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.

Masked Hypertension: Lessons for the Future.

Masked hypertension (MH) is a commonly overlooked phenotype of hypertension in practice. Lifestyle factors and conditioned stress response specific to out of clinic blood pressure readings may be the mechanisms leading to this phenomenon. 24-hour ambulatory blood pressure monitoring or home blood pressure monitoring in an out of office setting are required for its reliable diagnosis. MH has a high risk of progressing to sustained hypertension with comparable cardiovascular and mortality risk. In this review, we discuss current evidence-based perspectives on definition, pathological mechanisms, risk factors, screening, clinical implications, and treatment of MH.

Epidemiological Impact and Clinical Consequences of Masked Hypertension: A Narrative Review.

Masked hypertension (MHT) is a clinical condition characterized by normal blood pressure (BP) levels during clinical consultation and above normal out-of-office BP values. MHT is associated to an increased risk of developing hypertension-mediated organ damage (HMOD) and major cardiovascular (CV) outcomes, such as myocardial infarction, stroke, and hospitalizations due to CV causes, as well as to metabolic abnormalities and diabetes, thus further promoting the development and progression of atherosclerotic disease. Previous studies showed contrasting data on prevalence and clinical impact of MHT, due to not uniform diagnostic criteria (including either home or 24-h ambulatory BP measurements, or both) and background antihypertensive treatment. Whatever the case, over the last few years the widespread diffusion of validated devices for home BP monitoring has promoted a better diagnostic assessment and proper identification of individuals with MHT in a setting of clinical practice, thus resulting in increased prevalence of this clinical condition with potential clinical and socio-economic consequences. Several other items, in fact, remain unclear and debated, particularly regarding the therapeutic approach to MHT. The aim of this narrative review is to illustrate the clinical definition of MHT, to analyze the diagnostic algorithm, and to discuss the potential pharmacological approaches to be adopted in this clinical condition, in the light of the recommendations of the recent European hypertension guidelines.

Resistant hypertension: new insights and therapeutic perspectives.

Resistant hypertension (RH) is a concept that currently goes beyond the classical definition of blood pressure ≥140/90 mmHg in subjects receiving three or more drugs of different classes at maximally tolerated doses. Here, we review the clinical relevance of RH and the different types of RH-associated phenotypes, namely refractory hypertension, controlled resistant hypertension, and masked uncontrolled hypertension. We also discuss current drug strategies and future treatments for these high-risk phenotypes.

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.

When Office Blood Pressure Is Not Enough: The Case of Masked Hypertension.

An increasing attention has been devoted in the last two decades to masked hypertension (MH), a condition characterized by the fact that classification of a normal blood pressure (BP) status by office measurements is not confirmed by home and/or ambulatory BP monitoring (ABPM). MH definition (i.e., normal office BP, but high out-of-office BP) should be restricted to untreated subjects (true MH) whereas masked uncontrolled hypertension (MUCH) reserved to treated patients previously classified as hypertensives, presenting normal office BP and high ABPM or home values. Both MH and MUCH are associated with metabolic alterations, comorbidities, and hypertension-mediated organ damage (HMOD). Furthermore, the risk of cardiovascular events related to these conditions has been shown to be close or greater than that of sustained hypertension. This review discusses available evidence about MH and MUCH by focusing on its prevalence, clinical correlates, association with HMOD, prognostic significance, and their therapeutic implications.

Delayed systolic blood pressure recovery following exercise as a mechanism of masked uncontrolled hypertension in chronic kidney disease.

