White Coat Phenomenon Research Articles

CAN PATIENTS WITH CARDIOVASCULAR RISK FACTORS AND DIFFERENCE BETWEEN OFFICE AND OUT-OF-OFFICE BP MEASUREMENTS BENEFIT FROM ABPM?

Objective: Blood pressure (BP) is a dynamic parameter characterized by fluctuations during the 24-hour period. During the nighttime hours, BP drops 10-20% in normotensive and untreated hypertensive patients - a dipping phenomenon, followed by a rapid and gradual increase during waking hours. The dipping phenomenon can be checked by Ambulatory Blood Pressure Measurement (ABPM). The main clinical indications for ABPM, suggested by the available studies, are white-coat phenomena, masked hypertension, and nocturnal hypertension. Design and method: Our study involved 45 patients with over 20% difference between office and out-of-office blood pressure measurements. We checked their medical history for other cardiovascular risk factors, such as Dyslipidemia, Diabetes Mellitus, Coronary Disease. Our patients were under 24 hour- ABPM and they were classified according to the rate of fall in systolic BP during 24-hour recording into four categories: the extreme-dippers drop >20%, dippers drop >10% and <20%, non-dippers drop <10% and >0%, and reverse-dippers or risers drop <0%. The purpose of our study is to consider the significance of ABPM in specific target groups of patients with cardiovascular risk factors. Results: In our study 44 patients participated (56,8% men) with mean age 55,9 and mean value of systolic BP 120,7mmHg. 40,9% of the patients had a history of hypertension, 36,4% dyslipidemia, 15,9% diabetes mellitus and 11,4% coronary disease. 77,3% of the patients were judged to be normotensive, but 35,3% of them had a history of hypertension and were under medication, only 11,4% were judged to be hypertensive, 6,8% with isolated diastolic hypertension and 4,5% with isolated systolic hypertension. According to ABPM, we changed medication in 29,5% of the patients. 76.9% of them had already history of hypertension and were under medication, 38,5% had dyslipidemia and 30,7% diabetes mellitus and coronary disease. Conclusions: In our study we were not able to demonstrate that patients with difference between office and out-of-office BP measurements and cardiovascular risk factors could benefit most from ABPM but we demonstrated that patients with a history of hypertension could benefit form ABPM, so that physician could choose the appropriate treatment.

Management of Resistant Hypertension.

Resistant hypertension (RH) is a severe form of hypertension associated with increased cardiovascular risk. Although true RH affects less than 10% of the patients receiving antihypertensive therapy, the absolute number is high and continues to increase. The workup of these patients requires screening for secondary hypertension and pseudoresistance, including poor adherence to prescribed medicines and the white-coat phenomenon. The treatment of RH consists of lifestyle modifications and pharmacological therapies. Lifestyle modifications include dietary adjustments, weight loss, physical activity, and limiting alcohol consumption; pharmacological therapies include diuretics, mineralocorticoid receptor antagonists, beta blockers, angiotensin receptor-neprilysin inhibitors, and others. Over the last 15 years, interventional approaches have emerged as adjunct treatment options; we highlight catheter-based renal denervation. This review summarizes the rationales and latest clinical evidence and, based thereon, proposes an updated algorithm for the management of RH.

Modulation of executive functioning by social stress: a behavioural study (Modulación del funcionamiento ejecutivo por estrés social: un estudio conductual)

ABSTRACT Executive Functions (EFs) correspond to a general construct of cognitive abilities aimed at optimizing problem-solving and regulating behaviour effectively and efficiently. The current consensus model of EFs comprises three components: working memory, inhibitory control and cognitive flexibility. The present study sought to evaluate differences in task performance assessing EFs when subjects are confronted with a social stress paradigm related to the ‘white coat phenomenon’. It involved 40 Chilean university students, mean age 21.8 years, who were randomly assigned to one of two conditions: in the presence of social stress (treatment) or in the absence of social stress (control). The results showed a partial impact of the white coat phenomenon, with statistically significant differences at p ≤ .05, when comparing both conditions in relation to the tasks that evaluated inhibitory control and cognitive flexibility, with both tasks presenting a higher speed of response in the experimental condition of social stress, with the accuracy of the responses being unaffected.

