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Blood Pressure Monitoring. Task force V: White-coat hypertension
T G Pickering1, A Coats, J M Mallion
1Hypertension Center, New York Presbyterian Hospital, New York, USA. tpicker@mail.med.cornell.edu
Insights
White-coat hypertension, characterized by high blood pressure only in medical settings, does not typically require medication. Long-term monitoring of blood pressure outside the clinic is recommended for these patients.
Area of Science:
- Cardiology
- Hypertension Research
- Clinical Medicine
Background:
- White-coat hypertension (WCH) is defined by elevated clinic blood pressure with normal ambulatory blood pressure (ABP).
- Prevalence varies, approximately 20% in mild hypertensives, increasing with age.
- The white-coat effect is the difference between clinic and daytime ABP.
Framework:
- WCH is generally associated with less target-organ damage than sustained hypertension.
- Some studies suggest a higher prevalence of target-organ damage in WCH compared to normotensives.
- Association with metabolic abnormalities like hyperlipidemia is debated.
Implementation:
- Antihypertensive medication typically lowers clinic blood pressure but not ABP in WCH.
- Drug treatment is often not indicated for WCH.
- Indefinite monitoring of out-of-office blood pressure is recommended.
Implications:
- Prognosis in WCH is more closely linked to ABP than clinic readings.
- Patients may be misclassified or progress to sustained hypertension.
- Further research is needed to clarify long-term risks and optimal management strategies.
Terminology:
Two terms are in current use to describe patients whose blood pressures are high only in a medical setting (white-coat hypertension and isolated office or clinic hypertension). The term white-coat effect is also commonly used to describe the pressor response to the clinic setting.
Definitions:
White-coat hypertension is generally defined as a persistently elevated clinic blood pressure in combination with a normal ambulatory blood pressure (ABP). There is disagreement regarding the optimal cutoff point for ABP. The white-coat effect is operationally defined as the difference between the clinic blood pressure and daytime ABP. PREVALENCE OF WHITE-COAT HYPERTENSION: This varies according to the definition of white-coat hypertension and the population studied, but is approximately 20% among mild hypertensives, and increases with age.
Metabolic And Biochemical Aspects:
Authors of some studies have suggested that white-coat hypertension is associated with metabolic abnormalities such as hyperlipidemia that lead to an increase in cardiovascular risk, but most have not found this. TARGET-ORGAN DAMAGE: Several measures of target-organ damage have been compared among normotensives, white-coat hypertensives, and sustained hypertensives; these include left ventricular mass, microalbuminuria, and carotid atherosclerosis. In general, target-organ damage in white-coat hypertension is less than that in sustained hypertension, but in some studies it has been found to be more prevalent than in normotensives.
Morbidity And Mortality:
Authors of a relatively small number of prospective studies have concluded that white-coat hypertensives have a lower risk of morbidity than do sustained hypertensives, but a larger number have drawn the more general conclusion that, when there is a discrepancy between the clinic blood pressure and ABP, the prognosis is more closely related to the ABP.
Management:
When white-coat hypertensives are prescribed antihypertensive medication there is usually a decrease in clinic blood pressure, but little or no change in ABP. Thus drug treatment is not necessarily indicated. Another issue is the follow-up of white-coat hypertensives; there is general agreement that blood pressure outside the office should be monitored indefinitely. Some patient may have been wrongly classified as white-coat hypertensives, and others may progress to develop sustained hypertension.