White Coat Hypertension Patients Research Articles

#2227 Exploring the interplay between gut microbiome, fecal metabolomics and ambulatory blood pressure in white-coat hypertensive patients

Abstract Background and Aims Recent evidence showed the relationship between gut microbiota with hypertension. Few studies also demonstrated that ambulatory blood pressure monitoring variables such as dipping status and linear variability are associated with fecal microbiota and metabolomics. However, the relationship between gut microbiota and metabolomic composition of white-coat hypertensive patients has not been studied yet. In addition, although the link between gut microbiota, blood pressure variability and high salt intake has been shown, none of the studies addressed these changes simultaneously in the same study population. Here, we aimed to investigate the interplay between the gut microbiome, fecal metabolites and 24-hour urine sodium levels between hypertensive, white-coat hypertensive (WCH) and healthy participants diagnosed with ambulatory blood pressure monitoring. Method The study included 18 newly diagnosed hypertensive, 8 WCH, and 21 healthy participants from our tertiary center. Ambulatory blood pressure (BP) monitoring was performed in all participants and nighttime dipping, morning BP surge (MBPS), pre-wake MBPS and linear BP variability were calculated. 16S rRNA sequencing was performed using Illumina MiSeq sequencer. DeSeq2 and linear discriminant analysis effect size (LEfSe) were performed with R. Fecal metabolite levels were analyzed by GC-MS. A partial least squares-discriminant analysis (PLS-DA) model was constructed for the feature selector and classifier. The variable importance in the projection (VIP) coefficient was calculated based on the PLS-DA model. Results ANOVA and post-hoc Tukey test showed WHC and hypertensive groups had higher blood pressure variability and morning-thorough MBPS than normotensive patients (p = 0.02 and 0.04, respectively), whereas 24-h urine Na levels were statistically similar between WCH and hypertensive groups (p = 0.11). There were no significant differences in α- and β-diversity metrics of gut microbiome between study groups. Select taxa were specific to WHC patients, notably Rikenellaceae family and Mitsuokella were higher in WHC against normotensive patients, whereas Ruminococcus callidus, Roseburia, Clostridium, Lactobacillus ruminis, Sutterall, Lachospiraceae and Muribaculaceae were decreased in WHC against normotensive patients in DeSeq2 analysis. Dialister was increased, whereas Bacteroides genus and Bacteroides fragilis were decreased in WHC against hypertensive patients. LEfSe analysis showed positive enrichment in Proteobacteria phylum and negative enrichment in Mitsuokella genus in WHC against hypertensive group. Enterococcus, Lachnobacterium, Odoribacter and Pseudomonas genera had positive; whereas Lactobacillus and Clostridium had negative correlations with 24-h urine Na levels. Positive correlations were shown between linear BP variability and Bacteroides and Paraprevotella genera. Several genera and species were enriched in Q3-4 against Q1-2 quartiles of pre-wake and sleep-thorough MBPS in LEfSe analyzes (Fig. 1). Normotensive and essential hypertensive groups could also be differentiated based on fecal metabolomic composition. Specifically, metabolites with the highest VIP values discriminating WCH from normotensive and hypertensive groups were methyl-palmitoleate, oxalic acid and phenyl β-D-glucopyranoside, respectively (Fig. 2). Conclusion In conclusion, we performed the first study focusing on the fecal microbiome and metabolomic characteristics of white-coat hypertensive patients. Urine Na levels and ambulatory blood pressure variables of the WCH group are different than those of the normotensive and similar to the hypertensive group. Comparative and correlation analyses revealed novel relationships between ambulatory blood pressure variables and gut microbiome of both WCH and hypertensive patients. Fecal metabolomic differences between study groups imply possible mechanisms underlying the effects of gut microbiome on blood pressure. Gut microbiota and metabolites may become valuable targets for interventions of both white-coat and essential hypertension in the near future.

