value was in high agreement with the value measured using the pressure sensor (FF_m). The mean ± standard deviations of the FF difference (FF_m − FF_s) were 0.03 ± 0.06 without skull and 0.01 ± 0.05 with skull.
Ambulatory blood pressure monitoring. Current status and future perspectives
2024, Medicina Clinica
La monitorización ambulatoria de la presión arterial (MAPA) permite obtener una medida más exacta y fiable de este parámetro. Los valores observados en los periodos de 24 horas, diurno y nocturno se correlacionan mejor con la morbimortalidad cardiovascular, comparados con la presión clínica. La presión nocturna es el estimador con una relación más estrecha con el riesgo. La MAPA complementa a la medida clínica y, además de los valores medios de presión, permite definir los fenotipos de hipertensión de «bata blanca» (WCH) y de hipertensión enmascarada, cuando hay discordancia en la normalidad de las cifras de presión clínica y la obtenida por MAPA. Otros elementos de interés se refieren a la variabilidad de los valores de presión durante el periodo de monitorización, incluyendo el descenso nocturno, el incremento matutino o la inestabilidad de estos, evaluada mediante la desviación estándar o el coeficiente de variación.
Ambulatory Blood Pressure Monitoring (ABPM) is considered the best method for obtaining a reliable estimation of the true blood pressure. Average values obtained during the whole 24-hour period, or during daytime and nighttime periods are better correlated with the risk of mortality and cardiovascular disease compared to clinic or office blood pressure. Indeed, nighttime blood pressure, a measure only obtained through ABPM, is the most powerful risk predictor. ABPM is complementary to clinic blood pressure measurement and allows the definition of blood pressure phenotypes, such as “white-coat or masked hypertension, when clinic and ABPM measurements show discrepancy in normal values. Additional potentially relevant features include blood pressure variability, such as nocturnal blood pressure decline, morning surge or short-term variability, as determined by standard deviation or the coefficient of variation.
Resting heart rate, self-reported physical activity in middle age, and long-term risk of hip fracture. A NOREPOS cohort study of 367,386 men and women
2023, Bone
Citation Excerpt :
Resting heart rate was measured only at one point in time, at enrolment into the study. This measurement could have been affected by inadequate rest prior to measurement and the “white coat effect” [52,53]. Furthermore, self-reported physical activity is flawed because people tend to overestimate their leisure-time physical activity when reporting moderate levels of physical activity, which also could explain why self-reported physical activity in leisure time was only weakly associated with resting heart rate, in line with previous studies [20].
Enhanced knowledge regarding modifiable risk factors for hip fractures are warranted. We aimed to study the associations between two indicators of physical fitness (resting heart rate and level of physical activity) in middle-aged individuals, and the risk of hip fractures during the subsequent three decades. Data on objectively measured resting heart rate and self-reported leisure time physical activity from a national health survey (1985–1999) was linked to a database including all hip fractures treated in Norwegian hospitals from 1994 through 2018. We calculated hazard ratios (HR) with 95 % confidence intervals (95 % CI) for hip fractures according to categories of resting heart rate (mean of two repeated measures), and leisure time physical activity level in adjusted Cox proportional hazard models. In total, 367,386 persons (52 % women) aged 40 to 45 years were included, of whom 5482 persons sustained a hip fracture during a mean follow-up of 24.8 years. Higher resting heart rate was associated with higher hip fracture risk. Men with a resting heart rate above 80 bpm, who also reported low levels of physical activity, had a HR of 1.82 (95 % CI 1.49–2.22) for hip fracture compared to men with a resting heart rate below 70 bpm who reported high levels of physical activity. The same measure of association for women was 1.62 (95 % CI 1.28–2.06). Physical fitness measured by low resting heart rate in middle age, and a high physical activity level were associated with a lower long-term risk of hip fractures in both men and women.
Criteria for White-Coat and Masked Hypertension Diagnosis
2023, Hypertension: A Companion to Braunwald's Heart Disease
A proper assessment of blood pressure (BP) values requires the combined use of office BP and out-of-office BP measurements including 24-hour ambulatory BP monitoring and home BP monitoring. In clinical practice, substantial discrepancies between BP values provided by out-of-office BP monitoring and by office BP measurements are frequently observed, leading to identification of “white-coat” hypertension (WCH) when office BP is elevated but out-of-office BP levels are within normal limits, and “masked” hypertension (MH), when office BP is normal, but out-of-office BP levels are elevated. In treated hypertensive subjects, these discrepancies may continue to be present even after initiation treatment, and take the name of “white-coat resistant” hypertension (WCRH), when office BP values remain uncontrolled despite normalized out-of-office BP during treatment, and “masked uncontrolled” hypertension (MUCH) when out-of-office BP values remain uncontrolled despite normalized OBP values. The growing awareness on the prognostic significance of MH and WCH (which in the case of MH may indeed be very similar to that of sustained hypertension) has led current international guidelines to more strongly support the use of ambulatory and home BP monitoring for the diagnostic approach of these conditions. This chapter will review contemporary definitions of MH and WCH in untreated and treated individuals, with emphasis on their clinical significance for cardiovascular prognosis, as well as on the diagnostic and management approach to these conditions.
The authors reply
2022, Kidney International

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EFFECTS OF BLOOD-PRESSURE MEASUREMENT BY THE DOCTOR ON PATIENT'S BLOOD PRESSURE AND HEART RATE

Abstract

Factors determining the design and construction of a portable pressure transducer system

Postgrad Med J

The Oxford continuous blood pressure recorder

Postgrad Med J

Blood pressure and heart rate variability at normal and high blood pressure

Blood pressure variability: its relation to high blood pressure, age and baroreflex sensitivity

Clin Set

Five-year findings of the hypertension detection and follow-up program

JAMA

The Australian therapeutic trial in mild hypertension

Lancet

Blood pressure determinations in patients with essential hypertension. The difference between clinic and home recordings before treatment

Am J Med Sci

The discrepancy between home and office recordings of blood pressure in patients under treatment with pentapirrolidinium: importance of home recordings in adjusting dosage

Med Ann DC

Relationship between level of blood pressure measured casually and by portable recorders and severity of complications in essential hypertension

Circulation