Prevalence Of White-coat Effect Research Articles

PREVALENCE OF THE WHITE COAT EFFECT IN A POPULATION OF HYPERTENSIVE PATIENTS

Objective: The white coat effect (WCE), defined as elevated office blood pressure (BP) and normal out-of-office BP, is of great importance in medical practice since it leads to overestimate the degree of BP figures. The objective of the study is to determine the prevalence of WCE in treated and untreated hypertensive patients. Design and method: we conducted an analytical cross-sectional study including 100 patients aged > 18 years, followed at the outpatient cardiology clinic of the Mohamed Taher Maamouri university hospital in Nabeul over a six months period (July-December 2021). The BP measurement in the office was performed on the day of inclusion. Patients were asked to measure BP at home as instructed by the physician using validated blood pressure self-measurement devices (MICROLIFE BP A3 PLUS, MICROLIFE BP A2 Basic and Beurer BM 40 ). These devices were loaned to the patient who had to return them on the day of the ABPM installation. Laying of ABPM was performed immediately after the HBPM using a Bravo Mini validated device from Sun Tech Medical. The comparisons of percentages were carried out by the Chi-square test. Results: The average age of our population was 59.14±13.12 years (range 21-92 years), composed of 47 women and 53 men. 84% of the population has treated hypertension. The prevalence of WCE was 30% in HBPM and 27% in ABPM, 26 patients (31%) and 21 patients (25%) were objectified in treated hypertension respectively by HBPM and ABPM. The difference between these two methods was not statistically significant (p = 0.198). Conclusions: The prevalence of WCE was high in this population. HBPM and ABPM are two effective methods for diagnosing and confirming this phenomenon.

PREVALENCE AND CLINICAL CORRELATES OF HYPOTENSIVE EPISODES AMONG OLDER HYPERTENSIVE ADULTS UNDERGOING 24-H AMBULATORY BLOOD PRESSURE MONITORING

Objective: Older adults have increased susceptibility to hypotension. Hypotensive episodes have a negative prognostic impact at old age, being associated with adverse events such as syncope, falls and injuries, which impair quality of life and functional autonomy. 24-hour ambulatory blood pressure monitoring (ABPM) is a useful diagnostic tool to detect hypotension, although it is rarely used for this purpose. The present study aimed at assessing the prevalence and the clinical variables associated with hypotensive episodes on ABPM among older hypertensive adults. Design and method: prospective observational study involving hypertensive patients aged 75 or older evaluated at two outpatient clinics of Careggi Hospital, Florence, Italy. All participants underwent a comprehensive geriatric assessment, office blood pressure measurement and ABPM. Hypotensive episodes were defined as single daytime systolic blood pressure (SBP) measures <90 mmHg. Clinical variables associated with hypotensive episodes were investigated using multivariable logistic regression. Results: Among 123 participants (mean age 81 years, 59% female), the 16% showed hypotensive episodes on ABPM. Patients with hypotensive episodes were older (84±5 vs 81±4 years, p = 0.002), had a higher prevalence of dementia (50% vs 26%, p = 0.034) and received a higher number of daily medications (8[6-10] vs 6 [5-9], p = 0.036). Moreover, they showed lower 24h-SBP (139±15 vs 149±15, p = 0.008), daytime SBP (141±15 vs 151±15, p = 0.005) and night-time SBP (129±18 vs 140±20, p = 0.005) and a higher prevalence of white coat effect (30% vs 12%, p = 0.034). At multivariable analysis, hypotensive episodes were associated with use of angiotensin-receptor blockers (ARBs, OR 24.325, p = 0.002), independently of age, sex, dementia, 24h-SBP and number of medications. By contrast, use of ACE-inhibitors (OR 0.719, p = 0.013) and thiazide diuretics (OR 0.978, p = 0.048) were inversely associated with hypotension on ABPM. Conclusions: Hypotensive episodes are a common finding in older adults undergoing ABPM. Hypotensive episodes more frequently occur in patients with lower SBP and white coat effect and are independently associated with ARBs use. ACE-inhibitors and thiazides are inversely associated with hypotensive episodes on ABPM.

Effects of Intensive Versus Standard Office-Based Hypertension Treatment Strategy on White-Coat Effect and Masked Uncontrolled Hypertension: From the SPRINT ABPM Ancillary Study.

