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white-coat hypertension

Hypertension attributed to the transient rise in blood pressure some individuals experience when being evaluated by a physician. Definition: - at least 3 separate office blood pressure measurements > 140/90 mm Hg with at least 2 separate blood pressure measurements < 140/90 outside of the office without evidence of target organ damage [1] Etiology: - sympathetic nervous system activity mediates white-coat hypertension [11] Epidemiology: 1) more common in elderly than in general population [4,8] 2) accounts for 1/3 of resistant hypertension cases [5] Special laboratory: - ambulatory blood pressure monitoring is gold standard [5] - electrocardiogram for evidence of LV hypertrophy if sustained chronic hypertension suspected Radiology: - echocardiogram for evidence of LV hypertrophy if sustained chronic hypertension suspected Complications: patients with white-coat hypertension a) experience clinical outcomes similar to patients with consistently normal blood pressure. [2] b) no evidence of increased cardiovascular events [6] c) are twice as likely as normotensive patients to develop hypertension (at home) within 8 years [3] d) true white coat hypertension is associated with mortality similar to normal blood pressure [7] e) elderly with white coat hypertension at risk for hypotension if inappropriately treated with antihypertensive(s) [8] f) white coat hypertension associated with 36% higher risk of cardiovascular event & 33% higher risk for mortality, compared with normotension [10] - risks still lower than those in patients with sustained hypertension - increased risk may apply only to high-risk older adults - out-of-office BP monitoring needed to identify those with true white coat hypertension [10] Management: 1) home blood pressure monitoring, especially the elderly 2) 1 in-office, 2 out-of-office blood pressure measurements [7] 3) monitor for emergence of sustained chronic hypertension or end organ damage [1] 4) antihypertensive therapy generally not required [1]; of no benefit [12]

Related

ambulatory blood pressure monitoring (ABPM) masked hypertension

General

hypertension (HTN, high blood pressure, HBP)

References

  1. Medical Knowledge Self Assessment Program (MKSAP) 11, 15, 16, 17, 19. American College of Physicians, Philadelphia 1998, 2009, 2012, 2015, 2021
  2. Journal Watch 24(8):64, 2004 Bobrie G et al Cardiovascular prognosis of "masked hypertension" detected by blood pressure self-measurement in elderly treated hypertensive patients. JAMA 291:1342, 2004 PMID: 15026401
  3. Ugajin T, Hozawa A, Ohkubo T, Asayama K, Kikuya M, Obara T, Metoki H, Hoshi H, Hashimoto J, Totsune K, Satoh H, Tsuji I, Imai Y. White-coat hypertension as a risk factor for the development of home hypertension: the Ohasama study. Arch Intern Med. 2005 Jul 11;165(13):1541-6. PMID: 16009871
  4. Internal Medicine World Report 2006; 21(2)
  5. de la Sierra A et al. Clinical features of 8295 patients with resistant hypertension classified on the basis of ambulatory blood pressure monitoring. Hypertension 2011 May; 57:898. PMID: 21444835
  6. Polonia JJ, Gama GM, Silva JA et al Sequential follow-up clinic and ambulatory blood pressure evaluation in a low risk population of white-coat hypertensive patients and in normotensives. PMID: 15812251
  7. Mancia G et al. Long-term prognostic value of white coat hypertension: An insight from diagnostic use of both ambulatory and home blood pressure measurements. Hypertension 2013 Jul; 62:168 PMID: 23716584 http://hyper.ahajournals.org/content/62/1/168 - de la Sierra A. Definition of white coat hypertension: Ambulatory blood pressure, self-measured blood pressure, or both? Hypertension 2013 Jul; 62:16. PMID: 23716585 http://hyper.ahajournals.org/content/62/1/16
  8. Tanner RM, Shimbo D, Seals SR et al White-Coat Effect Among Older Adults: Data From the Jackson Heart Study. J Clin Hypertens (Greenwich). 2015 Aug 17 PMID: 26279070
  9. Stergiou GS, Asayama K, Thijs L et al Prognosis of white-coat and masked hypertension: International Database of HOme blood pressure in relation to Cardiovascular Outcome. Hypertension. 2014 Apr;63(4):675-82. PMID: 24420553 Free Article
  10. Cohen JB, Lotito MJ, Trivedi UK et al Cardiovascular Events and Mortality in White Coat Hypertension: A Systematic Review and Meta-analysis. Ann Intern Med. 2019. June 11. PMID: 31181575 https://annals.org/aim/article-abstract/2735719/cardiovascular-events-mortality-white-coat-hypertension-systematic-review-meta-analysis - Shimbo D, Muntner P Should Out-of-Office Monitoring Be Performed for Detecting White Coat Hypertension? Ann Intern Med. 2019. June 11. PMID: 31181573 https://annals.org/aim/article-abstract/2735721/should-out-office-monitoring-performed-detecting-white-coat-hypertension
  11. Grassi G, Quarti-Trevano F, Seravalle G et al. Sympathetic neural mechanisms underlying attended and unattended blood pressure measurement. Hypertension 2021 Oct; 78:1126. PMID: 34365811 https://www.ahajournals.org/doi/10.1161/HYPERTENSIONAHA.121.17657
  12. Geriatric Review Syllabus, 11th edition (GRS11) Harper GM, Lyons WL, Potter JF (eds) American Geriatrics Society, 2022