White Coat Normotension Research Articles

Masked Hypertension–A Systematic Review

Background/Aim: The significance of Masked Hypertension(MHT) and Masked Uncontrolled Hypertension(MUCH) in clinical practice is unclear. We systematically reviewed the literature on MHT and MUCH, with a particular focus on prevalence, epidemiology, pathogenesis, clinical significance, evaluation and management. Methods: Medline(OvidSP), PubMed and Cochrane databases were searched for articles published in English from 2000 to 6th Jan 2017 using the MeSH terms and keywords “MHT”, “MUCH”, “Reversed white coat hypertension”, “out of office hypertension”, “Ambulatory hypertension”, and “white coat normotension”. All but publications in paediatric age group, case reports, editorials and narrative reviews were included. Results: 240 articles met the inclusion criteria: 92(epidemiology); 7(pathogenesis); 93(clinical significance); 74(evaluation) and 7(management). The prevalence of MHT/MUCH was variably reported(5.7%-32.1%). Potential risk factors included older age; male gender; African inheritance; mental stress; tobacco, alcohol and caffeine use: obstructive sleep apnoea(OSA); diabetes; chronic kidney disease; hypothyroidism; treatment of hypertension and a high office BP, ambulatory pulse rate and BMI. The pathogenesis of MHT/MUCH is unclear, although it was associated with endothelial dysfunction, oxidative stress, increased plasma leptin levels and sympathetic activity. MHT conferred similar cardiovascular risk as sustained hypertension; increased cardiovascular morbidity/mortality and target organ damage. Ambulatory BP monitoring was the preferred diagnostic method although Home BP monitoring was a useful alternative. Anecdotal evidence supports risk factor modification(OSA), however the evidence for drug treatment of MHT is scant. Conclusion: MHT/MUCH is widely prevalent. Patients with high normal clinic BP should be screened for MHT/MUCH. RCTs are needed to assess the efficacy of drug treatment of MHT.

Untreated masked hypertension and carotid atherosclerosis: A meta-analysis

Aim. Masked hypertension (MH) is recognized as a clinical entity with an unfavorable cardiovascular prognosis; a limited number of reports, however, investigated the impact of this condition on subclinical vascular damage. We performed a meta-analysis aimed at evaluating the association of MH with subclinical carotid atherosclerosis in initially untreated subjects. Design. Studies were identified by the following search terms: “masked hypertension”, “isolated clinic normotension”, “white coat normotension”, “carotid artery”, “carotid atherosclerosis”, “carotid intima-media thickness”, “carotid damage” and “carotid thickening”. Full articles published in English language reporting data from studies performed in untreated adult individuals were considered. Results. Overall, 2752 untreated subjects (1039 normotensive, 497 MH and 766 hypertensive individuals) of both genders were included in five studies (sample size range 18–222 for MH participants). Common carotid intima-media thickness (IMT) showed a progressive increase from normotensive (681 ± 24 μm) to MH (763 ± 57 μm) (standardized mean difference, SMD: 0.51 ± 0.19, 95% CI 0.13–0.89, p < 0.01) and to sustained hypertensive subjects (787 ± 58 μm) (SMD: 0.33 ± 0.07, 95% CI 0.20–0.46, p < 0.01). The statistical difference between MH and NT became borderline after correction for publication bias. A sensitivity analysis showed that the final result was not substantially affected by a single study effect. Conclusions. Our findings support the view that MH subjects tend to have a higher risk of developing early carotid atherosclerosis than their true normotensive counterparts. From a practical perspective, the ultrasound search of preclinical carotid disease may improve cardiovascular risk stratification and decision making strategies in these subjects.

Untreated Masked Hypertension and Subclinical Cardiac Damage: A Systematic Review and Meta-analysis.

