White Coat Uncontrolled Hypertension Research Articles

The HOPE Asia Network consensus on blood pressure measurements corresponding to office measurements: Automated office, home, and ambulatory blood pressures.

For adopting recently introduced hypertension phenotypes categorized using office and out of office blood pressure (BP) for the diagnosis of hypertension and antihypertension drug therapy, it is mandatory to define the corresponding out of office BP with the specific target BP recommended by the major guidelines. Such conditions include white-coat hypertension (WCH), masked hypertension (MH), white-coat uncontrolled hypertension (WUCH), and masked uncontrolled hypertension (MUCH). Here, the authors review the relevant literature and discuss the related issue to facilitate the use of corresponding BPs for proper diagnosis of WCH, MH, WUCH, and MUCH in the setting of standard target BP as well as intensive target BP. The methodology of deriving the corresponding BP has evolved from statistical methods such as standard deviation, percentile value, and regression to an outcome-based approach using pooled international cohort study data and comparative analysis in randomized clinical trials for target BPs such as the SPRINT and STEP studies. Corresponding BPs to 140/90 and 130/80mm Hg in office BP is important for safe and strict achievement of intensive BP targets. The corresponding home, daytime, and 24-h BPs to 130/80mm Hg in office BP are 130/80, 130/80, and 125/75mm Hg, respectively. However, researchers have found some discrepancies among the home corresponding BPs. As tentative criterion for de-escalation of antihypertensive therapy as shown in European guidelines was 120mm Hg in office BP, corresponding home, daytime, and 24-h systolic BPs to 120mm Hg in office systolic BP are 120, 120, and 115mm Hg, respectively.

Uncontrolled and masked uncontrolled blood pressure in treated pregnant women with chronic hypertension and risk for preeclampsia/eclampsia.

To analyze the relationship between the level of BP achieved with treatment and the risk for development of preeclampsia/eclampsia (PE), we conducted a historical cohort study on 149 consecutive pregnant women with treated chronic hypertension, evaluated between January 1, 2016, and November 31, 2022. According to office BP readings and ambulatory blood pressure monitoring (ABPM) performed after 20 weeks of gestation, the cohort was classified in controlled hypertension, white-coat uncontrolled hypertension, masked uncontrolled hypertension and sustained hypertension. Risks for the development of PE were estimated using logistic regression. One hundred and twenty-four pregnant women with a control BP evaluation were included in this analysis. The rates of PE were 19.4%, 27.3%, 44.8% and 47.1% for controlled, white-coat uncontrolled, masked uncontrolled and sustained uncontrolled hypertension, respectively. Compared with women with controlled hypertension, the relative risk for PE increased markedly in women with sustained uncontrolled (OR 3.69, 95% CI, 1.19-11.45) and masked uncontrolled (OR 3.38, 95% CI, 1.30-11.45) hypertension, but not in those with white-coat uncontrolled (OR 1.56 95% CI, 0.36-6.70); adjustment for covariates did not modify the results. Each mmHg higher of systolic and diastolic daytime ABPM increased the relative risk for PE ~4% and ~5%, respectively. Each mmHg higher of systolic and diastolic nocturnal BP increased the risk ~5% and ~6%, respectively. When these risks were adjusted for ABPM values in opposite periods of the day, only nocturnal ABPM remained as a significant predictor. In conclusion, masked uncontrolled hypertension implies a substantial risk for the development of PE, comparable to those of sustained uncontrolled. The presence of nocturnal hypertension seems important.

