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A practical approach to persistent elevation of blood pressure in the hypertension clinic
1Section of Hypertension and Clinical Pharmacology, Farmington, CT 06030-3940, USA. Mansoor@NSO1.uchc.edu
Insights
Persistent high blood pressure (BP) readings in clinic pose a challenge. This scheme helps specialists differentiate true hypertension from other causes, guiding appropriate patient evaluation and management.
Area of Science:
- Cardiology
- Hypertension Management
- Clinical Diagnostics
Background:
- Persistent elevation of office blood pressure (BP) is a common challenge in hypertension clinics.
- Patients often present with difficulties in achieving BP goals, necessitating specialist evaluation.
- Home and ambulatory BP monitoring data are frequently available in this setting.
Purpose of the Study:
- To propose a systematic scheme for hypertension specialists to evaluate persistent elevation of office BP.
- To guide the differentiation of true hypertension from other causes of elevated office readings.
- To encourage a conscious consideration of underlying reasons for sustained high BP.
Main Methods:
- Initial consideration of falsely elevated office BP readings due to pseudohypertension or equipment issues.
- Distinguishing between transient office BP elevation with normal out-of-office readings (white-coat hypertension) and sustained elevation.
- Evaluating patients with consistently elevated office and out-of-office readings for sustained hypertension and secondary causes.
Main Results:
- The proposed scheme categorizes persistent high office BP into potentially artifactual, transient (white-coat), or sustained hypertension.
- Sustained hypertension, often the majority, requires further investigation for secondary causes.
- The intensity of secondary hypertension evaluation should be tailored to the patient's clinical presentation.
Conclusions:
- A structured approach is recommended for evaluating persistent high office BP in hypertension clinics.
- Differentiating white-coat hypertension from sustained hypertension is crucial for appropriate management.
- Systematic consideration of secondary hypertension causes is essential for patients with persistently elevated BP readings.
Abstract:
Patients seen with persistent elevation of office blood pressure (BP) in the hypertension clinic are common and pose a significant challenge to the hypertension specialist. These are usually patients sent to the clinic because of difficulty in achieving BP goals. In this clinical setting there is usually data available from home self measurement and ambulatory BP readings. We propose a scheme to encourage specialists to consciously consider the causes of persistent elevation of office BP. The scheme relies initially on consideration that the measured office readings are falsely elevated due to pseudohypertension, small cuff size or other equipment problems. If this is not the case then the measured office BP is truly elevated. If so, a further distinction can be made in this group into those with (1). transient office BP elevation and normal home and/or ambulatory readings and (2). elevated office and out of office readings. The first subgroup is usually called white-coat hypertension but may also be seen with transient increases in BP due to talking or other factors. The second subgroup probably is the majority of patients with persistent high office BP and reflects sustained hypertension and its own list of causes including secondary hypertension. The nature and intensity of evaluation for secondary hypertension varies depending on the clinical presentation of the patient. We recommend an explicit consideration of reasons for persistent high office BP in the hypertension clinic.