BACKGROUND: Among people treated for hypertension, the presence of elevated blood pressure (BP) out of the clinic but normal BP in the clinic is called masked uncontrolled hypertension (MUCH). What causes MUCH remains unknown. The purpose of this study was to answer the question of whether patients with MUCH have an increased hemodynamic reactivity to exercise and delayed hemodynamic recovery following exercise. METHODS: Four groups were compared: controlled hypertension (CH, n = 58), MUCH (n = 34) and uncontrolled hypertension (UCH, n = 12), all of which had chronic kidney disease (CKD), and a group of healthy normal volunteers who did not have hypertension or CKD (n = 16). All participants underwent assessment of 24-h ambulatory BP monitoring, BP measurement during a graded symptom-limited exercise using a cycle ergometer and BP recovery over 7 min following exercise. RESULTS: Exercise-induced increase in systolic BP was similar among the four groups. When compared with healthy controls, recovery of systolic BP following termination of exercise was blunted among the CKD groups in unadjusted (P < 0.0001) and adjusted (P < 0.001) models. During recovery, the healthy control group had 5.9% decline in systolic BP per minute. In contrast, MUCH had only 3.3% per minute reduction and the UCH group had 0.3% reduction per minute. A test of linear trend was significant (P = 0.002, adjusted model). CONCLUSION: Because there was no impairment in the heart rate recovery among groups, we speculate that the parasympathetic pathway appears intact among treated hypertensives with CKD. However, the failure to withdraw sympathetic tone upon termination of exercise causes ongoing vasoconstriction and delayed systolic BP recovery providing a biological basis for MUCH. Delayed recovery from exercise-induced hypertension in those with poorly controlled BP provides potentially a new target to assure round-the-clock BP control.

Masked hypertension: understanding its complexity.

Masked hypertension, which is present when in-office normotension translates to out-of-office hypertension, is present in a surprisingly high percentage of untreated persons and an even higher percentage of patients after beginning antihypertensive medication. Not only are persons with prehypertension more likely to have masked hypertension than those with optimal blood pressure (BP), but also they frequently develop target organ damage prior to transitioning to sustained hypertension. Furthermore, the frequency of masked hypertension is high in individuals of African inheritance and in the presence of increased cardiovascular risk factors and disease states, such as diabetes and chronic renal failure. Nocturnal hypertension and non-dipping may be early markers of masked hypertension. Twenty-four hour ambulatory BP monitoring (ABPM), which can detect nighttime and 24 h elevated BP, remains the gold standard for diagnosing masked hypertension. Almost one-third of treated patients with masked hypertension remain as 'masked uncontrolled hypertension', and it becomes important, therefore, to use ABPM (and supplemental home BP monitoring) for the effective diagnosis and control of hypertension.

The effect of continuous positive airway pressure therapy on the prevalence of masked hypertension in obstructive sleep apnea patients.

BACKGROUND AND AIM: Obstructive sleep apnea (OSA) is a common cause of secondary arterial hypertension. Masked hypertension (MH) is defined as normal office blood pressure and abnormal results in 24 h ambulatory blood pressure monitoring (ABPM). The aim of this study was to evaluate the effect of CPAP therapy on the prevalence of MH in patients with OSA. METHODS: 43 patients (40 men) were included, average age 54.2±10.5 years. All underwent sleep study (PG or PSG) with a diagnosis of OSA indicated for CPAP treatment, average apnea-hypopnea index (AHI) 60.6±23.6. Patients were treated with CPAP for one year. Ambulatory blood pressure monitoring was performed before and after one year of treatment. RESULTS: Masked hypertension was initially present in 25 (58.1%) and in 26 (60.5%) patients after one year of CPAP therapy. However, there was a statistically significant improvement in BP for all evaluated intervals of ABPM with the exception of systolic pressure during the daytime. CONCLUSIONS: Masked hypertension was very prevalent in these patients with OSA. The CPAP treatment for one year however had no affect on prevalence of masked hypertension although there was a positive effect of CPAP treatment on blood pressure for all assessed intervals of ABPM with the exception of systolic BP during daytime.

How should we manage a patient with masked hypertension?