Guidelines recommend using out-of-office blood pressure (BP) measurements to confirm the diagnoses of hypertension and in the titration of antihypertensive medication. The prevalence of out-of-office BP phenotypes for an office systolic/diastolic BP goal <140/90 mm Hg has been reported. However, the prevalence of these phenotypes when targeting an office systolic/diastolic BP goal <120/80 is unknown. The SPRINT (Systolic Blood Pressure Intervention Trial) Ambulatory BP Ancillary study evaluated out-of-office BP using ambulatory BP monitoring in 897 participants 27 months after randomization to intensive versus standard BP targets (office systolic BP <120 versus <140 mm Hg). We used office and daytime BP to assess the proportion of participants with white-coat effect (standard target: office BP ≥140/90 mm Hg and daytime BP <135/85 mm Hg versus intensive target: office BP ≥120/80 mm Hg and daytime BP <120/80 mm Hg) and masked uncontrolled hypertension (standard target: office BP <140/90 mm Hg and daytime BP ≥135/85 mm Hg versus intensive target: office BP <120/80 mm Hg and daytime BP ≥120/80 mm Hg) in each treatment arm. The prevalence of white-coat effect and masked uncontrolled hypertension was 9% and 34%, in both treatment groups. Among participants with uncontrolled office BP, white-coat effect was present in 20% and 23% in the intensive and standard groups, respectively. Among participants with controlled office BP, masked uncontrolled hypertension was present in 62% and 56% in the intensive and standard groups, respectively. In conclusion, a more intensive BP target resulted in a similar proportion of patients with white-coat effect and masked uncontrolled hypertension compared with a standard target.

Comparison between unattended automated office blood pressure and conventional office blood pressure under the environment of health checkup among Japanese general population.

Unattended automated office blood pressure (AOBP) measurement has been endorsed as the preferred in-office measurement modality in recent Canadian and American clinical practice guidelines. However, the difference between AOBP and conventional office blood pressure (CBP) under the environment of a health checkup remains unclear. We aimed to identify the clinical significance of AOBP as compared to CBP under the environment of a health checkup. There were 491 participants (333 females, mean age of 62.5years) who were at least 20years old, including 179 participants who were previously diagnosed with hypertension. Mean AOBPs were 131.8±20.9/76.6±11.7mmHg, and CBPs were 135.6±21.6/77.3±11.5mmHg. There was a difference of 3.9mmHg in systolic blood pressure (SBP) and 0.8mmHg in diastolic BP between AOBP and CBP. In all participants, SBP and pulse pressure, as well as the white coat effect (WCE), increased with age. The cutoff value used was 140/90mmHg for CBP and 135/85mmHg for AOBP, and the prevalence of WCE and masked hypertension effect (MHE) was 12.4% and 14.1%, respectively. Even in a health checkup environment of the general population, there was a difference between the AOBP and CBP, and the WCE was observed more strongly in the elderly with a history of hypertension, suggesting that a combination of AOBP with CBP may be useful in detecting WCE and MHE in all clinical scenarios including health checkups, and help solve the "hypertension paradox" not only in Japan but in all over the world.

White-Coat Effect Is Uncommon in Patients With Refractory Hypertension

Refractory hypertension is a recently described phenotype of antihypertensive treatment failure defined as uncontrolled blood pressure (BP) despite the use of ≥5 different antihypertensive agents, including chlorthalidone and spironolactone. Recent studies indicate that refractory hypertension is uncommon, with a prevalence of ≈5% to 10% of patients referred to a hypertension specialty clinic for uncontrolled hypertension. The prevalence of white-coat effect, that is, uncontrolled automated office BP ≥135/85 mm Hg and controlled out-of-office BP <135/85 mm Hg, by awake ambulatory BP monitor in hypertensive patients overall is ≈30% to 40%. The prevalence of white-coat effect among patients with refractory hypertension has not been previously reported. In this prospective evaluation, consecutive patients referred to the University of Alabama at Birmingham Hypertension Clinic for uncontrolled hypertension were enrolled. Refractory hypertension was defined as uncontrolled automated office BP ≥135/85 mm Hg with the use of ≥5 antihypertensive agents, including chlorthalidone and spironolactone. Automated office BP measurements were based on 6 serial readings, done automatically with the use of a BpTRU device unobserved in the clinic. Out-of-office BP measurements were done by 24-hour ambulatory BP monitor. Thirty-four patients were diagnosed with refractory hypertension, of whom 31 had adequate ambulatory BP monitor readings. White-coat effect was present in only 2 patients, or 6.5% of the 31 patients with refractory hypertension, suggesting that white-coat effect is largely absent in patients with refractory hypertension. These findings suggest that white-coat effect is not a common cause of apparent lack of BP control in patients failing maximal antihypertensive treatment.

Prevalence and predictors of white-coat hypertension in a large database of ambulatory blood pressure monitoring

The objective of this study was to determine both the prevalence of white-coat effect and white-coat hypertension (WCH) and which selected clinical variables were predictors of WCH. A total of 2462 patients underwent ambulatory blood pressure monitoring either in borderline hypertension (group 1) or for assessment of antihypertensive treatment (group 2) or for hypotension (group 3). In the overall population 33.0% of patients showed WCH, 32.8% in group 1 and 37.0% in group 2. In multivariate analysis, sex and grade of hypertension were independent predictors of WCH in groups 1 and 2.