CORRELATION BETWEEN HOME AND AMBULATORY BLOOD PRESSURE MEASUREMENT: DIAGNOSIS AND MONITORING OF HYPERTENSION

Objective: Home Blood Pressure Measurement (HBPM) and Ambulatory Blood Pressure Measurement (ABPM) are 2 valid approaches to measure out of office blood pressure to confirm and monitor hypertension. The objective of our study was to compare the results of HBPM to ABPM considered as the reference technique and to determine its contribution in the management of hypertension Design and method: An analytical cross-sectional study including 100 patients aged > 18 years, followed at the outpatient cardiology clinic of the Mohamed Taher Maamouri university hospital in Nabeul over a six months period (July-December 2021). Patients were asked to measure blood pressure (BP) at home as instructed by the physician using validated blood pressure self-measurement devices (MICROLIFE BP A3 PLUS, MICROLIFE BP A2 Basic and Beurer BM 40 ). Laying of ABPM was performed immediately after the HBPM using a Bravo Mini validated device from Sun Tech Medical. The correlation was analyzed using Pearson correlation coefficient (r). Results: Our population was composed of 47 women and 53 men. The mean age was 59.14±13.12 years. HBPM and ABPM were realized in 84% of cases for monitoring hypertensive patients and in 16% of cases to confirm newly diagnosed. The diagnosis of hypertension was confirmed in 75% by HBPM and in 62.5% by ABPM. White coat uncontrolled hypertension (WCUH) was noted in 31% of cases by HBPM and in 25% by ABPM and masked uncontrolled hypertension (MUCH) was noted in 6% of cases by HBPM and in 8.3% by ABPM. The difference between HBPM and ABPM was not statistically significant for the detection of MUCH (p = 0.320) and WCUH (p = 0.198). A strong correlation was found between HBPM and ABPM of systolic BP (P <0.001; r = 0.728; Curve A) as well as of diastolic BP (P <0.001; r = 0.773; Curve B). Conclusions: HBPM has a value very close to ABPM. So, it's important to increase its availability in clinics, outpatient clinics and even in private practice given its lower cost and better availability compared to ABPM for the diagnosis of hypertension and its monitoring.

Ambulatory Resistant Hypertension and Risk of Heart Failure in the Elderly.

(1) Background: The aim of the study was to assess the risk of heart failure (HF) in elderly treated hypertensive patients with white coat uncontrolled hypertension (WUCH), ambulatory nonresistant hypertension (ANRH) and ambulatory resistant hypertension (ARH), when compared to those with controlled hypertension (CH). (2) We studied 745 treated hypertensive subjects older than 65 years. CH was defined as clinic blood pressure (BP) < 140/90 mmHg and 24-h BP < 130/80 mmHg; WUCH was defined as clinic BP ≥ 140/90 mmHg and 24-h BP < 130/80 mmHg; ANRH was defined as 24-h BP ≥ 130/80 mmHg in patients receiving ≤2 antihypertensive drugs; ARH was defined as 24-h BP ≥ 130/80 mmHg in patients receiving ≥3 antihypertensive drugs. (3) Results: 153 patients had CH, 153 had WUCH, 307 had ANRH and 132 (18%) had ARH. During the follow-up (8.4 ± 4.8 years), 82 HF events occurred. After adjustment for various covariates, when compared to CH, the hazard ratio (95% confidence interval) for HF was 1.30 (0.51-3.32), 2.14 (1.03-4.43) and 3.52 (1.56-7.96) in WUCH, ANRH and ARH, respectively. (4) Conclusions: among elderly treated hypertensive patients, those with ARH are at a considerably higher risk of developing HF when compared to CH.

The frequency of hypertension in patients with pathological obesity

Obesity and hypertension are one of the most important cardiovascular risk factors. It is predicted that by 2030 almost two-thirds of the global population will struggle with being overweight or obese. Ambulatory Blood Pressure Measurement (ABPM) is a tool for a detailed analysis of mean blood pressure values and assessing the blood pressure profile during the night with the daily values and optimal treatment determination. The study aimed to assess the frequency of hypertension in patients with pathological obesity. The study consisted of two groups depending on their Body Mass Index (BMI): Group 1 BMI &gt; 25 kg/m2; &lt; 40 kg/m2; Group 2 (243 overweight and obese patients): BMI ≥ 40 kg/m2. Each patient was carefully interviewed, considering their use of the antihypertensive drugs. Each patient was subject to the ABPM assessment. Arterial hypertension (HT) was diagnosed at arterial blood pressure (BP) values &gt; 135/85 mmHg based on the European Society of Hypertension (ESH) test bench. Depending on the patient’s history, ABPM, and in-office BP measurements, patients were diagnosed with HT treated, newly diagnosed, or without HT. Based on the in-office BP and ABPM measurements taken, the diagnosis of white-coat uncontrolled hypertension (WUCH) and masked uncontrolled hypertension (MUCH) was diagnosed. The analysis of parameters revealed that all BP values were significantly higher in group 2. More than half of the patients in both groups had been previously treated for HT. Based on ABPM, newly diagnosed HT was identified significantly more often in patients with higher BMI. The younger individuals were significantly more likely to have WUCH.