THE SUBCLINICAL INFLAMMATION IN PEDIATRIC PATIENTS WITH PRIMARY HYPERTENSION AND WHITE COAT HYPERTENSION

Objective: Adult and experimental data indicate the vital role of inflammation in the pathogenesis of primary hypertension. The study aimed to evaluate subclinical inflammation in patients with primary hypertension (PH) and white coat hypertension (WCH). Design and method: In 56 untreated pediatric patients with PH, 40 with WCH, and 30 healthy individuals (CG – control group), we evaluated high sensitivity C-reactive protein (hsCRP), interleukin 18 (IL18) concentrations, complete blood count-derived markers of inflammation, office and ambulatory blood pressure, and selected clinical and biochemical parameters. Results: hsCRP was significantly higher in PH patients compared to CG (PH vs. CG: 4.9±5.2 vs. 2.8±5.4 [mg/dL], p=0.002), and neutrophil and monocyte counts were significantly higher in PH and WCH patients compared to CG (PH vs. WCH vs. CG, neutrophils: 3.89±1.44 vs. 3.40±1.75 vs. 2.63±0.96 [∗10^3/μL], p=0.001, monocytes: 0.56±0.17 vs. 0.53±0.18 vs. 0.46±0.14 [∗10^3/μL], p=0.026). Receiver operating characteristic analysis revealed good prognostic profiles for hsCRP (area under curve [AUC]=0.668, p=0.0005), neutrophil (AUC=0.691, p=0.0001), lymphocyte (AUC=0.615, p=0.0230), monocyte (AUC=0.622, p=0.0148), and platelet counts (AUC=0.606, p=0.0364), as well as the neutrophil-to-lymphocyte ratio (AUC=0.619, p=0.0181), monocyte-to-neutrophil ratio (MNR) (AUC=0.617, p=0.0204), and platelet-to-mean platelet volume ratio (AUC=0.606, p=0.0370) as predictors of the presence of primary hypertension. In multivariate analysis monocyte-to-lymphocyte ratio (MLR) and platelet count (beta=0.217, p=0.011; beta=0.191, p=0.036) were significant predictors of office diastolic blood pressure Z-score, neutrophil count predicted 24h systolic blood pressure Z-score (beta=0.365, p=0.005); MLR, lymphocyte count, IL-18, and MNR predicted 24 h diastolic blood pressure Z-score (beta=0.305, p=0.002; beta=0.253, p=0.010; beta=-0.197, p=0.019; beta=-0.189, p=0.029), and neutrophil count together with IL-18 predicted 24h mean arterial pressure Z-score (beta=0.210, p=0.027; beta=-0.209, p=0.012). Conclusions: 1.Patients with primary hypertension and white coat hypertension are characterized by similar levels of subclinical inflammation, significantly higher compared to healthy peers. 2. Complete blood count-derived indices, especially neutrophil count and MLR, can be an important adjunct to the clinical evaluation of pediatric patients with primary hypertension.

Evaluation of Office and Ambulatory Central Blood Pressure and Augmentation Index by Two Methods and Their Changes After Lifestyle or Medical Interventions in Hypertension

ObjectiveCentral systolic blood pressure (cSBP) and augmentation index (Aix) can be evaluated in office and also in ambulatory condition, during 24-h monitoring. The aim of our study was to measure cSBP and Aix in the office and in 24-h setting cSBP with two calibration methods and also Aix. Thereafter, we aimed to compare their changes after the initiation of lifestyle modifications or antihypertensive medications.MethodsOffice cSBP and Aix were measured with the tonometric PulsePen device (PP-cSBP, PP-Aix, respectively), while 24-h ambulatory cSBP and Aix (24 h-Aix) were evaluated with Mobil-O-Graph. For the calculation of 24-h cSBP both systolic/diastolic and systolic/mean BP calibration methods were considered (24 h-cSBPC1 and 24 h-cSBPC2, respectively). In new hypertensive patients (HT) the measurements were repeated 3 months after the initiation of antihypertensive medication while in white-coat hypertensive patients (WhHT) 12 months after lifestyle modifications.Results105 patients were involved including 22-22 HT and WhHT subjects, respectively. PP-cSBP (128 ± 13 mmHg,) was higher than 24 h-cSBPC1 (118 ± 9 mmHg, p < 0.05), but equal with 24 h-cSBPC2 (131 ± 11 mmHg). PP-Aix (14 ± 14%) was lower than 24 h-Aix (22 ± 7%, p < 0.05). For medical intervention PP-cSBP (Δ16 mmHg) decreased more, than 24 h-cSBPC1 (Δ10 mmHg, p < 0.05) and 24 h-cSBPC2 (Δ9 mmHg, p < 0.05).ConclusionsOffice tonometric and 24 h oscillometric cSBP values differ depending on the calibration. When examining the effect of antihypertensive treatment, the more marked changes in office tonometric cSBP suggests its higher variability compared with 24 h oscillometric central SBP. During follow-up, the two calibration methods of 24 h-cSBP seems not to be interchangeable.

IMPACT OF NON-DIPPING PATTERN AND NOCTURNAL HYPERTENSION ON LEFT VENTRICULAR MASS INDEX IN UNTREATED WHITE-COAT HYPERTENSIVE SUBJECTS

