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Hypertension, Work and White Coat Syndrome

Within occupational health some employees need to undergo safety critical, fork-lift truck or driver medicals to ensure they are fit for the role they undertake. During the above medicals the OH clinician will take the individual blood pressure (BP), to determine whether an individual has high blood pressure or not, this is important as individuals who have high blood pressure are more likely to have a heart attack or stroke.


The blood pressure reading consists of 2 numbers, the systolic pressure is a measure of the pressure on the blood vessels at its highest, during contraction and the diastolic pressure is a measure of the pressure on the blood vessels when it is at its lowest, at rest (in between heart beats), both are vital indicators of an individual’s cardiovascular health.


The BP reading is normally represented as 120/80 where the 120 is the systolic pressure and the 80 is the diastolic pressure, it is measured in millimetres of mercury or mmHg, i.e. 120/80 mmHg, although these units are often omitted when written down.


Most individuals who attend OH and have their BP taken as part of any OH medical will generally have a BP below 140/90, which is considered normal. However, a BP reading of more than 140/90, may be indicative of high blood pressure and chronic disease and in these cases the clinician will need to take the individuals blood pressure several times to see if it falls below 140/90. They may encourage the individual to take deep breaths, close their eyes and try to relax as they do this.


In situations where an individual’s BP remains over 140/90 during the medical then it will be necessary for clinician to reduce the timescale for which the medical is valid to 1-month, if a BP reading below 140/90 is obtained during this period, then the validity will be returned to the appropriate duration for the individuals age (generally 1 – 3 years).


Individuals with a raised BP above 140/90 are advised to speak with their GP, and obtain evidence of a normal BP reading, or that they are now under the care of their GP i.e. commenced on prescribed anti-hypertensive medication, this should be sent to Insight Workplace Health (IWH) as soon as reasonably practicable, ideally within 1 month.


IWH will require any evidence of a normal BP to clearly show the individuals, name, date of birth, the blood pressure reading(s) and/or medication prescribed along with the name of the clinician taking the BP and the name of the GP practice*.


*IWH recognise that in some cases these tasks may be delegated to healthcare workers, practice nurses or associated pharmacies etc. In such cases the name and role of the clinician and the name of any clinic or pharmacy should be clearly noted.


For BP readings between 140/90 and 180/100 no workplace restrictions are required to be put in place, other than reducing the validity to 1 month (as above). However, where BP readings are noted as being greater than 180/100 then the individual will be advised to speak with their GP or local hospital (A&E) ideally within 7 days, AND it will be necessary for restrictions to individuals working activities to be put in place until evidence of improved BP readings have been obtained.


Where a BP reading is above 180/100 the individual will need to be restricted from the following: safety critical work, working at height, confined space work, lone working and from driving Group 2 vehicles. Where individuals have attended an OH appointment in a works vehicle they should check with their employer before driving any works vehicle. Where an employer has alternative, non-safety critical duties available the individual may be able to remain in work.


For BP readings greater than 200/110 (severe hypertension) the OH medical will not be completed, individuals will be advised to speak with their GP or local hospital (A&E) IMMEDIATELY, and their line managers will be advised as necessary. In such cases an individual’s GP may need to provide a fit note for the individual until such time as their BP is better controlled, often with the use of prescribed medication, which may take a few weeks.

 

White Coat Hypertension (Syndrome)


Some individuals may have been advised by their GP that they have a phenomenon known as white coat syndrome (WCS), which will raise their blood pressure artificially, often due to the stress associated with being in a clinic or hospital, as such BP readings may be higher than if taken at home.


WCS is defined by the National Institute for Health and Care Excellence (NICE)

“Blood pressure that is unusually raised when measured during consultations with clinicians but is normal when measured in 'non-threatening' situations. It is reported to occur in about 15–30% of the population. A 'white-coat' effect is defined by NICE as a discrepancy of more than 20/10 mmHg between clinic and average daytime BP measurements at the time of diagnosis, but is generally used to describe persistent discrepancy between clinic and home or ambulatory day time averages in those being treated for hypertension and those who are not.”


Research has suggested that having white coat syndrome may be a risk factor in developing high (or very high) blood pressure as a chronic condition.


If an individual’s GP feels it is appropriate they will often arrange for a 24-hour blood pressure recording (which measures an individual’s blood pressure every 20 – 30 min) to be obtained to identify whether an individual has WCS or not. Where WCS is suspected but there is no history of this on the individuals OH file, it may be necessary for OH restrictions relating to high BP, to remain in place until this is proven to be the case.

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