S-30-2: ASIAN MANAGEMENT OF HYPERTENSION: CURRENT STATUS, HOME BP MONITORING, AND SPECIFIC CONCERNS IN PHILIPPINES

Introduction: Cardiovascular disease (CVD) in the Philippines showed hypertension as the highest (38.6%), followed by stroke (30%), coronary artery disease (17.5 %), heart failure (10.4%). Risk factor were: diabetes at 3.9%, dyslipidemia at 72%, smoking at 31%, obesity at 4.9% (BMI). Latest hypertension prevalence is 37%. Aware hypertensives were 19%, unaware was 18%. Treatment rate was 68%, compliance was 86%, blood pressure (BP) control rate was 37%. Mortality from CVD were stroke, mostly infarct (22.6%), MI (6.5%), Heart Failure (6.5%). Drugs used were angiotensin receptor blockers (64%), calcium channel blockers (42%), beta-blockers (6%), ACE inhibitors (4%) and diuretics (1%). Current status of home BP monitoring (HBPM): HBPM is performed by 23% of hypertensive population in the Philippine. Barriers to its use include cost, availability and lack of trust regarding the accuracy of digital BP devices. Currently, physicians encourage patients to monitor BP at home to better assess their treatment to rule out white coat, masked hypertension and other parameters. Philippine sub-analysis of AsiaBP@Home study: Data on HBPM offer solution to problems encountered particularly in Asia. Based on AsiaBP@Home study as a multi-national Asian specialty center performance regarding home and clinic BP control, majority of uncontrolled hypertension simulated by the new lower ACC/AHA guideline threshold gave additional 18% increase in sustained uncontrolled hypertension (SUCH) and to additional 5% increase in white-coat uncontrolled hypertension (WUCH). In a sub-group analysis of the Philippines in this study (Fig.1), using conventional threshold values, well-controlled clinic SBP was only 69% and well controlled morning home SBP was 79%. Using the new threshold levels, the well-controlled clinic SBP decreased to 43% and well controlled morning home SBP was lower at 67%. Comparing the conventional to the new thresholds, controlled hypertension decreased from 62% to 37%, masked morning hypertension decreased from 8% to 6%, Sustained hypertension increased from 13% to 27%, and white-coat hypertension increased from 18% to 31%. Summary: Hypertension still remains a major problem in the Philippines. Office BP measurement remains to be our standard for hypertension assessment and it appears to be insufficient in guiding us in our management approach. With the availability of newer and practical tools such as the HBPM, it will certainly improve hypertension evaluation, patient awareness, physician alertness in achieving better BP control and hence, better outcomes.

JS-ISH-KSH-4: EPIDEMIOLOGY OF RESISTANT HYPERTENSION IN KOREA: ABPM REGISTRY DATA

Resistant hypertension (RH) may be one of the major challenges in improving the control rate in hypertension (HTN) management. Accurate diagnosis is usually difficult only by measuring office blood pressure(OBP). For 1230 subjects taking one or more antihypertensive medication (AHM) enrolled in the Korean Ambulatory Blood Pressure Monitoring (Kor-ABP) registry, the prevalence of RH was calculated when RH was defined as uncontrolled BP by three AHM classes including diuretic or controlled BP by 4 or more classes. Prevalence of RH was 11.9 % (146/1230). By using nighttime BP criteria, there was significant difference in the prevalence of RH for OBP versus nighttime BP. Masked uncontrolled HTN was 16.9 % and white-coat uncontrolled HTN was 14.1 %. For nighttime BP control status, odd ratios for smoking (odds ratio(OR), 0.624), drinking (OR, 1.512), coronary artery disease (OR, 0.604), calcium antagonist (OR, 1.705), and loop diuretics (OR, 0.454) were all significant. The prevalence of RH by nighttime BP was significantly higher than using daytime BP criteria.

Prevalence and Clinical Characteristics including Patterns of Antihypertensive Drug Administration of the Different Home Blood Pressure Phenotypes in Treated Hypertensive Patients.