Objective: Several studies have demonstrated that subjects with white-coat hypertension (WCH) have an increased risk of adverse cardiovascular outcome and target organ damage (TOD) progression compared to normotensives. The potentially detrimental effect of non-dipping or nocturnal hypertension on TOD has not been fully elucidated in subjects with WCH. The aim of our study was to investigate the impact of both dipping status and nocturnal hypertension on the left ventricle mass index (LVMI) of WCH individuals. Design and method: A total of 387 untreated WCH subjects underwent echocardiographic measurements. LVM was estimated using Devereux's formula according to the Penn Convention Protocol. LVMI was defined as LVM divided by the body surface area. The study population was divided into dippers (blood pressure (BP) nocturnal fall &gt;10%) and non-dippers (BP nocturnal fall &lt;10%) as well as into nocturnal hypertensives (nighttime systolic BP&gt; = 120mmHg or nighttime diastolic BP&gt; = 70mmHg) and nocturnal normotensives (nighttime systolic BP&lt;120mmHg and nighttime diastolic BP&lt;70mmHg). Statistical analysis was performed by means of independent-samples t-test, chi-square test and linear regression. Results: The percentages of non-dippers and nocturnal hypertensives in WCH subjects were 49% and 28%, respectively. The variables associated with LVMI in the univariate analyses were: age, male gender, body mass index, 24-hour diastolic BP and non-dippers. The multivariate regression analyses demonstrated significant associations of LVMI with the following factors: age (B = 5.760, 95% CI: 3.282 to 8.239; p&lt;0.001), male gender (B = 10.941, 95% CI: 5.756 to 16.125; p&lt;0.001), body mass index (B = 0.685, 95% CI: 0.138 to 1.232; p = 0.014), 24-hour diastolic BP (B = -6.634, 95% CI: -11.212 to -1.456; p&lt;0.011) and non-dippers (B = 8.415, 95% CI: 3.449 to 13.380; p = 0.001). Non-dipping pattern was correlated to an increase of 8.415 g/m2 in the LVMI in WCH subjects. Conclusions: Non-dipping status is positively and independently associated with LVMI in untreated WCH patients. In contrast, statistically significant association between nocturnal hypertension and LVMI was not observed.

White Coat Effect: Is It Because of the Hospital Setting, or Is It Physician-Induced?

White coat hypertension (WCH) patients are those individuals who have high blood pressure (BP) in the medical environment but are normal during their daily activities. White coat hypertensive patients with normal daytime ambulatory blood pressure monitoring (ABPM) rapidly progress to sustained hypertension. WCH is mainly treated with non-pharmacological methods. Alpha-1 agonists and beta blockers are logical treatment choices for patients with fixed hypertension with the White Coat Effect (WCE). Masked hypertension patients are those individuals who have normal values at the doctor's office but elevated BP at home or during 24-hour ABPM (24-hour or daytime). ABPM is a more practical and reliable method for detecting patients with WCH. This observational study was conducted at Dayanand Medical College & Hospital, Ludhiana, over the course of one year (December 2015 to November 2016). The primary objective of the study was to determine whether there was a difference in blood pressure readings between the home setting and the hospital setting. The secondary objective was to determine whether the difference, if present, between the hospital and home readings was due to the hospital setting, physician presence, or a combination of both. Patients with stage 1 hypertension were included in the study, irrespective of antihypertensive treatment. Patients with ischemic heart disease, chronic liver failure, and chronic kidney disease who could not follow protocol instructions were excluded. In our study, the mean age of patients was 53.91±12.86 years. The patient's mean systolic blood pressure (SBP) and diastolic blood pressure (DBP) readings at the hospital were higher than their home readings (p-0.012; p-0.001, respectively). Mean hospital SBP and DBP readings recorded by the physician were higher than readings recorded by patients alone at home (p-0.002; p-0.014, respectively) and alone at the hospital (p-0.004; p-0.001, respectively). BP readings taken by the physician with a manual sphygmomanometer were significantly lower than those taken with a digital sphygmomanometer by patients and physicians in all settings (p<0.05). The mean rise in BP was significant in both the physician's presence and the hospital environment (p<0.05 for both), and this rise was more significantly associated with the hospital effect than the physician effect (p<0.05). Misdiagnosis of hypertension results in inappropriate prescription and overuse of antihypertensive medications for individuals who are not persistently hypertensive. So it is very important to rule out WCH in both the hospital setting and the physician's presence, more precisely by ABPM. WCH can be diagnosed with regular BP monitoring by a digital sphygmomanometer at home.

FREQUENCY OF WHITE COAT HYPERTENSION USING 24 HOUR AMBULATORY BLOOD PRESSURE MONITORING (ABPM) IN PATIENTS PRESENTING TO TERTIARY CARE HOSPITAL

Objectives: Prevalence and epidemiologic characteristics of patients with white coat hypertension in our population. Ambulatory blood pressure monitoring is an effective tool to diagnose white coat hypertension. To know the frequency of white coat hypertension in patients presenting to cardiology division of Khyber Teaching Hospital with the help of ambulatory blood pressure monitoring.&#x0D; Methodology: This cross sectional study was conducted at department of cardiology, MTI / Khyber Teaching Hospital, Peshawar. This study was conducted from 28th August 2021 till 28th February 2022. 102 patients of either gender presenting for blood pressure and cardiac evaluation were enrolled. Diagnosis of hypertension was made on 24 hour ambulatory blood monitoring device. Office blood pressure ≥130/80mmHg and average blood pressure less than 130/80mmHg was considered confirmatory for white coat hypertension.&#x0D; Results: Age of the patients ranged from 30 to 65 years. Mean age of the patient was 46.68 ± 10.239 years. Male to female ratio was 2.1:1. White coat hypertension was found in 35 patients (34.3%). Gender and smoking history were found to have significant association with white coat hypertension.&#x0D; Conclusion: White coat hypertension is a frequent finding in patients presenting for evaluation to cardiology department. Elderly female and patients with smoking history are more likely to have it.