Data on the association of masked hypertension (MH) (i.e., normal office and elevated out-of-office blood pressure (BP)) with cardiac damage are scanty. We performed a meta-analysis in order to provide a comprehensive information on subclinical cardiac alterations in subjects with MH. Studies were identified by the following search terms: "masked hypertension," "white coat normotension," "isolated ambulatory hypertension," "left ventricular mass," "left ventricular hypertrophy," "cardiac damage," and "echocardiography." Full articles published in English language providing data on left ventricular (LV) mass and/or prevalence of LV hypertrophy in MH, as assessed by ambulatory BP monitoring, were considered. Overall, 4,884 untreated subjects (2,467 normotensive, 776 MH, and 1,641 sustained hypertensive individuals) of both genders included in 12 studies were analyzed. LV mass index showed a progressive increase from normotensive (79.2 ± 0.35 g/m(2)) to MH (91.6 ± 4.0 g/m(2)) (standard difference in means (SDM): 0.50 ± 0.11, confidence interval (CI): 0.28-0.73, P < 0.01) and to hypertensive subjects (102.9 ± 3.3g/m(2)) (SDM: 0.22 ± 0.07, CI: 0.09-0.35, P < 0.01). After assessing data for publication bias, the difference between groups was still significant. Our findings support an association between MH and increased risk of LV structural alterations compared to true normotensive individuals. Due to the worse cardiovascular prognosis associated with subclinical cardiac damage, subjects with MH should be carefully screened in order to detect hypertensive organ damage and provide appropriate therapeutic interventions.

Causal mechanisms of masked hypertension: socio-psychological aspects

The contribution of Dr Thomas Pickering's study to the measurement of blood pressure (BP) is the defining aspect of his academic career and achievement - narrowly defined. In this regard, two important areas characterized his study as it relates to masked hypertension. First, he introduced the term, masked hypertension, to replace the rather inappropriate term 'reverse white-coat hypertension' and 'white-coat normotension'; thus drawing attention to the fact that these patients are genuinely hypertensive by ambulatory BP but were missed by normal office BP. More importantly, he rightly maintained that masked hypertension is a true continuum of sustained hypertension rather than an aberrant measurement artifact. Second, is his pivotal study on the important role of psychosocial factors as a potential mechanism for the development of masked hypertension. In this regard, he explained masked hypertension as a conditioned response to anxiety in office settings, and highlighted the role that diagnostic labeling plays in its development. His view of masked hypertension is that of a continuum from prehypertension (based on office BP measurement) to masked hypertension (based on ambulatory BP) and finally to sustained hypertension (based on both office and ambulatory BP). He strongly believes that it is the prehypertensive patients who progress to masked hypertension. Subsequently, patients who are prehypertensive should be screened for masked hypertension and treated. In this manuscript, we summarize his study as it relates to the definition of masked hypertension, the psychosocial characteristics, mechanisms and its clinical relevance.

Improving patient outcomes with ambulatory blood pressure monitoring in elderly with hypertension

The purpose of this article is to review the current knowledge regarding ambulatory blood pressure monitoring (ABPM) use in clinical practice and to provide example cases for its use in a hypertension (HTN) specialty clinic. Published research trials, medical literature, and cases from the Center for Senior Hypertension. The knowledge of ABPM benefits to using ABPM are substantial and improves the care and management of many conditions, including white coat HTN, white coat normotension, resistant, borderline, episodic, paroxysmal HTN, and finally orthostatic hypotension. Third-party payers only cover ABPM for "white coat" HTN. This article reviews previous studies and explains the benefit to changing our current practice to match the knowledge we have gained through research through case studies.

Is there any real target organ damage associated with white-coat normotension?

Subjects with white-coat normotension (WCNT) or masked hypertension, i. e. a normal office blood pressure (BP) reading but elevated ambulatory blood pressure monitoring (ABPM) results, have not been extensively studied. The aim of this work was to compare true normotensive subjects (NT), WCNT and nevertreated hypertensive subjects (HT, with elevated BP according to both office and ABPM readings). One hundred and fifty subjects were recruited to analyze cardiovascular characteristics. Office BP readings coupled with ABPM results were used to break this population down into 51 NT, 18 WCNT and 81 HT. Office BP readings were higher in WCNT than in NT. In WCNT, carotid-femoral pulse wave velocity (PWV) was higher than in NT (with a borderline significance p = 0.05) and the standing baroreflex sensitivity (BRS) was lower (p = 0.04). Left ventricular mass index (LVMI) and carotid intima-media thickness (IMT) tended to increase and BRS measurements tended to decrease from NT through WCNT to HT. However, the difference across the board is only significant (p < 0.05) between NT and HT. If only the subset of NT subjects with SBP readings comparable to those of the WCNT subjects (i. e. SBP > 120 mmHg) is considered, no significant difference is detected in PWV and the only difference is detected in BRS (respectively for standing [PS+/RR+]: 5.7 +/- 1.4 ms/mmHg vs 4.9 +/- 1.2 ms/mmHg, p = 0.04). In conclusion, the principal cardiovascular differences measured between the NT and the WCNT can probably be explained by their difference in clinical level of pressure at rest. Only the BRS remains different between NT and WCNT when the real level of clinical pressure is taken into account.

