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.

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.

White Coat Hypertension: to Treat or Not to Treat?

Definition of white coat hypertension (WCH) traditionally relies on elevated office blood pressure (BP) during repeated visits concomitant with normal out-of-office BP values, as assessed by home and/or 24-h ambulatory BP monitoring measurements. Accumulating evidence focusing on the association of WCH with target organ damage and, more importantly, with cardiovascular events indicates that the risk conveyed by this condition is intermediate between normotension and sustained hypertension. This article will review a number of issues concerning WCH with particular emphasis on the following: (1) prevalence and clinical correlates, (2) association with target organ damage and cardiovascular events, (3) therapeutic interventions. Data will refer to the original WCH definition, based on out-of-office BP determined by 24-h ambulatory BP monitoring; at variance from home BP measurement, this approach rules out the potentially confounding effect of a clinically relevant abnormal BP phenotype such as isolated nocturnal hypertension.

White coat hypertension in pediatrics.

The article summarizes current information on blood pressure changes in children during clinic visit. White coat as a general dressing of physicians and health care personnel has been widely accepted at the end of the 19th century. Two problems can be associated with the use of white coat: white coat phenomenon and white coat hypertension. Children often attribute pain and other unpleasant experience to the white coat and refuse afterwards cooperation with examinations. Definition of white coat hypertension in the literature is not uniform. It has been defined as elevated blood pressure in the hospital or clinic with normal blood pressure at home measured during the day by ambulatory blood pressure monitoring system. White coat effect is defined as temporary increase in blood pressure before and during visit in the clinic, regardless what the average daily ambulatory blood pressure values are. Clinical importance of white coat hypertension is mainly because of higher risk for cardiovascular accidents that are dependent on end organ damage (heart, vessels, kidney). Current data do not allow any clear recommendations for the treatment. Pharmacological therapy is usually started in the presence of hypertrophic left ventricle, changes in intimal/medial wall thickness of carotic arteries, microalbuminuria and other cardiovascular risk factors. Nonpharmacological therapy is less controversial and certainly more appropriate. Patients have to change their life style, need to eliminate as much cardiovascular risk factors as possible and sustain a regular blood pressure monitoring.

White-Coat Effect Among Older Adults: Data From the Jackson Heart Study.

Many adults with elevated clinic blood pressure (BP) have lower BP when measured outside the clinic. This phenomenon, the "white-coat effect," may be larger among older adults, a population more susceptible to the adverse effects of low BP. The authors analyzed data from 257 participants in the Jackson Heart Study with elevated clinic BP (systolic/diastolic BP [SBP/DBP] ≥140/90 mm Hg) who underwent ambulatory BP monitoring (ABPM). The white-coat effect for SBP was larger for participants 60 years and older vs those younger than 60 years in the overall population (12.2 mm Hg, 95% confidence interval [CI], 9.2-15.1 mm Hg and 8.4 mm Hg, 95% CI, 5.7-11.1, respectively; P=.06) and among those without diabetes or chronic kidney disease (15.2 mm Hg, 95% CI, 10.1-20.2 and 8.6 mm Hg, 95% CI, 5.0-12.3, respectively; P=.04). After multivariable adjustment, clinic SBP ≥150 mm Hg vs <150 mm Hg was associated with a larger white-coat effect. Studies are needed to investigate the role of ABPM in guiding the initiation and titration of antihypertensive treatment, especially among older adults.

[Screening and management of hypertension in elderly]. / Dépistage et prise en charge de l'hypertension artérielle chez la personne âgée.

The prevalence of hypertension in elderly is extremely high. Because of the burden of ageing of population, this condition considered as the most important risk factor for mortality is supposed to increase. There are some specific pitfalls in the diagnosis and management of hypertension in elderly. The definition of hypertension is the same in all age groups, however the phenotype is different in the elderly: white coat effect, non-dipping pattern, orthostatic hypotension, dysautonomia and pseudohypertension. The hallmark of hypertension in the elderly is pure systolic hypertension and an increased variability of blood pressure. The diagnosis is often difficult to establish. The elderly can be overtreated with undesirable effects of falls or hypoperfusion, particularly when there is frailty, or polymedication.

White-coat hypertension.

1. Numerous studies have examined whether white-coat hypertension (WCHT) is associated with increased cardiovascular risk, but with definitions of WCHT that were not sufficiently robust, results have been inconsistent. The aim of the present review was to standardize the evidence by only including studies that used a definition of WCHT consistent with international guidelines. 2. Published studies were reviewed for data on vascular dysfunction, target organ damage, risk of future sustained hypertension and cardiovascular events. 3. White-coat hypertension has a population prevalence of approximately 15% and is associated with non-smoking and slightly elevated clinic blood pressure. Compared with normotensives, subjects with WCHT are at increased cardiovascular risk due to a higher prevalence of glucose dysregulation, increased left ventricular mass index and increased risk of future diabetes and hypertension. 4. In conclusion, management of a patient with WCHT should focus on cardiovascular risk factors, particularly glucose intolerance, not blood pressure alone.

White coat hypertension: addressing the 10 most important questions.

The term 'white coat' hypertension (WC-HTN) is intended to reflect the situation in which measurement of blood pressure (BP) by a health professional (often a physician in a white coat) in an office setting is found to be elevated in comparison with BP measured by a more consistent and less error-prone method such as ambulatory BP monitoring (ABPM), or home BP monitoring (HBPM). Office BP (also sometimes called 'casual BP') has formed the basis of clinical trials that confirm meaningful reductions in MI (25 %), stroke (40 %), and heart failure (50 %) with pharmacotherapy. Nonetheless, within clinical trials, a substantial minority of patients have been determined to have WC-HTN, for which treatment is not known to be of benefit, and is hence not indicated. Clinicians continue to have a good deal of uncertainty about the definition, consequences, course, and best management of WC-HTN. The intention of this communication is to address the top priority questions about WC-HTN to enable clinicians to become more confident in its identification and management.

Diagnosis and management of patients with white-coat and masked hypertension.

White-coat hypertension is characterized by an elevation in clinic blood pressure but normal home or ambulatory blood-pressure values, whereas patients with masked hypertension have normal clinic blood pressure and elevated ambulatory or home blood-pressure load. Both white-coat and masked hypertension are frequent clinical entities that need appropriate recognition and a close diagnostic follow-up. White-coat and masked hypertension seem to be associated with organ damage and increased cardiovascular risk, although not invariably. In addition, patients with masked or white-coat hypertension have an increased risk of abnormalities affecting their glucose and lipid profiles. Therefore, the diagnosis of these conditions should be accurate and include the assessment of cardiovascular as well as of metabolic risk. Once diagnosed, first-line therapeutic interventions should be nonpharmacological and aim at lifestyle changes, but drug treatment can be indicated, particularly when the patient's cardiovascular risk profile is elevated or when target-organ damage is detected.