Nighttime mean arterial pressure is associated with left ventricular hypertrophy in white-coat hypertension.

White‐coat hypertension (WCH) is associated with increased cardiovascular risks. To investigate the relationship between WCH and left ventricular hypertrophy (LVH), the authors recruited 706 participants who underwent anthropometric measurements, blood laboratory analysis, 24h ambulatory blood pressure monitoring (ABPM), and echocardiography. The authors defined WCH as elevated office BP but normal ABPM over 24h, daytime, and nighttime periods. The authors compared the proportion of LVH between the true normotension (NT) and the WCH population, and further assessed the associations between BP indexes and LVH in the two groups, respectively. The proportion of LVH was significantly higher in the WCH group than in NT participants (19.70% vs. 13.12%, P = .036). In the NT group, 24h SBP, 24h PP, daytime SBP, daytime PP and SD of nighttime SBP were associated with LVH after adjustment for demographic and blood biochemical data (all P < .05). In the WCH population, LVH was associated with 24h SBP, nighttime SBP, nighttime MAP, and office SBP after adjustment (all P < .05). However, on forward logistic regression analysis with all the BP indexes listed above, only 24h SBP (OR = 1.057, 1.017–1.098, P < .001) in the NT group, and nighttime MAP (OR = 1.114, 1.005–1.235, P < .05) and office SBP (OR = 1.067, 1.019–1.117, P < .001) in the WCH group were still significantly associated with LVH. Our study suggests that the proportion of LVH is higher in WCH patients than in the NT population. Furthermore, elevated nighttime MAP and office SBP may play critical roles in the development of LVH in the WCH population.

The relationship between white coat hypertension and the index of cardiac electrophysiological balance (ICEB)

Aim: The index of cardiac electrophysiological balance (ICEB) is a new marker that can show the potential for ventricular arrhythmia and indicate the balancebetween ventricular depolarization and repolarization. A tendency toward ventricular arrhythmia has been shown innon-dipper hypertension and prehypertensive patients in various studies. White coat hypertension (WCH) has been shown to be associated with target organ damage and the actual development of hypertension. In this study, we aimed to evaluate the effect of dipper and non-dipper patterns on the ICEB in patients diagnosed with WCH.&#x0D; Material and Method: A total of 108 patients were included in this study. Patients were divided into two groups as dipper and non-dipper patterns according to ABPM. QT/QRS (ICEB) and cQT/QRS (ICEBc) were recorded with computerized interpretation of the electrocardiogram.&#x0D; Results: While electrocardiographic parameters including heart rate, PR interval, QT interval, cQT interval, and ICEB were similar in both groups (p&gt;.05), in the non-dipper group, QRS duration was lower (p=.017) and ICEBc was higher (p=.001).&#x0D; Conclusion: ICEBc may predict asusceptibility to ventricular arrhythmias in WCH patients. Therefore, non-dipper WCH patients with a high ICEBc should be followed for arrhythmia outcomes in addition to hypertensive outcomes.

Is there a relationship between heart rate recovery and blood pressure in white coat hypertension?

Aim Increasing evidence suggests that autonomic dysfunction may be involved in the etiology of white coat hypertension (WCH). The aim of this study was to evaluate cardiac autonomic function by using heart rate recovery (HRR) indices in patients with WCH classified according to their circadian rhythm type of blood pressure (BP).Material and methods This cross-sectional study included 120 participants over the age of 18 yrs, including 50 patients diagnosed with WCH and 70 healthy controls with normal in- and out-of-office BP and without any known disease. Circadian rhythm types, i.e., dippers and non-dippers, were identified using ambulatory BP monitoring. The HRR indices were calculated by subtracting the 1st-minute (HRR1), 2nd-minute (HRR2), and 3rd-minute (HRR3) heart rates from the maximal heart rate recorded during stress testing.Results The lesser decline in nighttime BP (6.4±2.14 and 13.3±2.2 mmHg, respectively; p&lt;0.001) and the smaller mean HRR1 (25.5±3.0 and 30.3±3.1 beats / min, respectively; p&lt;0.001) were evident in WCH non-dippers compared to WCH dippers. Linear regression analysis showed that HRR1 (β±SE=0.43±0.11; p&lt;0.001) and diastolic BP at maximum exercise (β±SE=0.14±0.07; p=0.040) are independent risk factors for the blunted decline in nighttime BP.Conclusion Delayed recovery of heart rate after an exercise stress test is associated with non-dipper type of circadian rhythm of BP. This was more pronounced in WCH patients, and these patients are at risk of autonomic dysfunction.

Isolated systolic hypertension is associated with increased left ventricular mass index and aortic stiffness in adolescents: a cardiac magnetic resonance study.