S-39-1: COVID-19 AND HYPERTENSION IN JAPAN, AND KANAGAWA RASI COVID-19 STUDY

Severe acute respiratory syndrome coronavirus 2 (SARSCoV2) caused a global coronavirus disease-2019 (COVID19) pandemic, as declared by the World Health Organization on March 11, 2020. COVID19 was confirmed for the first time in January 2020, and despite epidemic prevention efforts, the number of patients with COVID19 continued to increase, primarily in metropolitan areas. To prevent the further spread of COVID19, the Japanese government announced a state of emergency on 7 April 2020, similar to the lockdowns impleme nted in other countries. We showed a significant increase in office BP with the white coat phenomenon was observed during the state of emergency, as well as an increase in related stress, thereby indicating that we should pay more attention to BP management during stressful global events, including the COVID19 pandemic, to prevent cardiovascular events (Kobayashi K, et al. Hypertens Res 2022; Kobayashi K, et al. Ito S, et al. J Diabetes Investig Apr 18 Epub, 2022). In addition, since the onset of the COVID19 pandemic, the possible roles of renin angiotensin system (RAS) inhibitors in COVID19 have been debated as favorable, harmful, or neutral. ACE2 not only is the entry route of SARSCoV2 infection but also triggers a major mechanism of COVID19 aggravation by promoting tissue RAS dysregulation, which induces a hyperinflammatory state in several organs, leading to lung injury, hematological alterations, and immunological dysregulation. ACE inhibitors and ARBs inhibit the detrimental hyperactivation of the RAS by SARSCoV2 and increase the expression of ACE2, which is a counterregulator of the RAS. Several studies have investigated the beneficial profile of RAS inhibitors in COVID19; however, this finding remains unclear. Further prospective studies are warranted to confirm the role of RAS inhibitors in COVID19 (Matsuzawa Y, et al. Hypertens Res 2020; Matsuzawa Y, et al. Hypertens Res, 202; Sato R, et al. Clin Exp Nephrol 2022).

PSUN115 Features of Metabolic and Hemodynamic Parameters in Obese Patients with True and Pseudo-Resistant Hypertension

Abstract Given the negative contribution of obesity-associated metabolic disorders to the formation of cardiovascular complications, adequate blood pressure (BP) control is very important in patients with arterial hypertension (AH) and obesity comorbidity. Objective to conduct a comparative assessment between metabolic and hemodynamic parametersinobese patients with true and pseudo-resistant AH. Methods The study included 302 patients with uncontrolled AH and obesity. Initial treatment efficacy was assessed 3 months after dual therapy was administered. Those patients who did not reach target BP in dual therapy were transferred to triple therapy. Among patients who received triple therapy, 69 people did not reach target BP (they received the fourth drug spironolactone). All patients were additionally examined 6 months after the initiation of antihypertensive therapy. Results A comparative assessment of BP levels was carried out between non-resistant and resistant patients: at the initial stage of enrolling patients, there was no significant difference in BP between non-resistant and subsequently resistant patients; after 3 months of follow-up (after prescribing double fixed combinations), there was a significant difference in the indicators of both office and out-of-office BP in resistance and non-resistance; despite the achievement of target BP levels after 6 months of therapy, in the presence of resistance, both office, home and most ABPM indicators were significantly higher than in non-resistance. An assessment of the possible causes of pseudo-resistance showed that most often, pseudo-resistance was observed in patients with non-compliance with recommendations to increase physical activity (55.26%) and reduce the calorie intake of food consumed (44.77%), as well as with poor compliance to the prescribed therapy (42.11%). At the same time, high salt intake, chronic kidney disease, obstructive sleep apnoea, and the white-coat phenomenon also contributed to the formation of pseudo-resistance. More than half of the patients (63.16%) had a combination of several factors that could contribute to the formation of pseudo-resistance. If at the stage of enrolling patients into the study and 3 months after the start of therapy there was no significant difference in BP levels between true and pseudo-resistant patients, then after 6 months of antihypertensive therapy, patients with true resistance had significantly higher levels of office SBP (p<0.01) and 24 h average SBP according to ABPM data (p<0.05) compared with pseudo-resistant patients. Obese patients with true resistance had also significantly lower BMI and LDL-cholesterol (p<0.05) as well as higher levels of aldosterone and SBP (p<0.05) compared with pseudo-resistance. Conclusions Even when target BP levels in antihypertensive therapy are achieved, obese resistant patients are characterized by higher levels of office and out-of-office BP, compared with non-resistance. Compared with pseudo-resistance, the presence of true resistance in obesity is associated with higher SBP and aldosteron levels, as well as lower BMI and LDL-cholesterol. Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.