Is increased arterial stiffness the main cardiovascular abnormality in patients with “white coat normotension”?

Is increased arterial stiffness the main cardiovascular abnormality in patients with “white coat normotension”?

White-coat hypertension and normotension in the League of Hypertension of the Hospital das Clínicas, FMUSP: prevalence, clinical and demographic characteristics

To assess the prevalence of white-coat normortension, white-coat hypertension, and white-coat effect. We assessed 670 medical records of patients from the League of Hypertension of the Hospital das Clínicas of the Medical School of the University of S o Paulo. White-coat hypertension (blood pressure at the medical office: mean of 3 measurements with the oscillometric device > or = 140 or > or = 90 mmHg, or both, and ambulatory blood pressure monitoring mean during wakefulness < 135/85) and white-coat normotension (office blood pressure < 140/90 and blood pressure during wakefulness on ambulatory blood pressure monitoring > or = 135/85) were analyzed in 183 patients taking no medication. The white-coat effect (difference between office and ambulatory blood pressure > 20 mmHg for systolic and 10 mmHg for diastolic) was analyzed in 487 patients on treatment, 374 of whom underwent multivariate analysis to identify the variables that better explain the white-coat effect. Prevalence of white-coat normotension was 12%, prevalence of white-coat hypertension was 20%, and prevalence of the white-coat effect was 27%. A significant correlation (p<0.05) was observed between white-coat hypertension and familial history of hypertension, and between the white-coat effect and sex, severity of the office diastolic blood pressure, and thickness of left ventricular posterior wall. White-coat hypertension, white-coat normotension, and white-coat effect should be considered in the diagnosis of hypertension.

How often is white coat normotension in overweight and obese children and adolescents?

How often is white coat normotension in overweight and obese children and adolescents?

How often do office blood pressure measurements fail to identify true hypertension? An exploration of white-coat normotension.

The often-observed differences between ambulatory (ABP) and office blood pressure (OBP) measurements have brought attention to the problem of misdiagnoses. Although there has been much focus on white-coat hypertension (elevated OBP with normal ABP means), few studies have examined "white-coat normotension" (WCN; normal OBP with elevated ABP means). To describe patients with WCN in terms of prevalence and quantitative differences between ABP and OBP; to identify psychological and demographic features that discriminate them from true normotensive patients; and to offer possible corrections for diagnostic limitations of OBP measurements in clinical practice. Five OBP measurements and 10- to 12-hour daytime ABP monitoring in 319 presumed healthy participants. Prevalence rates of WCN were 23% for systolic BP and 24% for diastolic BP. Participants with WCN were more often male, past smokers, and older and consumed more alcohol. Increasing the number of office readings and discarding the first office reading did not improve the accuracy of OBP measurements. Participants with BP of 10 mm Hg above or below the 140/90 office reading cutoff showed the lowest accuracy, with more than 50% of normotensive diagnoses being incorrect. Office measures of BP lack sensitivity, missing a sizable portion of individuals who have hypertensive mean ABP measurements. Subjects with WCN differ from true normotensive subjects on several demographic and lifestyle variables. Only those office readings averaging 20 points above or below the 140/90 cutoff represent safe diagnostic information.

White coat hypertension and normotension and hypertensive heart disease in an elderly population

White coat hypertension and normotension and hypertensive heart disease in an elderly population

Cardiac and arterial target organ damage in adults with elevated ambulatory and normal office blood pressure

“White coat normotension”—elevated ambulatory blood pressure but normal office blood pressure—is associated with left ventricular mass and carotid wall thickness similar to those in patients with s...

Cardiac and arterial target organ damage in adults with elevated ambulatory and normal office blood pressure.