Despite the high prevalence of isolated systolic hypertension (ISH) among hypertensive adolescents, its clinical significance is not determined. In addition, it is hypothesized that ISH with normal central blood pressure (BP) in young patients is a benign phenomenon and was hence labeled spurious hypertension (sHTN). Using cardiac magnetic resonance we evaluated a group of 73 patients with suspected primary hypertension, aged 13-17 years (median: 16.9, interquartile range 15.8-17.4; 13 girls), in whom, based on 24-h ambulatory BP monitoring either ISH (n = 30) or white-coat hypertension (WCH) (n = 43) was diagnosed. Based on noninvasive central BP measurement 13 participants in the ISH group were classified as having sHTN and 17 were diagnosed with true hypertension. Compared with WCH adolescents, ISH patients presented with higher indexed left ventricular mass index (LVMI) (P < 0.001), maximal left ventricular (LV) wall thickness (P < 0.001), LV concentricity (P = 0.001) and more often had LV hypertrophy (47 vs. 14%, P = 0.002). They had higher average pulse wave velocity (PWV) in the proximal aorta (P = 0.016) and the whole thoracic aorta (P = 0.008). In addition, we observed higher indexed LV stroke volume (P = 0.025) in patients with ISH. The sHTN subgroup had significantly higher LVMI and aortic PWV, and more often had LV hypertrophy compared with the WCH group. The sHTN and true hypertension subgroups did not differ in terms of aortic PWV, LVMI or LV geometry. Compared with adolescents with WCH patients with ISH, including the sHTN subtype, have more pronounced markers of cardiac end-organ damage, higher aortic stiffness and stroke volume.

Cross-sectional comparison of office and ambulatory pulse wave velocity by two methods, and their changes after lifestyle or medical interventions in hypertension.

Pulse wave velocity (PWV), the most accepted biomarker of arterial stiffening can be measured by different methods and in the past decade, its 24 h monitoring has also become available. The aim of our study was to compare office and ambulatory PWVs and in a proportion of patients to compare the changes of PWVs after the initiation of lifestyle modifications or antihypertensive medication. Office carotid-femoral PWV was measured with the tonometric PulsePen device (PP PWV), first hour and 24 h ambulatory oscillometric PWVs were evaluated with Mobil-O-Graph (MOB first hour PWV and MOB 24 h PWV, respectively). In new hypertensive patients, the measurements were repeated 3 months after the initiation of antihypertensive medication. In white-coat hypertensive patients after lifestyle modifications the measurements were repeated at 12 months. One hundred and five participants were involved with 22 new hypertensive and 22 white-coat hypertensive (WhHT) patients. PP PWV [8.7 (7.3-9.9) m/s] differed from MOB first hour PWV [7.3 (6.5-8.8) m/s] and MOB 24 h PWV [7.4 (6.4-8.8) m/s] as well (P < 0.05). PP PWV significantly decreased both in hypertensive [by 0.9 (0.4-1.5) m/s, P < 0.05] and WhHT patients [by 0.3 (-0.1 to 1) m/s, P < 0.05]. MOB first hour PWV did not change neither in hypertensive patients, nor in WhHT patients. MOB 24 h PWV decreased only in hypertensive patients [by 0.2 (0-0.6) m/s], which was less pronounced compared with PP PWV (P < 0.05). The significant differences observed both in the cross-sectional and in the prospective parts of our study suggests that the two methods are not interchangeable.

Five years of cardio-ankle vascular index (CAVI) and CAVI0: how close are we to a pressure-independent index of arterial stiffness?

Pulse wave velocity, a common metric of arterial stiffness, is an established predictor for cardiovascular events and mortality. However, its intrinsic pressure-dependency complicates the discrimination of acute and chronic impacts of increased blood pressure on arterial stiffness. Cardio-ankle vascular index (CAVI) represented a significant step towards the development of a pressure-independent arterial stiffness metric. However, some potential limitations of CAVI might render this arterial stiffness metric less pressure-independent than originally thought. For this reason, we later introduced CAVI0. Nevertheless, advantages of one approach over the other are left debated. This review aims to shed light on the pressure (in)dependency of both CAVI and CAVI0. By critically reviewing results from studies reporting both CAVI and CAVI0 and using simple analytical methods, we show that CAVI0 may enhance the pressure-independent assessment of arterial stiffness, especially in the presence of large inter-individual differences in blood pressure.

REMAINING CARDIOVASCULAR RISK MARKERS IN PARTICIPANTS WITH WHITE-COAT HYPERTENSION DIAGNOSED BY HOME BLOOD PRESSURE RECORDINGS