IMPROVED OFFICE BLOOD PRESSURE CONTROL BY AUTOMATIC DELAYED-READING OSCILLOMETRIC DEVICE

Objective: Office blood pressure measurement is a recommended procedure by clinical guidelines. We designed the study to know the degree of blood pressure control by clinical measurement using an automatic delayed-reading oscillometric device. Design and method: During one month we collect demographic and clinical data, office attended systolic blood pressure and diastolic blood pressure measured with an automatic device with a delayed start of the measurement and, if performed, data from ambulatory blood pressure monitoring. Results: We included 102 patients (67 men), with a mean age of 64.9 years, 30% diabetic and 34% with cardiovascular complications. 70% had a controlled hypertesion (<140/90 mmHg) by office blood pressure, the mean systolic blood pressure was 131 ± 16.5 mmHg and the diastolic blood pressure was 73 ± 9.5 mmHg which is a high percentage compared with other studies. Old age and diabetes were associated with uncontrolled hypertension. Thirty three patients had ambulatory blood pressure monitoring data, which allowed them to be classified according to the 24-hour blood pressure into: 30% true normotension, 9% white-coat hypertension, 15% sustained hypertension, and 45% masked hypertension. Therefore, ambulatory measurements did not confirm the good blood pressure control. Conclusions: The use of automatic delayed-reading device reduces the white-coat phenomenon, improving the percentage of patients with office blood pressure controlled. However, this control is not confirmed outside the clinic, showing the importance of ambulatory blood pressure monitoring in the global evaluation of hypertension control. Aspects such as the presence or not of an observer, the number of blood pressure readings and the use of validated automatic devices with or without delayed start of the measurement should be the subject of clinical studies to determine the optimal technique for measuring office blood pressure.

Self-Monitoring Home Blood Pressure in Community-Dwelling Older People: Age Differences in White-Coat and Masked Phenomena and Related Factors-The SONIC Study.

Some studies reported that home blood pressure (HBP) monitoring was conducted by community-dwelling older people themselves, but there have been few studies on HBP including very old populations aged over 90 years old. Thus, the aim of the present study was to clarify the current situation of white-coat and masked phenomena defined by on-site and home BP measurements in community-dwelling old and oldest-old populations. The study subjects were 380 participants from the SONIC study, a cohort study of a community-dwelling old population, who measured their HBP in a series of 3–5 days by themselves and brought their HBP records to the venue on the survey day. Study participants' characteristics were as follows: female, 185 (48.7%); male, 195 (51.3%); 70s, 95 (25.0%); 80s, 245 (64.5%); and 90s, 40 (10.5%). A total of 344 (90.5%) participants had hypertension. A total of 291 (76.6%) hypertensive participants taking antihypertensive medication were analyzed in the present study. Regarding the types of hypertension defined by home and on-site BP, they showed white-coat phenomenon, 183 (48.2%); masked phenomenon, 115 (30.3%); sustained hypertension, 130 (34.2%); and normotension, 82 (21.6%). On comparison of age groups, there was a tendency for the white-coat phenomenon to be common in young-old people in their 70s and the masked phenomenon to be common in very old people in their 90s. Therefore, since the detection of white-coat and masked phenomena is closely associated with appropriate BP management, it is very important for community-dwelling older populations to self-monitor HBP.

