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Dilemma: Patient with white-coat hypertension refused surgery

A GP trainer, a GP hypertension specialist and medicolegal expert advise what to do if a patient with ‘white-coat’  hypertension is repeatedly refused surgery because of high pre-operative blood pressure 

A patient who suffers known ‘white-coat’ hypertension is sent to you from a pre-op assessment clinic because her blood pressure is high. Despite a recent, normal 24-hour blood pressure reading, the clinic sends her back again when her blood pressure is too high during their assessment, instructing you that ‘the anaesthetist will not go ahead unless her blood pressure is treated’. What should you do?

Dr Pipin Singh - online

GP trainer: Contact the anaesthetist directly

This is likely to be a stressful time for the patient who is eagerly awaiting their operation. First, explore the patient’s record and review their 24-hour ambulatory result, to confirm their clinic and 24-hour blood pressure readings support the diagnosis of white-coat hypertension. In case the anaesthetist is unaware of the 24-hour blood pressure reading, try to speak to them directly to inform them of the result and when and why it was done.

If this does not persuade the anaesthetist, explore with them why they are still reluctant to anaesthetise the patient. There may be a good reason from an anaesthetic point of view that you are not aware of. If not, explain it is clinically unsafe for you to treat a normal 24-hour blood pressure reading, based on NICE guidance on diagnosis and management of hypertension.1

If unable to contact the particular anaesthetist involved, speak to one of their colleagues or the pre-operative nurse to discuss your concerns further.

If you are unable to reach agreement, then involve your local hypertension service by either speaking to a consultant or writing a letter for advice to the appropriate service relaying the concerns highlighted by the anaesthetic team and the results of your ambulatory monitoring. Copy your referral to the relevant anaesthetist. Ensure you explain to the patient at each step what the plan is.

Dr Pipin Singh is a GP trainer in Wallsend, Tyne and Wear

chris clark square

GP hypertension expert: Write to the clinic citing pre-op guidelines

We know patients can experience elevated blood pressures during measurement by a healthcare professional – particularly in hospital settings.2 If surgery records indicate 24-hour blood pressure control is good, we can attribute any disparity to the white-coat effect.

In this case, our patient’s future care is being compromised. The British and Irish Hypertension Society and Association of Anaesthetists of Great Britain and Ireland recently produced joint guidelines for pre-operative blood pressure care, which state that GPs should only refer patients for elective surgery with mean blood pressure readings in the past 12 months of less than 160/100mmHg – and that pre-operative assessment clinics need not measure blood pressure in patients whose systolic and diastolic blood pressures are documented as below 160/100mmHg in the referral letter from primary care.3,4

So assuming the patient’s normal 24-hour blood pressure reading was provided with the referral (and many local referral policies now require this) the clinic should not have repeated her blood pressure at all.

You could therefore simply write to the secondary care team and refer them to the published guidelines.

The guidelines also include a template letter for communication between surgeon and GP when this dilemma is encountered.

Dr Chris Clark is a GP in Devon and executive board member of the British and Irish Hypertension Society

dollman square

Medicolegal adviser: Focus on the patient’s interests

The GMC states that doctors must make the care of their patients their first concern.5

In the first instance, the GP must be satisfied that the diagnosis of white-coat hypertension has been made appropriately.

If further tests are required, you should assess the patient, taking account of their history and if necessary examining them, and then arrange suitable investigations.

If satisfied with the white-coat hypertension diagnosis, explain the situation clearly to the patient, who may be confused by the differing opinions or disappointed by the delay.

The GMC reminds doctors that they must work collaboratively with colleagues, respecting each other’s expertise and contributions, and sharing all relevant information with colleagues. In this case, you could contact the anaesthetist directly, so they have all the relevant detail from a colleague with a better understanding of the patient’s condition than a clinician undertaking a one-off pre-operative assessment.

All appropriate steps as outlined above should be taken to determine whether or not the requested treatment is needed. The GMC states that doctors must prescribe drugs or treatment only when they have adequate knowledge of the patient’s health and are satisfied that the medications serve the patient’s needs.5

The focus should remain on the patient as an individual and doctors must work with colleagues in the ways that best serve the patient’s interests.

You could also view it as a learning opportunity and enquire whether the clinic has an established protocol in respect of patients with white-coat hypertension and, if not, it may be something the pre-assessment clinic decides to review.

Dr Greg Dollman is a medicolegal adviser at the Medical and Dental Defence Union of Scotland

References

1 NICE. Hypertension: The clinical management of primary hypertension in adults, CG127. 2011. 

2 Adiyaman A, Aksoy I, Deinum J et al. Influence of the hospital environment and presence of the physician on the white-coat effect.

J Hypertens 2015; 33: 2245–9

3 Hartle A, McCormack T, Carlisle J et al. The measurement of adult blood pressure and management of hypertension before elective surgery. Anaesthesia 2016;71:

326-37

4 McCormack T, Carlisle J, Anderson S et al. Preoperative blood pressure measurement: what should GPs be doing? Br J Gen Pr 2016; 66:230-31

5 GMC. Good medical practice. 2013

 

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Readers' comments (1)

  • 'The British and Irish Hypertension Society and Association of Anaesthetists of Great Britain and Ireland recently produced joint guidelines for pre-operative blood pressure care, which state that GPs should only refer patients for elective surgery with mean blood pressure readings in the past 12 months of less than 160/100mmHg '

    I don't refer any patients for surgery.
    I refer them to a specialist for assessment and treatment of a their symptoms, usually with a differential diagnosis, and sometimes for a condition where surgery is one of the treatment options!

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