Objective: White coat hypertension (WCH) is defined as having hypertensive blood pressure in the office but normal ambulatory or home blood pressure (HBP) levels. The cardiovascular prognosis in WCH is controversial. Some studies have demonstrated it to be a benign condition while others have linked it to possible health complications. The objective for this study is to evaluate remaining cardiovascular risk markers in WCH patients by analyzing interactions of WCH with metabolic factors, calcium score, pulse wave velocity (PWV) and carotid plaques in a large, randomly selected population-based cohort. Design and method: BP was measured in both clinic and at home in 5057 middle-aged participants. HBP was measured morning and evening for 7 days except for the first day in which the morning was spent in the clinic. WCH was defined as having a systolic OBP &gt; = 140 mmHg and/or diastolic BP &gt; = 90 mmHg while HBP systolic BP &lt; 135 and diastolic BP &lt; 85 mmHg. In some calculations WCH was lowered to HBP &lt; 125/ &lt; 75 mmHg. Normotensive BP was defined as OBP &lt; 140/ &lt; 90 and HBP &lt; 135/ &lt; 85. Blood tests, computer tomography (CT) scanning of the abdomen, coronary arterial angiography, arterial PWV, cardio-thoracic imaging and ultrasonography of the carotid arteries was performed. In addition, all participants filled out extensive electronic lifestyle questionnaires and this information was also accounted for. Independent t-tests were used for all calculations and to compare normotensives (NT) and WCH with the two different cut-offs, against known risk factors. Results: All tests showed significant signs of more metabolic and cardiovascular damage for WCH patients compared to normotensives, even with the stricter WCH definition (see table 1 and 2). Calculations from questionnaire data showed that normotensive women scored lower on a scale designed to measure nervousness than women with WCH (p = 0.022) and men with WCH reported a higher alcohol consumption than men with normal BP (0.012) Conclusions: Available data suggests that excessive BP reactivity limited to the doctor's office with stricter than usual definitions pose as a cardiovascular risk marker and that these patients probably could benefit from dedicated treatment.

Long-Term Risk of Progression to Sustained Hypertension in White-Coat Hypertension with Normal Night-Time Blood Pressure Values.

Background The long-term prognosis and transition towards sustained ambulatory hypertension (SHT) of white-coat hypertension (WCHT) remain uncertain particularly in those with both normal nighttime and daytime blood pressure (BP) values. Different classification criteria and the use of antihypertensive drugs may contribute to conflicting results. Patients and Methods. We prospectively evaluated for a 7.1 year transition to SHT in 899 nondiabetic subjects free from cardiovascular (CV) events: normotensive (NT) (n = 344; 52, 9% female; ageing 48 ± 14 years); untreated WCHT (UnWCHT n = 399; 50, 1% female; ageing 51 ± 14 years); and treated WCHT with antihypertensive drugs after baseline (TxWCHT n = 156; 54, 4% female; ageing 51 ± 15 years). All underwent 24 h ambulatory BP monitoring (24 h-ABPM) at baseline, at 30 to 60 months, and at 70 to 120 months thereafter. WCHT was at baseline (with no treatment) as office BP ≥ 140/or 90 mm·Hg, daytime BP < 135/85 mm·Hg, and nighttime BP < 120/70 mm·Hg. Development of SHT was considered if daytime BP ≥ 135/or 85 mm Hg and/or nighttime BP ≥ 120/or 70 mm·Hg. Results Baseline metabolic parameters did not differ among groups. At 30–60 months and at the end of follow-up, development of SHT occurred, respectively, in NT (3.8% (n = 13) and 9.6% (n = 33)) and in UnWCHT (10.1% (n = 40) and 16.5% (n = 66)) (p < 0.009). The mean annual increase of average 24 h-systolic BP was 0.48 + 0.93 in NT and 0.73 + 1.06 in UnWCHT, whereas annual SBP in office increased in NT by 1.2 + 0.95 but decreased in UnWCHT by 1.36 + 1.35 mm Hg (p < 0.01). Conclusion Untreated WCHT patients exhibit a faster and a higher risk of developing SHT compared to NT with TxWCHT assuming an intermediate position between them.

Clinical and psychological aspects of true arterial hypertension and white coat hypertension

Abstract Purpose To compare the clinical and psychological features, as well as echocardiographic and ambulatory blood pressure monitoring (ABPM) data in patients with true arterial hypertension (AH) and white coat hypertension (WCH). Methods Were studied 154 subjects (58 men and 96 women, average age 52.9±0.7 years) with increased office blood pressure. The control group consisted of 31 healthy individuals (12 men and 19 women, average age 51.5±2.4 years). All individuals underwent ABPM, Doppler echocardiography, and psychological status studies using the MMPI and Spielberger tests. Results ABPM confirmed the presence of AH in 127 (47 men and 80 women, average age 53.3±0.8 years) of 154 examined patients. 27 patients (17.5%) were diagnosed with WCH - 11 men and 16 women, the average age of 50.8±1.4 years. Among healthy individuals, dippers prevailed, while among AH patients the proportion of dippers was significantly lower (p&amp;lt;0.001) compared with the control group, and a larger number of non-dippers, over-dippers and night-peakers was noted (p&amp;lt;0.01). The distribution of patients with WCH by the type of the daily profile of blood pressure (BP) did not significantly differ from that in healthy individuals (p&amp;gt;0.05). Patients with AH compared with healthy patients had higher average values of the left ventricular (LV) posterior wall as well as interventricular septum thickness, left atrium diameter, and LV myocardial mass index. We found no signs of LV hypertrophy in WCH patients and healthy individuals. The correlation analysis confirmed a reliable relationship between most echocardiographic parameters and ABPM in AH patients (p&amp;lt;0.05). The results of the MMPI and Spielberger tests revealed higher levels of reactive and personal anxiety in patients with AH compared with healthy individuals. Patients with WCH were characterized by disharmonious personality profiles and, in comparison with the control group, more pronounced hypochondriac, hysteroid, and psychasthenic features. Compared with AH patients, subjects with WCH were characterized by less pronounced depression, isolation, rigidity of anxious affect, as well as a more pronounced demonstrative behavior. Conclusions In people with AH patients the structural and functional characteristics of the heart there correlate with the ABPM results. In contrast, echocardiographic findings in individuals with WCH do not significantly differ from those in healthy subjects. Individuals with WCH have more pronounced hypochondriacs, anxious-suspicious and hysteroid personality traits, while for patients with AH depression, isolation, and rigidity of anxious affect are more common. Funding Acknowledgement Type of funding source: None

