Definition Of White-coat Hypertension Research Articles

«Гіпертензія білого халата»: сучасний стан проблеми

Від першого описання в науковій літературі поняття «гіпертензія білого халата» пройшло понад 30 років, але відтоді все більше уваги вчені приділяють цьому стану. «Гіпертензію білого халата» констатують у випадку, коли показники артеріального тиску, визначеного в кабінеті лікаря, відповідають критеріям артеріальної гіпертензії, але остання не підтверджується показниками амбулаторного або домашнього моніторування артеріального тиску. Спочатку цей термін відносили лише до пацієнтів, які не отримували антигіпертензивного лікування, але нещодавно це визначення поширили й на осіб, які регулярно приймають ліки, що знижують артеріальний тиск, і цей стан отримав назву «неконтрольована гіпертензія білого халата». Одні з найвпливовіших організацій світу у галузі кардіології не дійшли консенсусу щодо єдиних критеріїв визначення «гіпертензії білого халата», що призвело до розбіжностей порогових значень артеріального тиску за даними амбулаторного моніторування. Доволі багато досліджень минулих років були присвячені вивченню клінічної та прогностичної значущості «гіпертензії білого халата» відносно таких наслідків, як метаболічні розлади, субклінічні й екстракардіальні ураження органів-мішеней, серцево-судинної захворюваності та смертності, а також смертності загалом. На теперішній час безсумнівним є той факт, що «гіпертензія білого халата» – це стан, який потребує корекції; однак досі спірними є гіпотези стосовно прогностичної ролі цього стану та ведення таких пацієнтів. Питання щодо лікування «гіпертензії білого халата» як стану залишається відкритим і потребує подальшого вивчення. Сьогодні вважається доцільним для осіб, у яких показники офісного артеріального тиску в нормі або нижчі від цільових, не призначати антигіпертензивне лікування, а інтенсифікувати модифікацію способу життя та скерувати всі зусилля на зниження серцево-судинного ризику.

Diagnosis and management of white‐coat hypertension in children and adolescents: A Midwest Pediatric Nephrology Consortium study

Although the definition of white-coat hypertension (WCH) in children and adolescents is clearly defined, little is known about how this condition is actually approached clinically. To better understand the contemporary approach to the diagnosis and management of WCH in pediatric patients, the authors surveyed the membership of the Midwest Pediatric Nephrology Consortium. Seventy-four faculty pediatric nephrologists responded to the survey. The survey results demonstrated uniformity in diagnosing WCH, including ambulatory blood pressure monitoring use in 93% of the respondents and a 75% adherence rate according to the 2014 American Heart Association scientific statement on pediatric ambulatory blood pressure monitoring. A total of 85% of respondents would not embark on further diagnostic evaluation once the WCH diagnosis was established, and none would initiate antihypertensive medications. There was a wide variety of practice habits in follow-up of WCH including frequency of office and out-of-office follow-up blood pressure measurements, the setting and timing of physician follow-up, and the role of repeat ambulatory blood pressure monitoring. The results of this survey highlight the need for prospective studies aimed at establishing the optimal approach to pediatric patients with WCH.

White Coat Hypertension: to Treat or Not to Treat?

Definition of white coat hypertension (WCH) traditionally relies on elevated office blood pressure (BP) during repeated visits concomitant with normal out-of-office BP values, as assessed by home and/or 24-h ambulatory BP monitoring measurements. Accumulating evidence focusing on the association of WCH with target organ damage and, more importantly, with cardiovascular events indicates that the risk conveyed by this condition is intermediate between normotension and sustained hypertension. This article will review a number of issues concerning WCH with particular emphasis on the following: (1) prevalence and clinical correlates, (2) association with target organ damage and cardiovascular events, (3) therapeutic interventions. Data will refer to the original WCH definition, based on out-of-office BP determined by 24-h ambulatory BP monitoring; at variance from home BP measurement, this approach rules out the potentially confounding effect of a clinically relevant abnormal BP phenotype such as isolated nocturnal hypertension.

White coat hypertension in pediatrics.

The article summarizes current information on blood pressure changes in children during clinic visit. White coat as a general dressing of physicians and health care personnel has been widely accepted at the end of the 19th century. Two problems can be associated with the use of white coat: white coat phenomenon and white coat hypertension. Children often attribute pain and other unpleasant experience to the white coat and refuse afterwards cooperation with examinations. Definition of white coat hypertension in the literature is not uniform. It has been defined as elevated blood pressure in the hospital or clinic with normal blood pressure at home measured during the day by ambulatory blood pressure monitoring system. White coat effect is defined as temporary increase in blood pressure before and during visit in the clinic, regardless what the average daily ambulatory blood pressure values are. Clinical importance of white coat hypertension is mainly because of higher risk for cardiovascular accidents that are dependent on end organ damage (heart, vessels, kidney). Current data do not allow any clear recommendations for the treatment. Pharmacological therapy is usually started in the presence of hypertrophic left ventricle, changes in intimal/medial wall thickness of carotic arteries, microalbuminuria and other cardiovascular risk factors. Nonpharmacological therapy is less controversial and certainly more appropriate. Patients have to change their life style, need to eliminate as much cardiovascular risk factors as possible and sustain a regular blood pressure monitoring.