A Study Comparing Office Blood Pressure with Ambulatory Blood Pressure in Successful Adult Kidney-Transplant Recipients at a Tertiary Care Center in North India

Introduction: Hypertension is common following successful renal transplantation and has adverse effects on cardio-vascular and graft health. Blood pressure (BP) readings obtained during clinical visits can be misleading and ambulatory blood pressure monitoring (ABPM) is a more reliable and accurate non-invasive method of BP monitoring. Aims and Objectives: To compare office BP with ambulatory BP recordings in successful adult kidney transplant recipients (KTRs). Material and Methods: Office BP (OBP) was measured with mercury sphygmomanometer according to standardized procedure as the mean of two readings taken 1 minute apart; thereafter, 24 hour ABPM was done using automated oscillometric device (Meditech device) in 56 KTRs. Results: OBP missed hypertension in 68% of KTRs who had normal OBP (masked phenomenon) and OBP overestimated hypertension in 11% of KTRs with uncontrolled OBP (white coat phenomenon). Thirty-four percent of patients were normal dippers, 32% non-dippers, 25% reverse dippers and 9% were extreme dippers. Conclusions: ABPM is a valuable tool in detecting dipping status, white coat and masked phenomena which are frequent problems among KTRs and should be considered as part of routine management of hypertension in KTRs.

Influence of stress induced by the first announced state of emergency due to coronavirus disease 2019 on outpatient blood pressure management in Japan

To prevent further spread of coronavirus disease 2019 (COVID-19), the Japanese government announced a state of emergency, resulting in major stress for the population. The aim of this study was to investigate a possible association between changes in daily stress and blood pressure (BP) in Japanese patients. We retrospectively investigated 748 patients with chronic disease who were treated by the Sagamihara Physicians Association to determine changes in stress during the COVID-19 state of emergency from 7 April to 31 May 2020. During the state of emergency, office BP significantly increased from 136.5 ± 17.5/78.2 ± 12.0 to 138.6 ± 18.6/79.0 ± 12.2 (p < 0.001 and p = 0.03, respectively). In contrast, home BP significantly decreased from 128.2 ± 10.3/75.8 ± 8.8 to 126.9 ± 10.2/75.2 ± 9.0 (p < 0.001 and p = 0.01, respectively), and the ratio of white coat hypertension was significantly increased (p < 0.001). Fifty-eight percent of patients worried about adverse effects of hypertension as a condition contributing to the severity and poor prognosis of COVID-19; decreased amounts of exercise and worsened diet compositions were observed in 39% and 17% of patients, respectively. In conclusion, a significant increase in office BP with the white coat phenomenon was observed during the state of emergency, as well as an increase in related stress. To prevent cardiovascular events, general practitioners should pay more attention to BP management during stressful global events, including the COVID-19 pandemic.

Three Hours Ambulatory Blood Pressure: A Surrogate for Daytime Ambulatory Blood Pressure Assessment in the Pakistani Population.

BackgroundOffice blood pressure (BP) measurement is affected by the white-coat phenomenon and shows a weaker correlation with the gold standard ambulatory blood pressure monitoring (ABPM). To overcome this limitation, 24-hour ABPM is recommended by the guidelines for the diagnosis of hypertension. However, 24-hour ABPM is expensive and cumbersome, which limits its use in low to middle-income countries like Pakistan. We aimed to assess if an abbreviated ABPM interval can be utilized to diagnose hypertension effectively in our population.MethodsA cross-sectional study, involving 150 participants as part of the Post Clinic Ambulatory Blood Pressure (PC-ABP) study, was conducted in the cardiology clinics. Participants ≥18 years of age, who were either hypertensive or referred for assessment of hypertension, were included. Blood pressure (BP) readings were taken with an ambulatory BP monitor over a 24-hour period. After excluding the first hour called the ‘white-coat window,’ the mean of the first six systolic readings taken every half hour during the daytime was calculated and was called systolic three-hour ABPM. Pearson correlation coefficients were calculated and Bland-Altman plots were constructed to determine the correlation and limits of agreement between mean systolic three-hour ABPM and daytime-ABPM. Receiver operating characteristic (ROC) curve for systolic and diastolic three-hour daytime ABPM and area under the curve (AUC) were analyzed for the level of accuracy in predicting hypertension.ResultsOf the 150 participants, 49% were male, and 76% of all were hypertensive. The mean age of participants was 60.3 ± 11.9 years. The mean systolic three-hour ABPM was 135.0 ± 16 mmHg. The mean systolic daytime ABPM was 134.7 ± 15 mmHg. Pearson correlation coefficient between mean systolic three-hour ABPM and mean systolic daytime ABPM was 0.85 (p-value <0.001). The limits of agreement were 18 mmHg to −17 mmHg between the two readings on Bland-Altman plots and the area under the curve of the receiver operating characteristic (ROC) was 0.96, suggesting that three-hour systolic ABPM is a good predictor of hypertension.ConclusionThree-hour ABPM correlates well with 24-hour ABPM in the Pakistani population. We recommend considering the use of this abbreviated ABPM to screen hypertension where a full-length ABPM cannot be used. Further studies can be conducted on a larger sample size to determine the prognostic implications of this shortened ABPM.