Assessment of the diagnostic accuracy of home blood pressure monitoring by patients

Introduction: According to available guidelines, home blood pressure monitoring (HBPM) can be used to diagnose hypertension and monitor its treatment; however, its effectiveness has rarely been studied in developing countries, including Iran. Objectives: This study aimed to evaluate the diagnostic accuracy of HBPM, as compared with that of 24-hour ambulatory blood pressure monitoring (ABPM) and office blood pressure measurement (OBPM). Patients and Methods: This study was conducted on 28 patients suspected of having primary hypertension. The blood pressure of the patients was measured by four methods. Initially, blood pressure was measured by a non-physician using a digital sphygmomanometer in a clinic (OBPM-Digital). After about 1 hour, blood pressure was measured by a physician at the clinic using a mercury sphygmomanometer (OBPM-Mercury). In the third stage, the patient’s blood pressure was monitored for 24 hours by the ABPM method. In the fourth stage, each subject used a digital sphygmomanometer to measure HBPM for seven consecutive days. Results: The blood pressure values measured through the ABPM method were significantly lower than those measured by other methods (P&lt;0.05). The prevalence of hypertension diagnosed by OBPM-Mercury, OBPM-Digital, HBPM, and ABPM method was 82%, 54%, 50%, and 21%, respectively. As compared with ABPM as the gold standard, the diagnostic accuracy of HBPM, OBPM-Digital, and OBPM-Mercury was 64%, 61%, and 32%, respectively. The frequency of white coat hypertension (WCH) diagnosed by HBPM and ABPM methods was 39% and 64%, respectively, and the frequency of masked hypertension (MH) diagnosed was 7% and 4%, respectively. The sensitivity, specificity, and diagnostic accuracy of HBPM, as compared with ABPM, in detecting MH were 100%, 96%, and 97%, respectively; in addition, as compared with WCH, they were 56%, 90%, and 68%, respectively. Conclusion: The findings of the present study showed that HBPM had higher diagnostic accuracy than OBPM in diagnosing hypertension. Also, HBPM was able to detect MH with a high level of diagnostic accuracy, and in more than two-thirds of cases, it was also able to detect WCH and diagnose patients with sustained hypertension.

THE RELATION OF LEFT VENTRICULAR DIASTOLIC DYSFUNCTION AND INCREASED LEFT VENTRICULAR MASS WITH BLOOD PRESSURE VARIABILITY IN NON-ESTABLISHED HYPERTENSIVE PATIENTS

Background: Long term high blood pressure is a major risk factor for coronary artery disease, stroke, heart failure, peripheral vascular disease, vision loss and chronic kidney disease. Objective: To demonstrate the relation between left ventricular diastolic dysfunction increased left ventricular mass and ambulatory blood pressure recording in subjects not known to be hypertensive. Patients and Methods: This was a- cross sectional study that carried out on (100) normotensive patients in Cardiology Department Clinic at Matrouh Specialized Cardiothoracic and Interventional Catheterization Center from October, 2017 to January 2019. Results: there was a-significantly marked difference in left ventricular (LV) mass between two groups (normal blood pressure and latent hypertension) and significantly marked difference in diastolic dysfunction. According to normal circadian and impaired circadian, there was a- significant difference between the two major groups in sex, where male >female, and marked difference in LV mass between the two groups (normal circadian and impaired circadian), and in smoking. Conclusion: Ambulatory blood pressure (AMBP) played an important role as a predictor to estimate prevalence of hypertension based on diastolic dysfunction and increased left ventricular mass in persons with normal blood pressure measures at office specially masked hypertension in white coat hypertensive patients.

Evaluation of affective temperaments and arterial stiffness in different hypertension phenotypes.