Relentless Progression Toward Sustained Hypertension

Blood pressure (BP) measured carefully by cuff under standardized conditions in physician offices has been shown to be an acceptable predictor of morbidity and mortality.1 However, 24-hour ambulatory BP monitoring is a closer surrogate end point for heart attack and stroke than office BP.2,3 Because the correlation between 24-hour ambulatory BP measurement and office BP measurement is moderate at best, not unexpectedly there will be a significant number of people who are truly hypertensive but in whom the diagnosis is missed by office BP measurements (masked hypertension). Conversely, BP may be elevated in the office but not on ambulatory BP monitoring, an entity known to most clinicians as white-coat hypertension. Both masked hypertension and white-coat hypertension can be considered prehypertensive states not uncommonly evolving into sustained hypertension. The article by Mancia et al4 in the present issue of Hypertension assesses the risk of developing sustained hypertension in the Pressioni Arteriose Monitorate e Loro Associazioni population over a 10-year follow-up. Regardless of whether the definition of white-coat hypertension or masked hypertension was based on home BP measurements or 24-hour ambulatory monitoring, both forms of hypertension were at an increased risk of progressing to sustained hypertension. In fact, Mancia et al4 showed that >40% of patients having white-coat or masked hypertension will developed sustained hypertension over a 10-year period (Figure). In contrast, only 16% of truly normotensive subjects will progress to sustained hypertension within the same …

Ambulatory blood pressure monitoring in heart failure: a systematic review

Ambulatory blood pressure monitoring has established its use in the definition of white coat hypertension and monitoring of treatment of essential hypertension. Any role for ambulatory blood pressure monitoring in heart failure is not well defined. However, from the limited studies available, ambulatory blood pressure monitoring may be used to optimise heart failure therapy, and as a prognosis marker in this patient group. Most studies that have examined the circadian pressure profile have found blunting of decline of blood pressure during sleep in patients with heart failure. In advanced heart failure, this may be due to hypoperfusion of vital organs partly due to pump failure and partly due to multiple drug therapy associated with the treatment of heart failure. Ambulatory blood pressure monitoring may also clarify hypoperfusion effects on vital organs in individual patients and improve the risk/benefit ratio of treatments in advanced heart failure. Prospective controlled studies on the impact of treatments on circadian blood pressure profile in congestive heart failure patients are needed.

White-coat hypertension in adults and children

The measurement of blood pressure in the clinic triggers an altering reaction and a rise in blood pressure in the patient. Such a reaction is usually defined as a 'white-coat effect' or 'white-coat phenomenon', while the coexistence of persistently high office blood pressure with normal blood pressure outside the medical setting is referred to as 'white-coat' or 'office' hypertension. The white-coat effect can be estimated on a beat-to-beat basis using invasive (intra-arterial) or non-invasive methods, or, more commonly, by measuring the difference between office blood pressure and average daytime ambulatory blood pressure. The white-coat effect has little clinical importance because it is not associated with the target-organ damage and prognosis. We found that cardiovascular morbidities of healthy normotensive controls and subjects with white-coat hypertension did not differ. Results of a prospective study with intra-arterial blood pressure monitoring and preliminary prospective data from another group confirm our findings. A recent analysis of our database suggests that we should use a restrictive definition of white-coat hypertension (for example, average daytime blood pressure <130/80 mmHg) in order to identify the minority of subjects with low probabilities of developing a major cardiovascular event in the subsequent years. Also a recent document by the American Society of Hypertension suggests that one should use restrictive upper normal limits of ambulatory blood pressure (i.e., average daytime blood pressure <135 mmHg systolic and 85 mmHg diastolic). We have found that, over a follow-up period of 0.5-6.5 years, 37% of subjects with white-coat hypertension spontaneously evolve into ambulatory hypertension, with accompanying increase in left ventricular mass. The probability of developing ambulatory hypertension increased with the baseline values of ambulatory blood pressure, not of clinic blood pressure. A final answer on the clinical significance of white-coat hypertension will come from very large surveys of the natural history of this condition in the long term. Authors of these longitudinal studies should also compare the response to drug treatment of these subjects with that to life-style-modification measures.