What's the difference between white coat hypertension and true hypertension?

You walk into your doctor’s office. The cuff tightens. The reading flashes: 145/90. The nurse raises an eyebrow. “Your blood pressure’s high again.” But here’s the thing: you’ve been checking it at home, and it’s usually normal. Is this really hypertension? Or something else?

This situation is more common than most people realize. It’s called white coat hypertension (WCH): when blood pressure is high in the clinic but normal outside. It’s a real diagnosis, not a fluke. And it’s crucial to distinguish it from true (sustained) hypertension, where blood pressure stays high both in the office and at home, because the long-term health risks and treatment plans are very different.

White coat hypertension affects up to 30% of people who appear to have high blood pressure in the clinic. It’s especially common in older adults, women, and people with borderline readings. You might be told you have “high blood pressure” based on your office visit alone, but unless we measure your blood pressure outside of the clinic, either with a 24-hour monitor or repeated home readings, we can’t confirm the diagnosis.

So why does this distinction matter?

Because the risk of heart attack, stroke, and kidney disease is dramatically lower in people with WCH than in people with true hypertension. True hypertension causes wear and tear on your arteries over time. It leads to structural changes like left ventricular hypertrophy (enlargement of the heart’s main pumping chamber), arterial stiffness, and kidney dysfunction. WCH, on the other hand, doesn’t typically cause this kind of target organ damage, at least not if it stays “white coat” and doesn’t progress.

That said, WCH is not entirely benign. People with this pattern are more likely to eventually develop sustained hypertension compared to those with consistently normal readings. And if you already have other risk factors, like diabetes, high cholesterol, or a strong family history of heart disease, then WCH could tip the scale just enough to matter.

Another reason to pay attention to WCH is psychological. Studies have shown it’s associated with higher anxiety and specific personality traits. In other words, it’s not “just in your head,” but your brain might be part of the equation. The spike in office readings may reflect how your nervous system responds to perceived stress, which can be a health issue in itself.

So what’s the right approach?

1. First, get an accurate diagnosis. If your doctor suspects WCH, they should ask you to track your blood pressure at home over several days using a validated monitor. In some cases, they may recommend a 24-hour blood pressure monitor, which gives the most complete picture.
2. Second, don’t rush into medications. Unless there’s evidence of organ damage or very high cardiovascular risk, drug treatment is usually not necessary for WCH. Instead, focus on lifestyle changes, e.g. cutting sodium, increasing physical activity, managing stress, and optimizing sleep.
3. Third, monitor over time. Because WCH can progress to true hypertension, it’s smart to re-check your home blood pressures every few months, or more often if your overall risk is high.

One final note: WCH is not the only “masked” form of high blood pressure. Some people have the opposite problem: normal readings in the clinic, but high blood pressure at home. That’s called masked hypertension, and it’s actually more dangerous because it can fly under the radar for years. The only way to uncover either pattern is with out-of-office monitoring.

If you’ve ever been told your blood pressure is high but you feel unsure about starting lifelong medications, ask your doctor whether white coat hypertension could be at play. With the right tools and a little patience, we can figure out whether that elevated reading is a true threat, or just a false alarm triggered by the white coat.