severe white coat hypertension during stress echo

I recently had a stress echo test and had severe white coat hypertension meaning that going into the test I knew my heart rate was significantly higher than normal. I was very anxious about having a stress echo to say the least and wonder if this would skew the test?

It was very hard for me to let go (relax) and have it return to a normal rate. At rest it was in the 110 to 120 range. My resting blood pressure was also high 170/72 which is high for me. When I check my BP it is usually 126/78 and my HR is around 85.

During the treadmill exercise my HR went to 179 (103% of predicted MHR) after 10 minutes. My BP was 170/62 at the beginning and after 3 minutes, 160/62 after 6 minutes, 162/70 after 9 minutes, 191/73 (173 HR) immediate recovery, 169/68 (151 HR) one minute recovery, 161/88 (139 HR) 2 minute recovery, 167/74 (126 HR) 5 minute recovery. Beyond this point I could not relax and my HR stayed elevated at around 125 ( I could feel it and knew it was high, not because of the exercise but because of the environment). During the treadmill I almost felt a slight calming because I had something to do but was still anxious. The treadmill was stopped secondary to fatigue (which sounds like I got tired and they stopped it, but I reached the target maximal heart rate and then they stopped it).

Here are some results:

Resting EKG demonstrates normal sinus rhythm with possible left atrial enlargement, ST-T wave abnormalities consistent with ischemia. Just standing up, heart rate increased to 120 with development of further ST depression inferoapically and laterally before exercise was performed. During exercise, the ST changes that occured with standing do not increase further. It was about 2 mm of ST depression in II, II, and aVF and V4 and V5 with 1 mm in V3 and V6. These changes are consistent with ischemia but must be interpeted with caution in light of the resting abnormalities and the change in EKG with just standing up. There is an occasional APC and PVC. There is no VT.

My resting echo images demonstrate normal left ventricular function, normal wall motion with a preserved ejection fraction of 60%. A limited Doppler and color Doppler study at rest demonstrates structurally normal-appearing valves with trace mitral regurgitation and trace tricuspid regurgitation. It is technically somewhat limited.

With exercise, left ventricular function improves, walls improve in thickening and contractility, and there are no wall abnormalities seen and no electrocardiography evidence of ischemia.

[kenkeith]

An occasional APC and PVC is not significant...common to have skipped beats, etc.

Although more evidence is required, and EKG with an abnormal ST-T (depression) 2mm or greater is in general a sign of ischemia (vessel occlusion).

Does you doctor recommend or treat you for high blood pressure, medication for anxiety, or a beta blocker to slow your heart rate?  Yes, a faster than normal heart rate can skew the EKG. QT  and QTc (corrected QT) interval.  The QTc diviides heart rate into the QT interval and involves left and right right vetricular contractions.

QT represents the duration of activation and recovery of the ventricular muscle. This duration varies inversely with the heart rate. Since the duration of QT varies inversely with the heart rate, the QT is not used, but rather the corrected QT is.  But the EKG may compute an abnormal result based on QT.

Also a PVC can effect the outcome of a EKG.  The PVC may be perceived as a "skipped beat" or as palpitations. The depolarization of cardiac myocytes (vetricular contractions) begins in the ventricle instead of the usual place, the sinoatrial node (located in the right upper chamber and the signal is usually routed through the upper chambers, down the septal wall and into both lower chambers for contractions).. PVCs can be a useful natural probe, since they induce Heart rate turbulence whose characteristics can be measured, and used to evaluate cardiac function.

Your report quote: "My resting echo images demonstrate normal left ventricular function, normal wall motion with a preserved ejection fraction of 60%. A limited Doppler and color Doppler study at rest demonstrates structurally normal-appearing valves with trace mitral regurgitation and trace tricuspid regurgitation. It is technically somewhat limited".

No VT indicates no ventricular tachycardia (fast heart rate).  If your report stated abnormal VT, which it doesn't,  that would indicates there is an abnormally fast heart rate usually originating with the sinus node.

Ejection fraction is the amount of blood pumped out with each heart beat (normal is 55 to 75%).  Valves are of no significance impairment as trival and mild are common events for many people.

[bockoboy]

Thanks, I appreciate your response.

My doctor has not recommend or treated me for high blood pressure, medication for anxiety, or a beta blocker to slow my heart rate. I don't generally get "stressed out" or anxious, and my BP is usually 126/78 and HR is 85ish. The medical facility hypertension is about the only thing that gets me anxious.

It was when I went to get the stress echo that I started get anxious. Thats why they called it white coat hypertension. I knew my HR was going fast and the more I tried to slow it down (relax), the more I thought about its pace - which kept it going fast. I asked if I could wait a minute or two before they got started so I could calm myself but they told me there wasn't enough time because they had more patients that day. I was even told to try not to take deep breaths after exercising (recovery) because of the ultrasound imaging being done. So again, it was impossible for me to actually relax.

Needless to say, I am still unsure how my heart health is. Right now I am being told that a nuclear test should be done next year (which will leave me wondering until that time). I didn't know that anything was askew before I had a physical, and I exercise moderately 3 times a week, so having to do an echo stress test and then getting abnormal results has left me doubting the state I thought my current health and capabilities are in (which I thought was pretty good).

[peekawho]

People with "white coat" hypertension often develop generalized hypertension later in life.  

Plus, it is widely assumed that if your BP is so labile during medical tests or medical office visits, it is similarly elevated during other stressful situations such as stress at work or home, or other times.  

It merits watching.  I have a wonderful BP at home, resting, but at work it was quite elevated.  I had no idea until I started measuring it more often, under stress.  Now I take blood pressure meds and its much more even keel.