Prognostic value of masked uncontrolled apparent resistant hypertension detected through home blood pressure monitoring.

Resistant hypertension carries a poor prognosis and current guidelines recommend the exclusion of the white-coat phenomenon for proper diagnosis. However, guidelines do not focus on patients treated with at least three drugs whose blood pressure (BP) is controlled at the office but elevated out of it. We aimed at determining whether this masked uncontrolled apparent resistant hypertension (MUCRH) detected through home blood pressure monitoring (HBPM) has prognostic value for fatal and nonfatal events in these hypertensive patients. Hypertensive patients treated with at least three drugs who performed a baseline HBPM between 2008 and 2015 were followed to register the occurrence of total mortality, cardiovascular mortality, and fatal and nonfatal cardiac and cerebrovascular events. MUCRH was defined as office blood pressure less than 140/90 mmHg and home BP at least 135 and/or 85 mmHg. Multivariable Cox proportional hazard models were adjusted to determine the independent prognostic value of MUCRH for the events of interest. We included 470 patients, 35.5% male, mean age 71.9 years, and treated with 3.3 antihypertensive drugs on average. Among study population, 15.5% had MUCRH (33.3% when considering only patients with adequate BP control at the office). Median follow-up was 6.7 years. In multivariable models, MUCRH was an independent predictor for cardiovascular mortality and cerebrovascular events: hazard ratio 4.9 (95% CI 1.2-19.9, P = 0.03) and 5.1 (95% CI 1.5-16.9, P = 0.01), respectively. MUCRH is not rare and is independently associated with cardiovascular morbidity and mortality. The systematic monitoring of intensively treated individuals through HBPM would be useful for the detection of patients at increased risk of events.

Mejoría del control de la hipertensión en la consulta con el uso de un dispositivo oscilométrico automático de lectura diferida

IntroductionOffice blood pressure (BP) measurement is a recommended procedure, although the out-of-office BP measurements are increasingly used. ObjectiveTo know the degree of BP control by clinical measurement. Material and methodsDuring November 2019 demographic and clinical data, office attended systolic BP (SBP) and diastolic BP (DBP) measured with an automatic device with delayed reading and, if performed, data from ambulatory BP monitoring (ABPM) were collected. Results102 patients (67 men) were included, with a mean age of 64.9 years, 30% diabetic and 34% with cardiovascular complications. 70% had a controlled hypertesion (<140/90 mmHg) by office BP, the mean SBP was 131 ± 16.5 mmHg and the DBP was 73 ± 9.5 mmHg. Old age and diabetes were associated with uncontrolled hypertension. Thirty three patients had ABPM data, which allowed them to be classified according to the 24-hour BP into: 30% true normotension, 9% white-coat hypertension, 15% sustained hypertension, and 45% masked hypertension. ConclusionThe use of automatic devices reduces the white-coat phenomenon, improving the % of patients with office BP controlled. However, this is not confirmed outside the clinic, showing the importance of ABPM in the evaluation of hypertension control. Office BP measurement is useful in patients initial assessment and also provides educational aspects, although the methodology must be optimized to define its clinical role.

Office blood pressure measurement: A comprehensive review.