Quality and quantity of home blood pressure (BP) control are important for optimizing hypertensive treatment. The prevalence and associated clinical characteristics of the different home blood pressure phenotypes in treated hypertensive patients were not elucidated. This study was conducted in Siriraj Hospital, Thailand from 2019 to 2020. We included treated hypertensive patients with ≥1 antihypertensive drug and had self-home BP measurement data. Both traditional (office BP < 140/90 mmHg and home BP < 130/80 mmHg) and new BP targets (office and home BP < 130/80 mmHg) were used for the classification of BP phenotypes. Home BP phenotypes consisted of controlled hypertension (all home BPs achieved home BP targets), isolated uncontrolled morning hypertension (MoHT) (only morning BP was above home BP targets), isolated uncontrolled evening hypertension (EHT) (only evening BP was above home BP targets), and combined morning-evening uncontrolled hypertension (MoEHT) (all home BPs were above home BP targets). Our study included 1,406 patients. The total mean age was 62.94 ± 13.97 years. There were 39.40% men. The prevalence of each home BP phenotype (by traditional BP target) was 55.76%, 12.66%, 7.40%, and 24.18% in controlled (home) hypertension, MoHT, EHT, and MoEHT, respectively. Classical BP control status was 35.21% well-controlled hypertension, 30.01% white-coat uncontrolled hypertension, 9.74% masked uncontrolled hypertension, and 25.04% sustained uncontrolled hypertension. The multivariable analysis showed the significantly associated factor of MoHT was the presence of previous cardiovascular disease (adjusted OR 5.54, 95% CI (2.02-15.22); p value = 0.001). Taking once-daily long-acting antihypertensive drugs in the morning were significantly associated with both EHT (adjusted OR 0.20, 95% CI (0.05-0.82); p value = 0.025) and MoEHT (adjusted OR 0.20, 95% CI (0.04-1.00); p value = 0.049). These results were consistent in groups classified by new home BP target <130/80 mmHg.

Relationship Between White-Coat Effect and Blood Pressure Variability in Essential Hypertension

Abstract Background To investigate the incidence of white-coat effect (WCE) and to analyze the relationship between WCE and blood pressure (BP) variability in essential hypertension (EH). Methods A total of 410 patients with grade 1 and 2 EH voluntarily participated in this study. BP was self-measured at home for 1 week. Based on home and office BP, the untreated subjects were divided into white-coat hypertension (WCH, n = 38) and sustained hypertension (SHT, n = 66). The treated subjects were grouped into sustained controlled hypertension (SCH, n = 131), white-coat uncontrolled hypertension (WCUH, n = 95), masked uncontrolled hypertension (MUCH, n = 16), and sustained uncontrolled hypertension (SUCH, n = 64). A subgroup analysis was performed in the treatment hypertensives whose diagnosis based on BP inside and outside the clinic. Results WCH and WCUH patients accounted for 36.5% (95% confidence interval [CI] 27.2%–45.8%) and 31.0% (95% CI 25.8%–36.2%), respectively, in this population while only accounted for 21.7% (95% CI 14.5%–28.9%) in hypertensives whose diagnosis based on office BP and out-of-office BP, which was significantly lower than that based on office BP alone (34.5%). The WCE, that was, the difference between office and home BP, in the WCH patients was significantly higher than SHT patients (P &amp;lt; 0.05), and stronger in the WUCH group compared with SCH and SUCH groups (P &amp;lt; 0.05). Home systolic BP variability exhibited decreasing trends in the WCH and WUCH patients compared with SHT and SUCH patients. Conclusions The incidences of WCH and WUCH are high in grade 1 and 2 hypertensive patients. However, the incidence of WUCH decreases in treated patients diagnosed with office and out-of-office BP. Relative to other patients, WCH and WUCH patients exhibit stronger WCE and a decreasing trend of BP variability.

Prediction of white-coat hypertension and white-coat uncontrolled hypertension using machine learning algorithm.

The detection of white-coat hypertension/white-coat uncontrolled hypertension (WCH/WUCH) with out-of-office blood pressure (BP) monitoring is time- and resource-consuming. We aim to develop a machine learning (ML)-derived prediction model based on the characteristics of patients from a single outpatient visit. Data from two cohorts in Taiwan were used. Cohort one (970 patients) was used for development and internal validation, and cohort two (464 patients) was used for external validation. WCH/WUCH was defined as an office BP of ≥140/90 mmHg and daytime ambulatory BP of <135/85 mmHg in treatment-naïve or treated individuals. Logistic regression, random forest (RF), eXtreme Gradient Boosting, and artificial neural network models were trained using 26 patient parameters. We used SHapley Additive exPlanations values to provide explanations for the risk factors. All models achieved great area under the receiver operating characteristic curve (AUROC), specificity, and negative predictive value in both validations (AUROC = 0.754-0.891; specificity = 0.682-0.910; negative predictive value = 0.831-0.968). The RF model was the best performing (AUROC = 0.884; sensitivity = 0.619; specificity = 0.887; negative predictive value = 0.872; accuracy = 0.819). The five most influential features of the RF model were office diastolic BP, office systolic BP, current smoker, estimated glomerular filtration rate, and fasting glucose level. Our prediction models achieved good performance, underlining the feasibility of applying ML models to outpatient populations for the diagnosis of WCH and WUCH. Further validation with other prospective data sets should be considered in the future.