Abstract 855: White-Coat Effect among Older Patients with Suspected Cognitive Impairment: Prevalence and Clinical Implications

OBJECTIVES To evaluate prevalence of the white-coat effect (WCE), and its association with individual anxiety and insight of disease, among older patients attending for a first visit for suspected cognitive impairment (CI). DESIGN Prospective cohort study SETTING An Alzheimer Evaluation Unit. PARTICIPANTS Outpatients aged 55 years or older with suspected CI MEASUREMENTS WCE was defined as a difference of at least 20 mmHg in systolic or 10 mmHg in diastolic blood pressure (BP) measured either by a physician during the visit or by a nurse (before and after the visit), compared with home self blood pressure measurement (SBPM). Severity of CI was evaluated through the Mini-Mental State Examination (MMSE); the Clinical Insight Rating Scale (CIR) and the Guidelines for the Rating for Awareness Deficits (GRAD) were used to evaluate the subject’s insight; anxiety disorder was evaluated using the 7-question Generalized Anxiety Disorder scale (GAD-7) RESULTS Among 273 subjects, prevalence of WCE was 52%, 32.6% and 30.4%, according to physician’s and nurse’s BP measurements, respectively (p=.000). Prevalence of WCE did not differ between patients diagnosed with and without dementia, but was higher among patients with than in those without anxiety disorder (70.7% vs 38.2%, p=.000). Positive relations were observed between severity of anxiety and insight of disease, which were both inversely related with severity of CI CONCLUSIONS WCE is extremely common and is roughly correlated to individual anxiety and insight of disease among older outpatients with suspected CI; overestimation of hypertension severity might lead to unnecessary drug treatment and greater health costs in this setting.

White‐coat effect among older patients with suspected cognitive impairment: prevalence and clinical implications

To evaluate the prevalence of white-coat effect (WCE), and its association with individual anxiety and insight of disease, among older patients evaluated for suspected cognitive impairment. This prospective cohort study, conducted in an Alzheimer Evaluation Unit, involved patients aged 55 years or older with suspected cognitive impairment. WCE was defined as a difference of at least 20 mmHg in systolic or 10 mmHg in diastolic blood pressure (BP) measured either by a physician during the visit or by a nurse (before and after the visit), compared with home self-blood pressure measurement (SBPM). Severity of cognitive impairment was evaluated through the Mini-Mental State Examination (MMSE); the Clinical Insight Rating Scale (CIR) and the Guidelines for the Rating for Awareness Deficits (GRAD) were used to evaluate the subject's insight; anxiety disorder was evaluated using the seven-question Generalized Anxiety Disorder scale (GAD-7). Among 273 subjects, prevalence of WCE was 52%, 32.6% and 30.4%, according to physician and nurse BP measurements, respectively (p = 0.000). Prevalence of WCE did not differ between patients diagnosed with and without dementia, but was higher among patients with than in those without anxiety disorder (70.7% vs 38.2%, p = 0.000). Positive relations were observed between severity of anxiety and insight of disease, which were both inversely related with severity of cognitive impairment. WCE is extremely common and is correlated to individual anxiety and insight of disease among older outpatients with suspected cognitive impairment; overestimation of hypertension severity might lead to unnecessary drug treatment and greater health costs in this setting.

The feasibility of 24-h ambulatory blood pressure monitoring and the prevalence of white-coat effect in very elderly aged ≥80 years

The feasibility of 24-h ambulatory blood pressure monitoring and the prevalence of white-coat effect in very elderly aged ≥80 years

Prevalence of white coat effect in treated hypertensive patients in the community

Patients receiving drug therapy for hypertension in the tertiary care setting frequently exhibit higher office readings compared to ambulatory blood pressure values (white coat effect). In this study, the prevalence of a white coat effect was determined in an unselected population of 147 hypertensive patients receiving treatment from their family physicians in the community. The proportion of patients with a white coat effect (defined as office - ambulatory blood pressure > or = 20/10 mm Hg) was significantly (P < .001) higher when based upon the family physician's routine blood pressure readings (91/147), compared to special readings taken by the family physician for the study (54/147) or readings taken by a research nurse (30/147). There was a higher correlation (P < .05) between the ambulatory systolic blood pressure and the nurse's readings (r = 0.62) or special physician's readings (r = 0.55) v the routine physician's readings (r = 0.34). Left ventricular mass index as measured by echocardiography correlated (P < .01) with the special physician (r = 0.27), nurse (r = 0.23), and ambulatory systolic blood pressure readings (r = 0.24), but not with the routine physician's readings (r = 0.06). A white coat effect is frequently present in treated hypertensive patients when blood pressure is recorded by family physicians in routine clinical practice.