The conventional auscultatory methods for measuring blood pressure have been used to screen, diagnose, and manage hypertension since long. However, these have been found to be prone to errors especially the white coat phenomena which cause falsely high blood pressure readings. The Mercury sphygmomanometer and the Aneroid variety are no longer recommended by WHO for varying reasons. The Oscillometric devices are now recommended with preference for the Automated Office Blood Pressure measurement device which was found to have readings nearest to the Awake Ambulatory Blood Pressure readings. The downside for this device is the cost barrier. The alternative is to use the simple oscillometric device, which is much cheaper, with the rest and isolation criteria of the SPRINT study. This too may be difficult due to space constraints and the post‐clinic blood measurement is a new concept worth further exploration.

Prevalence and control of hypertension in hemodialysis patients using ambulatory blood pressure in the area of Blida (Algeria)

We aimed to evaluate the prevalence and control of hypertension using ABPM in a large hemodialysis population according to the latest definitions. A total of 178 hemodialysis patients underwent 24 hour ABPM during a regular hemodialysis session and pre-hemodialysis interval (PHD). HT was defined as pre-hemodialysis BP > = 140/90 mmHg or use of antihypertensive (ATH) drugs and ambulatory BP > = 130/80 mmHg or use of ATH drugs. The control phenotypes of hypertension were defined as follows: – concordant control (PHD BP < 140/90 mmHg and ABPM < 130/80 mmHg); – concomitant lack of control (PHD BP > = 140/90 mmHg and ABPM > = 130/80 mmHg); – “white coat” phenomenon (PHD BP > = 140/90 mmHg and ABPM < 130/80 mmHg); – masked hypertension (PHD BP < 140/90 mmHg and ABPM > = 130/80 mmHg). Mean BP values were: 141.7 ± 19 and 79.8 ± 11 mmHg. There was higher prevalence of uncontrolled systolic pressure and diastolic pressure rate in men ( P < 0.001). In PHD, the prevalence of HT was 93.1%. According to the ABPM and during the haemodialysis period, the prevalence was 84.6%. The proportion of hypertensive patients receiving treatment was 80.4%. With the use of BP in PHD and ABPM, 11.1% of hypertensive patients had concomitant control of BP, 63.2% of patients had no control of BP, 15.5% had a white coat phenomenon and 10.2% had masked HT. In multivariate analysis, only the use of antihypertensive drugs was independently associated with an increased likelihood of no control. A significant relationship between uncontrolled BP and diabetic nephropathy was found ( P = 0.01). Patients with uncontrolled BP most often used a calcium antagonist alone (87% vs. 48%). There was a significant difference in the presence of diabetes and cardiovascular disease between studied groups ( P < 0.01). The prevalence of hypertension in hemodialysis patients is extremely high. BP control rates differ between ABPM and office BP. Poor BP control in men may result from lower compliance. Combined antihypertensive therapy may increase adherence to reduce cardiovascular risk.

Defining the hemodynamic response of hypertensive and normotensive subjects through serial timed blood pressure readings in the clinic

BackgroundEvery third patient in the clinic is misdiagnosed due to white-coat phenomenon, necessitating needless and costly treatment. We aimed to study the hemodynamic response of the physician’s visit on hypertensive and normotensive patients by investigating the trend of blood pressure (BP) before, during and 15 min after the physician-patient encounter.MethodsA descriptive, cross-sectional study was conducted over a period of 8 months in the cardiology clinics at the Aga Khan University Hospital, Karachi. Both hypertensive and normotensive patients, aged ≥18 years, were recruited. Pregnant females or those with a history of volume loss were excluded. BP readings were taken using an automated, validated device (Omron-HEM7221-E) at three points: pre-clinic BP by the assessment nurse, in-clinic BP by the attending physician and post-clinic BP 15-min after the physician-patient encounter by a research assistant. Independent samples t-test was used to calculate the statistical difference between hypertensive and normotensive BP values.ResultsOf 180 participants, 71% (n = 128) were hypertensive and 57% (n = 103) of all were males. The mean age of the participants was 57 ± 15 years. The mean and standard deviation(±SD) systolic BP (SBP) taken pre-clinic, in-clinic and 15-min post-clinic for hypertensive population was 128.7 ± 20 mmHg, 137.1 ± 21 mmHg and 127.9 ± 19 mmHg. The mean and standard deviation(±SD) SBP taken pre-clinic, in-clinic and 15 min post-clinic for normotensive population was 112 ± 16 mmHg, 115.8 ± 20 mmHg and 111.8 ± 15 mmHg. The hypertensive SBP values showed statistically significant difference from the normotensive values (difference in pre-clinic SBP: 16.7 mmHg, p-value < 0.001; in-clinic SBP: 21.3 mmHg, p-value < 0.001; and 15 min post-clinic: 16.1 mmHg, p-value < 0.001).ConclusionsHypertensive and normotensive patients display congruent hemodynamics upon visiting the physician, the alert response being accentuated amongst the hypertensive group. In-clinic BP readings are higher for both hypertensive and normotensive patients making them unreliable for screening and management of hypertension amongst both the groups.