Ambulatory blood pressure may be higher or lower than clinic blood pressure. Attention has focused on "white coat hypertension" (normal ambulatory blood pressure elevated in the clinic). The converse phenomenon of high ambulatory blood pressure but normal office blood pressure-"white coat normotension"-has not been studied. To assess whether white coat normotension (awake ambulatory blood pressure > 134/90 mm Hg and clinic blood pressure < 140/90 mm Hg) is associated with target organ damage. Cross-sectional observational study. University hospital hypertension center and participant work sites. 295 clinically normotensive adults and 64 patients with sustained hypertension (elevated clinic and ambulatory blood pressure). Target organ abnormalities were measured by echocardiography and arterial ultrasonography in 61 patients with white coat normotension, 234 with sustained normotension (normal clinic and ambulatory blood pressure), and 64 with sustained hypertension. Patients with white coat normotension were older; had higher body mass indices, serum creatinine concentrations, and glucose levels; and a higher prevalence of current smokers. Left ventricular mass index and relative wall thickness were higher by 13 g/m2 (CI, 8 to 18 g/m2) and by 0.03 (CI, 0.01 to 0.04), respectively, in patients with white coat normotension compared with those who had sustained normotension. Patients with white coat normotension and those with sustained hypertension did not differ significantly for left ventricular mass index (4 g/m2 [CI, - 3 to 10 g/m2) or relative wall thickness (0.01 [CI, -0.01 to 0.03]). The prevalence of discrete atherosclerotic plaques was similar in patients with white coat normotension (17 of 61, or 28% [CI, 17% to 39%]) and those with sustained hypertension (17 of 64, or 27% [CI, 16% to 38%]), but the difference lost significance after adjustment for age. White coat normotension is associated with left ventricular mass and carotid wall thickness similar to those in sustained hypertension. The association of white coat normotension with prognostically important target organ damage may partly explain the ability of high normal left ventricular mass and high normal clinic blood pressure to predict subsequent hypertension and cardiovascular events in patients with clinical normotension.

P033 Metabolic risk factors and target organ damage in white coat hypertensives, essential hypertensives and normotensives

P033 Metabolic risk factors and target organ damage in white coat hypertensives, essential hypertensives and normotensives

Left ventricular filling profiles in young white-coat hypertensive patients without hypertrophy.

This study was to assess left ventricular diastolic function in young white-coat hypertensive subjects < 50 years of age without hypertrophy. Hypertensive patients (systolic or diastolic blood pressure > or = 140 or > or = 90 mm Hg on all three visits) were defined as white coat if their average 24-hour blood pressure was < 127/81 mm Hg and at least 18/16 mm Hg lower than their average office values. We chose three groups balanced for sex, age, and body mass index: 50 sustained hypertensives, 25 white-coat hypertensives, and 25 normotensives. Office blood pressure was similar in white-coat and sustained hypertensives. Ambulatory blood pressure was comparable in white-coat hypertensives and normotensives. Compared with normotensives, white-coat hypertensives had more impaired diastolic function: increased ratio of late to early filling velocities, raised ratio of late to early time-velocity integral, prolonged deceleration time, and lengthened isovolumic relaxation time (P<.001, P<.001, P=.002, and P<.001, respectively). No difference was noticed between white-coat and sustained hypertensives. Compared with normotensives, white-coat hypertensives had higher values of plasma and urine norepinephrine (P<.001 and P<.001, respectively), plasma and urine aldosterone (P<.001 and P=.002, respectively), plasma renin activity (P=.04), total cholesterol (P=.001), and LDL cholesterol (P<.001). No difference was observed between white-coat and sustained hypertensives. Within white-coat hypertensives, 24-hour urinary aldosterone closely correlated with the ratio of late to early filling velocities (P=.008), and plasma and 24-hour urinary norepinephrine correlated well with total cholesterol (P=.037 and P=.006, respectively). No correlation was detected within the sustained hypertensives and normotensives. Heightened neurohumoral activity clearly supported the progression of diastolic dysfunction and metabolic abnormality in white-coat hypertensives.

White-coat normotension and blood pressure variability.

The objective of this study was to assess blood pressure variability in patients with clinical normotension and ambulatory hypertension (the so-called white-coat normotension). In 58 white-coat normotensives (mean age 64.2 +/- 14.9 years; male/female ratio = 1.5:1) the authors evaluated blood pressure variability using the twenty-four-hour coefficient of variability. Fifty-eight essential hypertensives with the same age and sex distribution were recruited as a control group. The coefficient of variability in white-coat normotension was greater than in the control group (14.8/16.1 +/- 4.2/3.8% vs 13.5/15.1 +/- 3.3/3.1%), but this difference was not statistically significant. These findings suggest that white-coat normotension is the result of a specific relaxing response to medical visits and not the expression of an elevated blood pressure variability. It is probably due to the reverse of the alerting response, which causes white-coat hypertension.

Elevated ambulatory with normal clinic blood pressure (“White coat normotension”) is associated with cardiac and arterial target organ damade

Elevated ambulatory with normal clinic blood pressure (“White coat normotension”) is associated with cardiac and arterial target organ damade

G35 - Repeated office BP controls reduce the prevalence of white coat hypertension and detect a group of white coat normotensives

G35 - Repeated office BP controls reduce the prevalence of white coat hypertension and detect a group of white coat normotensives