Affective temperaments (depressive, anxious, irritable, hyperthymic, and cyclothymic) are stable parts of personality and describe emotional reactivity to external stimuli. Their relation to psychopathological conditions is obvious, but less data are available on their relationship with cardiovascular disorders. The aim of this study was to evaluate affective temperaments and hemodynamic and arterial stiffness parameters in healthy subjects (Cont), in white-coat hypertensive (WhHT) patients, and in non-resistant (non-ResHT) and resistant hypertensive (ResHT) patients. In this cross-sectional study, 363 patients were included: 82 Cont, 44 WhHT, 200 non-ResHT, and 37 ResHT. The patients completed the Temperament Evaluation of Memphis, Pisa, Paris, and San Diego Autoquestionnaire (TEMPS-A), and arterial stiffness was examined with tonometry (PulsePen). Significant differences were found between the Cont, WhHT, non-ResHT and ResHT groups in pulse wave velocity (7.76 ± 0.96, 8.13 ± 1.39, 8.98 ± 1.25, and 10.18 ± 1.18 m/s, respectively, p < 0.05 between Cont and non-ResHT/ResHT; p < 0.05 between non-ResHT and ResHT). Cyclothymic affective temperament points (4 (2.25-8)) were higher (p < 0.05) in the ResHT group than in the Cont (2 (0-5)) and non-ResHT (3 (1-5)) groups. The cyclothymic temperament points of the WhHT group (4 (2-7)) were also higher than those in the Cont group. ResHT was independently associated with a cyclothymic scale score above 6 (beta = 2.59 (95% CI: 1.16-5.77)), an irritable scale score above 7 (beta = 3.17 (95% CI: 1.3-7.69)) and an anxious scale score above 9 (beta = 2.57 (95% CI: 1.08-6.13)) points. WhHT was also independently associated with cyclothymic scale scores above 6 points (beta = 2.378, 95% CI: 1.178-4.802). In conclusion, white-coat and ResHT patients have specific affective temperament patterns, and the evaluation of these patterns can help to understand the psychopathological background of these conditions.

P104 White Coat Hypertension is Associated with Increased Small Vessel Disease in the Brain

ObjectiveSmall vessel disease, measured by brain white matter hyperintensity (WMH), is associated with increased stroke risk and cognitive impairment. This study aimed to explore the relationship between WMH on computerised tomography (CT) and white coat hypertension (WCH) in patients with recent transient ischaemic attack (TIA) or lacunar stroke (LS).MethodsNinety-six patients recruited for the ASIST trial (Arterial Stiffness in Lacunar Stroke and TIA) underwent measurement of clinic blood pressure (BP) and ambulatory BP monitoring (APBM) within two weeks of TIA or LS. Patients were grouped by BP phenotypes. Twenty-three patients had normotension (clinic BP <140/90 mmHg and day-time ABPM <135/85 mmHg) and 25 patients had WCH (clinic BP >140/90 mmHg and day-time ABPM <135/85 mmHg). CT brain images were scored for WMH using the four-point Fazekas visual rating scale. Patients were grouped into no-mild WMH (scores 0–1) or moderate-severe (scores 2–3) groups. The relationship between BP and WMH was explored with chi-square and logistic regression accounting for known cardiovascular risk factors (age, gender, smoking, diabetes and hyperlipidaemia).Results44% of WCH patients had moderate-severe WMH compared to 17% of normotensives (p = 0.047). Logistical regression incorporating WCH as the independent factor and cardiovascular risk factors as independent variables showed WCH to be the only independent significant factor contributing to WMH (p = 0.024).ConclusionPatients with WCH were more likely to have moderate-severe WMH on CT brain than normotensives. WCH was associated with increased WMH, independent of other cardiovascular risk factors. This study suggests that WCH is associated with increased small vessel disease in the brain and may benefit from treatment.Normotension (n = 23)WCH (n = 25)Statistical significanceFemale n(%)8 (35%)7 (28%)p = 0.613Age (years)69.7 ± 11.7976.52 ± 8.69p = 0.026Ever Smoker n(%)12 (52%)18 (72%)p = 0.156Hyperlipidaemia n(%)18 (78%)15 (60%)p = 0.458Diabetes n(%)4 (17%)7 (28%)p = 0.173No-Mild WMH n(%)19 (83%)14 (66%)p = 0.047Moderate-Severe WMH n(%)4 (17%)11 (44%)p = 0.047

Ambulatory Blood Pressure Monitoring in Pregnancy; Does It Influence Our Practice?

Background: Maternal hypertensive disorder is a well-known medical problem during pregnancy and is associated with morbidity and mortality. Out-of-office blood pressure (BP) measurement has been widely used but the importance of detecting white coat hypertension (WCH) is still a topic for debate. Objectives: The aim of this study was to determine the prevalence of WCH in high-risk pregnant women. Methods: We included 56 pregnant women with in-office higher-than-normal BP without previous history of HTN to assess their BP using 24-hour ambulatory blood pressure monitoring (ABPM). Results: The mean age of the participants was 31.61 ± 5.42 years (n = 56) and the majority in the second or third trimesters. Hypertension was detected in 55.4% using 24-hour ABPM. Twenty-five patients (44.6%) had WCH, 60% of whom were in the third trimester. There was a significant difference in the incidence of WCH between women younger than 30 and older individuals (P = 0.041). The mean age was 33.13 ± 5.16 years in patients with true HTN and 29.72 ± 5.22 years in WCH patients (P = 0.018). Conclusions: The prevalence of WCH in pregnancy is noteworthy. Regarding its favorable outcome, this might be a heads-up to avoid unnecessary medication during pregnancy and be concise about defining HTN in this population.