Ambulatory Blood Pressure Monitoring: Profiles in Chronic Kidney Disease Patients and Utility in Management.

Optimal control of blood pressure (BP) may reduce the risk of progression of CKD. Misclassification of hypertension (HTN) and status of control may result in suboptimal management. Clinic or home BP may overestimate or underestimate status of control compared with ambulatory BP monitoring (ABPM), which is considered the gold standard. The latter relates not only to the superiority of ABPM concerning outcome prognosis but also to its ability to accurately diagnose white coat and masked HTN, which is critical in assuring adequate BP control. However, ABPM has not gained widespread use in practice because of limited third-party reimbursement and a paucity of high quality randomized controlled intervention studies evaluating its use. Herein, we review HTN phenotypes that have been identified in patients with CKD, and the potential value of ABPM in this high-risk population.

Hipertensão resistente: abordagem clínica

Hipertensão arterial resistente é definida como a pressão arterial de consultório não controlada, apesar do uso de três ou mais anti-hipertensivos, incluindo, preferencialmente, um diurético. Indivíduos em uso de quatro ou mais medicamentos com controle pressórico também são considerados hipertensos resistentes. Por sua vez, hipertensão refratária é a pressão arterial não controlada, apesar do uso de cinco ou mais drogas, incluindo um tiazídico de ação prolongada e um antagonista da aldosterona. Sua prevalência vem crescendo com o envelhecimento da população e o avanço da obesidade, estando relacionada às altas taxas de morbidade e mortalidade de origem cardiovascular e renal. A abordagem diagnóstica se baseia em quatro pontos: afastar pseudorresistência, identificar o fenômeno do jaleco branco, investigar causas secundárias e identificar lesões subclínicas para estratificação do risco cardiovascular. O objetivo terapêutico é o controle da pressão arterial de 24 horas. Mudanças de estilo de vida devem ser implementadas e as três primeiras drogas devem incluir um diurético adequado, um inibidor do sistema renina-angiotensina-aldosterona e um bloqueador de canais de cálcio. Persistindo o descontrole pressórico, adicionamos a quarta droga: espironolactona. Quanto aos hipertensos refratários, novas modalidades terapêuticas vêm sendo desenvolvidas, como a denervação renal e a estimulação do barorreflexo.

A3916 The central aortic pressure in hypertensive patients may be companied with the White-coat phenomenon