Relations between white coat effect of blood pressure and arterial stiffness.

The aim of this study was to analyze the relationship between brachial-ankle pulse wave velocity (b-a PWV) and white coat effect (WCE), that is the difference between the elevated office blood pressure (BP) and the lower mean daytime pressure of ambulatory BP, in a mixed population of normotention, untreated sustained hypertension, sustained controlled hypertension, sustained uncontrolled hypertension, white coat hypertension, white coat uncontrolled hypertension. A total of 444 patients with WCE for systolic BP (54.1% female, age 61.86±13.3 years) were enrolled in the study. Patients were separated into low WCE(<9.5mmHg) and high WCE (≥9.5mmHg) according to the median of WCE. The subjects with a high WCE showed a greater degree of arterial stiffness than those with a low WCE for systolic BP values (P<.05). The b-a PWV were 17.2±3.3m/s and 18.4±3.4m/s in low WCE and high WCE, respectively. The b-a PWV increased with the increase of WCE, showing a positive correlation between them (P>.05 for non-linearity). The significant association between the high WCE and the b-a PWV was confirmed by the results of multiple regression analysis after adjusting for confounding factors (β=.78, 95% Cl .25-1.31, P=. 004). Similar results were observed in subgroups. In conclusion, WCE is significantly associated with arterial stiffness. More research is needed to determine the WCE and target organ damage.

HIGHER PREVALENCE OF MASKED UNCONTROLLED HYPERTENSION WITH NEW EUROPEAN BLOOD PRESSURE TARGETS IN AN ELDERLY PRIMARY CARE POPULATION

Objective: The aim of this study was to examine the distribution and clinical characteristics of hypertension phenotypes among patients aged 65 years or older, in a primary care setting, applying the new lower blood pressure targets, of 140/80 mmHg for office blood pressure measurement and 130/75 for ambulatory measurement, proposed by the European Society of Hypertension in 2018. Design and method: This is a cross-sectional analysis of 77 subjects previously diagnosed with hypertension who used at least one antihypertensive drug in a primary care setting in south-east Sweden. Data was collected between May 2012 and May 2016. All subjects were examined regarding general clinical characteristics, office blood pressure and ambulatory blood pressure (Spacelabs ABP monitor 90217). The participants were grouped based on office blood pressure target achievement. Furthermore, subjects were categorized in four groups based on hypertension phenotype. These groups were defined based on office- and ambulatory blood pressure target achievement; Sustained controlled hypertension i.e. concordant goal achievement, Sustained uncontrolled hypertension i.e. non-achievement, Masked uncontrolled hypertension i.e. controlled office blood pressure with uncontrolled ambulatory blood pressure and White coat uncontrolled hypertension i.e. uncontrolled office blood pressure with controlled ambulatory blood pressure. Lastly, shifts in the distribution of hypertension phenotypes using current and previous blood pressure targets respectively were examined. Results: Obesity related parameters (i.e. BMI and waist circumference) were significantly lower in the group with controlled hypertension based solely on current office blood pressure targets, with BMI (kg/m2) of 25.5 ± 3.9 vs. 28.8 ± 4.9 (p &lt; 0.01) and waist circumference (cm) of 91.0 ± 12.1 vs. 100.3 ± 12.7 (p &lt; 0.01). Among subjects with controlled office blood pressure, the prevalence of masked uncontrolled hypertension was higher (14/29 or 48%) when new office- and ambulatory blood pressure targets were applied than when older targets were applied (14/43 or 33%). Conclusions: The main finding of this observational study was that the prevalence of masked uncontrolled hypertension among subjects with controlled office blood pressure was higher applying new instead of old blood pressure targets. We believe that regular ambulatory blood pressure monitoring can facilitate optimized antihypertensive treatment.

White Coat Uncontrolled Hypertension in Teleconsultation: A New and Frequent Entity.

