White Coat Phenomenon: Removing the Stigma of Hypertension.

Abstract

The term white coat hypertension (WCH) was initially introduced in 19841 to describe patients who had hypertension in the office but were normotensive with ambulatory blood pressure monitoring (ABPM). At the time, WCH was simply a phenomenon with nothing known about its possible effect on the development of cardiovascular (CV) disease. Three decades later, it is apparent that hypertension in the office is a relatively poor predictor of CV risk in the individual, with ABPM now considered to be the best determinant of future CV events. Many patients diagnosed with WCH are not hypertensive on ABPM which leads one to ask: Why call a patient hypertensive when the final diagnosis will frequently be normal blood pressure (BP)? Despite numerous clinical studies, there is still no consensus on whether WCH is a benign condition or a risk factor for the development of sustained hypertension and CV disease.2 WCH is generally diagnosed when a patient’s office BP is high and out-of-office (ABPM or home BP) is normal. A typical study examining WCH as a CV risk factor consists of a patient population classified at baseline into categories of normotension or white coat, masked and sustained hypertension on the basis of office and out-of-office BP, with follow-up of several years for the occurrence of CV events. Patients are sometimes subdivided into groups who at baseline are either untreated or on antihypertensive drug therapy. Treatment during follow-up has not been taken into account in most of the studies because of lack of data or difficulty of modeling survival analysis. The results of individual studies on WCH and CV risk are somewhat inconsistent. In many instances, the investigators had difficulty matching a control (normotensive) group with the WCH patients for factors affecting future CV risk. The most easily recognized difference is the baseline …