Objectives: To explore whether the central aortic pressure be companied with the White-coat phenomenon in hypertensive patients. Methods: 44 newly diagnosed hypertensive patients were recruited. Each of the patients were instructed to measure their home blood pressure for the first week. Central aortic pressure (CAP) and pulse wave analysis were measured with the noninvasive A-Pulse CASPro. According to the home blood pressure (HBP) and office blood pressure (OBP), all patients were divided into two groups: the sustained hypertension group (SHT, n = 28) and the White-coat hypertension group (WCH, n = 16).CHSBP (CSBP-HSBP) was to be judged whether the blood pressure measurements be companied with the White-coat phenomenon. Results: The differences between OSBP, ESBP (examing room SBP), CASP and HSBP, were marked as OHSBP, EHSBP and CHSBP respectively. OHSBP, EHSBP and CHSBP were higher in the WCH when compared with the SHT (OHSBP:21.88 ± 11.85 vs. 11.98 ± 11.01 mmHg, p = 0.008;EHSBP:10.97 ± 13.55 vs. 2.28 ± 11.33 mmHg, p = 0.028;CHSBP:1.97 ± 14.54 vs. −7.07 ± 11.18 mmHg, p = 0.026). After adjudging the body height, BMI, age, PWV, ABI and the Family history of early cardiovascular, the differences above remained to be statistically significant (p < 0.05). Meanwhile, magnitude of White-coat effect among the groups was in order: OHSBP > EHSBP > CHSBP (p < 0.05). CASP were closely related with the blood pressure measured at the same time (r = 0.91, p < 0.001). Conclusion: The CAP in hypertensive patients is probably companied with the White-coat phenomenon. The magnitude of CSBP's ‘White-coat effect’ seems to be lower than that of OSBP and ESBP.

A0241 Use of Ambulatory Blood Pressure Monitoring in the Diagnosis of White Coat and Masked Hypertension

Objectives: We investigated the different methods on diagnosis of white coat and masked phenomena in ambulatory blood pressure (ABP). Methods: We collected information on clinical characteristics and laboratory data, and performed measurements of OBP and ABP in 274 subjects, including 46 persons with high normal OBP, 187 untreated patients with grade 1 and grade 2 hypertension, and 41 treated hypertensive patients. The 95 and 5 percentile for the difference between OBP and daytime ABP, respectively, as the cutoff for the definition of white coat phenomenon and masked phenomenon. Results: If white coat and masked phenomenon and hypertension were diagnosed according to the current hypertension guidelines, the prevalence of white coat phenomenon did not differ between untreated and treated hypertensive patients (P = 0.46). In the untreated group, the prevalence of white coat phenomenon was higher in grade 2 than grade 1 hypertension (P = 0.033), whereas the prevalence of WCH did not differ (P = 0.23).The prevalence of masked hypertension was 73.9% in high normal BP group.The prevalence of masked uncontrolled hypertension was 4.9%. If the 95 percentile (≥20.5/20.5mmHg)and 5 percentile (≤-18.67/−6.0mmHg)for the difference between OBP and daytime ABP were, respectively, used as cutoff for the definition of white coat and masked phenomenon, the prevalence of white coat phenomenon did not differ between treated and untreated groups (P = 0.54). In the untreated group, the prevalence of white coat phenomenon was higher in grade 2 than grade 1 hypertension (P < 0.0001).The prevalence of masked phenomenon did not differ between persons with high normal OBP (15.2%) and untreated (5.9%) and treated hypertensive patients (12.2%)(P > 0.05). Conclusion: The percentile methods may be useful for the diagnosis of white coat and masked phenomena.

Automated Office Blood Pressure Measurement.

Manual blood pressure (BP) recorded in routine clinical practice is relatively inaccurate and associated with higher readings compared to BP measured in research studies in accordance with standardized measurement guidelines. The increase in routine office BP is the result of several factors, especially the presence of office staff, which tends to make patients nervous and also allows for conversation to occur. With the disappearance of the mercury sphygmomanometer because of environmental concerns, there is greater use of oscillometric BP recorders, both in the office setting and elsewhere. Although oscillometric devices may reduce some aspects of observer BP measurement error in the clinical setting, they are still associated with higher BP readings, known as white coat hypertension (for diagnosis) or white coat effect (with treated hypertension). Now that fully automated sphygmomanometers are available which are capable of recording several readings with the patient resting quietly, there is no longer any need to have office staff present when BP is being recorded. Such readings are called automated office blood pressure (AOBP) and they are both more accurate than conventional manual office BP and not associated with the white coat phenomena. AOBP readings are also similar to the awake ambulatory BP and home BP, both of which are relatively good predictors of cardiovascular risk. The available evidence suggests that AOBP should now replace manual or electronic office BP readings when screening patients for hypertension and also after antihypertensive drug therapy is initiated.