Extreme white-coat effect in a healthy runner?

Medical Q&A [Moderated]
1

Hello Drs. Baraki and Feigenbaum,

I have a bit of a situation that has my primary care doc and I scratching our heads. I’m 42yo/5’1/125lbs male who established care with a PCP about 3 years ago after going my entire 20s and 30s without seeing a doctor. My overall health was pretty good: I had no specific medical complaints and my lipids, weight, and a1c all came back normal. I was expecting this, as I’d been an avid runner for 15 years and have never had an issue with weight or other cardiovascular vices like smoking or alcohol use.

However, my BP was alarmingly high, at 160/86, so I was prescribed a monitor and told to keep an eye on it. My home readings were consistently between 120s/60s and 130s/70s at most, which seemed to satisfy my previous PCP and kept him from prescribing any medications.

I upped my running routine since then, hitting about 15 miles per week and started participating in more organized races and local events. My home BP readings were still in the 120s/60s and blood chemistry remained normal, but every office visit returned scary pressures in the 160s/80s to 170s/90s. For what it’s worth, throughout this whole period my conscious resting heart rate always held in the low 40s (sometimes dipping into the high 30s during peak racing season) but would jump into the 80s in the doctor’s office.

Fast forward to this past summer when I saw a new PCP and hit my all-time high office BP of 201/92, earning me an amlodipine 5mg prescription on the spot. At my follow-up 2 months later my home readings didn’t budge much (still 120s-130s/60s-70s) and my office numbers were 190/91 and 184/89, so I was started on valsartan 160mg and tested for proteinuria, aldosteronism and pheochromocytoma, all of which came back clean.

So, any idea on what I’m dealing with here? Supposedly my office numbers are too high to be written off as mere white-coat hypertension, and according to my doctor my diet and lifestyle should be giving me pressures in the 90/60 range. I don’t have any history of anxiety disorders, and neither side of my family has a history of early CV issues, but both of my parents were diagnosed with hypertension later in life.

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RyMan600,

Sorry for the delay here. This question is a bit beyond what we can do on the forum, as would require additional discussion of your medical history, testing, goals, and so on. For that, a consultation is likely best.

I am happy to see that you appear to be getting worked up for other causes of high blood pressure. It’s also reassuring they are negative so far. One thing I didn’t catch is if you’ve been doing ambulatory blood pressure monitoring in addition to the home reading. There is no upper limit on white coat hypertension per se, tough > 200 does seem like an error. If the BP is so concerning and your home readings are not being used for management, ambulatory monitoring seems like the next step along with other testing.

As you probably know, there are a number of other secondary causes of high blood pressure, including sleep apnea, issues with the kidney’s blood supply, and more. Ruling those out while limiting exposure to elevated/high resting blood pressure would be the goal. I don’t have a good sense of what your resting blood pressure is right now, so I can’t weigh-in further.

-Jordan