IntroductionCardiovascular risk seems not to be greater in patients with white coat uncontrolled hypertension (WUCH) than in patients with sustained blood pressure (BP) control. Therefore, its detection is important to avoid overtreatment. The COVID-19 pandemic determined a massive migration of hypertension consultations from the face-to-face modality to teleconsultations, and it is unknown whether WUCH exists in this context.AimWe aimed to evaluate the prevalence of WUCH through home BP monitoring (HBPM) in treated hypertensive patients evaluated by teleconsultation.MethodsWe included treated hypertensive patients that owned a digital BP monitor. During teleconsultation, patients were asked to perform two BP measurements and then a 7-day HBPM, using the same device. Patients were classified as having WUCH if BP was ≥ 140 and/or 90 mmHg in teleconsultation and < 135/85 mmHg on HBPM. The prevalence of WUCH and its 95% confidence interval were estimated. One-way ANOVA, the Chi-square test or Fisher’s exact test were used to compare the characteristics of these patients with the other groups.ResultsWe included 341 patients (45.2% male, mean age 62.3 years). The prevalence of WUCH was 33.1% (95% CI 28.3–38.3%). Significant differences were found in terms of age, the number of antihypertensive drugs and the use of calcium channel blockers, all lower in the WUCH group as compared with the groups with elevated BP on HBPM.ConclusionWUCH exists in teleconsultation and is very frequent. It can be easily detected though HBPM, thus avoiding overmedication, and its potential impact on side-effects and health costs.

OR5. Ambulatory blood pressure profile among uncontrolled hypertensive patients in Indonesian Army Central Hospital Gatot Soebroto: an initial study

Abstract Aims Ambulatory blood pressure monitoring (ABPM) has an important role in the evaluation of blood pressure (BP) control, particularly in uncontrolled hypertension, to optimize therapy. This study assessed ambulatory blood pressure profiles among patients with uncontrolled hypertension in Indonesian Army Central Hospital Gatot Soebroto. Methods and Results During our initial study from February to May 2021, a total of 40 patients with uncontrolled hypertension from Cardiac Outpatient Clinic, Indonesian Army Central Hospital Gatot Soebroto were recruited. Uncontrolled hypertension was defined as systolic BP &amp;gt;140 mmHg and or diastolic BP &amp;gt;90 mmHg in patients taking antihypertensive treatment. The population was 67.5% female, aged 63.18 + 11.82 years old, with an average office systolic BP of 157.5 + 24.41 mmHg and diastolic BP of 80.55 + 15.37 mmHg. All patients underwent ABPM within a week after the index office visit to evaluate 24-hour BP, BP variability, and white coat effect. The average 24-hour systolic and diastolic BP of the population was 137.40 + 16.7 mmHg and 78.55 + 12.94 mmHg respectively. Reverse-dipper was the most frequent pattern presented (47.5%). White coat effect was found in 47.5% of subjects and 27.5% of the total population were classified as white coat uncontrolled hypertension. Conclusion A marked discrepancy was found between ambulatory blood pressure profiles with office BP among patients with uncontrolled hypertension. Nearly half of the population had white coat effect, which revealed the importance of blood pressure control evaluation by ABPM to prevent overtreatment.

The impact of changing home blood pressure monitoring cutoff from 135/85 to 130/80 mmHg on hypertension phenotypes

This study investigated the impact of changing abnormal home blood pressure monitoring (HBPM) cutoff from 135/85 to 130/80 mmHg on the prevalence of hypertension phenotypes, considering an abnormal office blood pressure cutoff of 140/90 mmHg. We evaluated 57 768 individuals (26 876 untreated and 30 892 treated with antihypertensive medications) from 719 Brazilian centers who performed HBPM. Changing the HBPM cutoff was associated with increases in masked (from 10% to 22%) and sustained (from 27% to 35%) hypertension, and decreases in white‐coat hypertension (from 16% to 7%) and normotension (from 47% to 36%) among untreated participants, and increases in masked (from 11% to 22%) and sustained (from 29% to 36%) uncontrolled hypertension, and decreases in white‐coat uncontrolled hypertension (from 15% to 8%) and controlled hypertension (from 45% to 34%) among treated participants. In conclusion, adoption of an abnormal HBPM cutoff of 130/80 mmHg markedly increased the prevalence of out‐of‐office hypertension and uncontrolled hypertension phenotypes.