A number of studies have shown that masked hypertension (MH) confers an increased risk of target organ damage and of cardiovascular events suggesting that patients with MH would benefit from antihypertensive treatment. However, there is no general agreement about how this condition should be diagnosed. Although ambulatory blood pressure monitoring (ABPM) and self blood pressure measurement (SBPM) provide different and complementary clinical information, the recently published ESH/ESC guidelines for the management of arterial hypertension suggest that for initial assessment of the patient, SBPM may be more suitable in primary care and ABPM in specialist care. If SBPM provides borderline values it is advisable to confirm the diagnosis of MH with ABPM. As the prevalence of MH declines with repeated ABPMs the diagnosis of MH should be based on at least two ABPMs. Patients with MH should undergo a careful diagnostic work-up to assess the existence of additional risk factors including a worsened metabolic profile and the presence of target organ involvement. Treatment of the patient with MH should initially be addressed to improve the patient's lifestyle in order to decrease out-of-office blood pressure and to ameliorate metabolic data. If non-pharmacological measures are insufficient to normalize blood pressure, MH may benefit from pharmacological treatment but no clinical trial has been implemented as yet with the specific purpose of testing this hypothesis. Despite this lack of evidence, the 2013 ESH/ESC guidelines have recommended that in patients with MH also drug treatment should be considered because in patients with MH the risk of adverse outcome is very close to that in sustained hypertension. When ambulatory blood pressure is measured, pharmacological treatment may be modulated according to whether blood pressure is elevated during daytime hours or during sleep.

Hipertensão mascarada: diagnóstico e tratamento / Masked hypertension: diagnosis and treatment

A elevação da pressão arterial (PA) aumenta o risco cardiovascular. A medida da PA obtida no consultóriotem sido o padrão-ouro para o acompanhamento desses pacientes. O advento da monitorização ambulatorialda PA (MAPA) e das medidas domiciliares da PA,entretanto, trouxe novos paradigmas nos conceitos,na classificação e no manejo desses pacientes. A hipertensão mascarada (HM) se caracteriza por PAnormal no consultório acompanhada de elevação da PA na MAPA ou nas medidas domiciliares. Esses pacientes são semelhantes aos hipertensos sustentados em risco cardiovascular. Nesta publicação os autores discutem o diagnóstico e o tratamento da HM.

High blood pressure (BP) steps up cardiovascular risk, with in-office BP measurements long the gold standardfor monitoring these patients. However, the advent of Ambulatory BP Monitoring (ABPM) and in-home BP measurements has ushered in new paradigms forconcepts, classifications and management of these patients. Masked hypertension (MH) is characterizedby normal BP during appointments with rising BP during ABPM or in-home BP measurements. In terms of cardiovascular risk, these patients aresimilar to those with sustained hypertension. In this paper, the authors discuss MH diagnosis and treatment.

Analysis of heart rate variability in masked hypertension.

To investigate heart rate variability (HRV) in patients with masked hypertension (MH), participants were classified based on clinic and 24-h ambulatory blood-pressure monitoring: essential hypertension (EH, n = 40; MH, n = 36) and normotension (NT, n = 48). The HRV parameters were observed using a 24-h Holter monitor. Compared with NT controls, the parameters of HRV (SDNN, SDANN, SDNN Index, RMSSD, HF) and parameters in EH and MH patients had significantly decreased. No statistically significant difference in the HRV parameters was found between the EH and MH groups. The changes in HRV parameters show cardiac autonomic nerve dysfunction in patients with MH.

Unmasking masked hypertension: prevalence, clinical implications, diagnosis, correlates and future directions.

'Masked hypertension' is defined as having non-elevated clinic blood pressure (BP) with elevated out-of-clinic average BP, typically determined by ambulatory BP monitoring. Approximately 15-30% of adults with non-elevated clinic BP have masked hypertension. Masked hypertension is associated with increased risks of cardiovascular morbidity and mortality compared with sustained normotension (non-elevated clinic and ambulatory BP), which is similar to or approaching the risk associated with sustained hypertension (elevated clinic and ambulatory BP). The confluence of increased cardiovascular risk and a failure to be diagnosed by the conventional approach of clinic BP measurement makes masked hypertension a significant public health concern. However, many important questions remain. First, the definition of masked hypertension varies across studies. Further, the best approach in the clinical setting to exclude masked hypertension also remains unknown. It is unclear whether home BP monitoring is an adequate substitute for ambulatory BP monitoring in identifying masked hypertension. Few studies have examined the mechanistic pathways that may explain masked hypertension. Finally, scarce data are available on the best approach to treating individuals with masked hypertension. Herein, we review the current literature on masked hypertension including definition, prevalence, clinical implications, special patient populations, correlates, issues related to diagnosis, treatment and areas for future research.

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.