Association of hyperuricemia and hypertension phenotypes in hypertensive patients without uric acid lowering treatment

ABSTRACT Background Current study was to evaluate the association of hypertensive and hypertension phenotypes in hypertensive populations. Methods Patients with primary hypertension and without any uric acid (UA)-lowering treatment were enrolled. Baseline characteristics including office blood pressure (OBP), 24 h ambulatory blood pressure (ABP), and serum UA (SUA) were measured. According to SUA, patients were divided into normal SUA and hyperuricemia groups. Based on OBP and 24 h-ABP, hypertension phenotypes were classified as controlled hypertension (CH), white-coat uncontrolled hypertension (WCUH), masked uncontrolled hypertension (MUCH), and sustained uncontrolled hypertension (SUCH). Results Compared to patients with normal SUA (n = 336), patients with hyperuricemia (n = 284) were older and more likely to be men, obese, physically inactive, and have a higher prevalence of diabetes. C-reactive protein (CRP) level was higher in patients with hyperuricemia. The prevalence of CH, WCUH, and MUCH was similar between these two groups. However, the prevalence of SUCH was higher in patients with hyperuricemia than patients with normal SUA. Linear regression analysis indicated that increased SUA was significantly associated with 24 h-systolic BP and daytime-systolic BP. Normal SUA was served as the reference group, and presence of hyperuricemia was associated with higher odds of SUCH (odds ratio 1.46 and 95% confidence interval 1.27–1.93) after adjusted for potential covariates including age, male gender, obesity, diabetes, CRP, and antihypertensive drugs. Conclusion In hypertensive patients without UA-lowering treatment, presence of hyperuricemia was associated with higher odds of SUCH. Future studies are needed to evaluate whether lowering SUA can help to improve 24 h-ABP control.

Risk of Atrial Fibrillation in Masked and White Coat Uncontrolled Hypertension.

Risk of atrial fibrillation (AF) in masked and white coat uncontrolled hypertension (MUCH and WUCH, respectively) has not yet been investigated. We assessed the risk of new-onset AF in MUCH and WUCH detected by ambulatory blood pressure (BP) monitoring. The occurrence of AF was evaluated in 2,135 treated hypertensive patients aged >40 years, with baseline sinus rhythm, by electrocardiogram. Controlled hypertension (CH) was defined as clinic BP <140/90 mm Hg and daytime BP, regardless of nighttime BP, <135/85 mm Hg, MUCH as clinic BP <140/90 mm Hg and daytime BP ≥135 and/or ≥85 mm Hg, WUCH as clinic BP ≥140 and/or ≥90 mm Hg and daytime BP <135/85 mm Hg, and sustained uncontrolled hypertension (SUCH) as clinic BP ≥140 and/or ≥90 mm Hg and daytime BP ≥135 and/or ≥85 mm Hg. MUCH was identified in 203 patients (9.5% of all the population, 29% of those with normal clinic BP) and WUCH in 503 patients (23.5% of all the population, 35% of those with high clinic BP). During the follow-up (mean 9.7 years), 116 cases of AF occurred. After adjustment for covariates, patients with MUCH (hazard ratio 2.02, 95% confidence interval, 1.06-3.85) and SUCH (hazard ratio 1.83, 95% confidence interval, 1.04-3.21) had higher risk of new-onset AF than those with CH, whereas those with WUCH (hazard ratio 1.12, 95% confidence interval, 0.59-2.13) did not. When compared with patients with CH, those with MUCH and SUCH are at higher risk (approximately doubled) of new-onset AF, whereas those with WUCH are not.

Blood pressure control in patients with chronic kidney disease according to office and home blood pressures.

The aim of this study was to assess blood pressure (BP) control in patients with chronic kidney disease (CKD) according to office and home BP and to assess the prevalence of normal BP, white-coat uncontrolled hypertension (WUCH), masked uncontrolled hypertension (MUCH) and elevated BP. Patients with renal failure with or without proteinuria were included in this multicenter observational study. Office BP was first measured by the physician using a self-monitoring BP device (three automatic readings), then by the patient at home (morning and evening) over 3 consecutive days. WUCH was defined as a systolic BP (SBP)/diastolic BP (DBP) ≥140/90 mmHg in the clinic and SBP/DBP<135/85 mmHg at home. MUCH was defined as SBP/DBP <140/90 mmHg in the clinic and SBP/DBP ≥135/85 mmHg at home. Among the 243 included subjects, data of 225 patients were analyzed. Mean estimated glomerular filtration rate was 37.7 ± 15.7 mL/min/1.73 m and mean office SBP/DBP was 154 ± 19/83 ± 13 mmHg. Mean office SBP/DBP was significantly higher than home SBP/DBP (+9.0 ± 15.1/+7.0 ± 10.0 mmHg, P < 0.01). Normal BP (office and home BP), WUCH, MUCH and elevated BP (office and home BP) rates were 12.0, 14.2, 6.7 and 67.1%, respectively. The patients were taking, on average, 2.8 ± 1.5 antihypertensive drugs/day. BP control in patients with CKD was poor. Routine use of 'out-of-office' BP measurement, in addition to office BP by which we can identify patients with WUCH or MUCH, should be recommended based on the current findings.

Uric Acid Is Not Associated With Blood Pressure Phenotypes and Target Organ Damage According to Blood Pressure Phenotypes.

Hypertensive patients with increased serum uric acid (SUA) are at increased cardiovascular (CV) risks. Both the European and American hypertension guidelines endorse the utilization of 24 h-ambulatory blood pressure monitoring (24 h-ABPM) for hypertensive patients with increased CV risk. While there is difference in identifying uric acid as a CV risk factor between the European and American guidelines. Therefore, it is unknown whether 24 h-ABPM should be used routinely in hypertensive patients with increased SUA. To address this knowledge gap, we investigated (i) the correlation between SUA and 24 h-ABP; (ii) the association between SUA and blood pressure (BP) phenotypes (controlled hypertension [CH], white-coat uncontrolled hypertension [WCUH], masked uncontrolled hypertension [MUCH], and sustained uncontrolled hypertension [SUCH]); (iii) the association between SUA and target organ damage (TOD: microalbuminuria, left ventricular hypertrophy [LVH], and arterial stiffness) according to BP phenotypes. In 1,336 treated hypertensive patients (mean age 61.2 and female 55.4%), we found (i) there was no correlation between SUA and 24 h, daytime, and nighttime systolic blood pressure/diastolic blood pressure, respectively; (ii) in reference to CH, SUA increase was not associated WCUH (odds ratio [OR] 0.968, P = 0.609), MUCH (OR 1.026, P = 0.545), and SUCH (OR 1.003, P = 0.943); (iii) the overall prevalence of microalbuminuria, LVH, and arterial stiffness was 2.3%, 16.7%, and 23.2%, respectively. After adjustment for covariates, including age, sex, smoking, body mass index, diabetes mellitus, and estimated glomerular filtration rate, there was no association between SUA and TOD in all BP phenotypes. These preliminary findings did not support routine use of 24 h-ABPM in treated hypertensive patients with increased SUA.

Smoking and overweight associated with masked uncontrolled hypertension: a Hypertension Optimal Treatment (HOT) Sub-Study

Purpose The Hypertension Optimal Treatment (HOT) Study investigated the relationship between target office diastolic blood pressure (BP) ≤80, ≤85 or ≤90 mmHg and cardiovascular morbidity and mortality in 18,790 patients aged 50–80 years. The home BP sub-study enrolled 926 patients and the aim was to clarify whether the separation into the BP target groups in the office prevailed in the out-of-office setting. The present study aimed to identify variables that characterised masked uncontrolled hypertension (MUCH) and white coat uncontrolled hypertension (WUCH). Material and Methods The sub-study participants took their home BP when office BP had been up titrated. The cut-off for normal or high BP was set to ≥135/85 mmHg at home and ≥140/90 mmHg in the office. We analysed data by using multivariate and stepwise multivariate logistic regression with home and office BP combinations as the dependent variables. Results WUCH was associated with lower body mass index (BMI) (odds ratio (OR) 0.92, 95% confident intervals (CIs) 0.88–0.96, p < 0.001). MUCH was associated with smoking (OR 1.89, 95% CIs 1.25–2.86, p = 0.0025) and with lower baseline heart rate (OR 0.98, 95% CIs 0.97–0.99, p = 0.03) and higher BMI (OR 1.03, CIs 1.00–1.06, p = 0.04). MUCH remained associated with smoking (OR 2.76, 95% CIs 1.76–4.35, p < 0.0001) also when using ≥140/90 mmHg as the cut-off for both home and office BP. MUCH was also associated with higher BMI (OR 1.05, 95% CIs 1.01–1.09, p = 0.009) while WUCH was associated with lower BMI (OR 0.93, 95% CIs 0.90–0.97, p = 0.0005) when using ≥140/90 mmHg as a cut-off. Conclusion Our data support that ‘reversed or masked’ treated but uncontrolled hypertension (MUCH) is common and constitutes about 25% of treated hypertensive patients. This entity (MUCH) is rather strongly associated with current smoking and overweight while uncontrolled white coat (office) hypertension (WUCH) is associated with lower BMI.