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The Cardiovascular Risk of White-Coat Hypertension
Stanley S Franklin1, Lutgarde Thijs2, Kei Asayama3
1Heart Disease Prevention Program, Division of Cardiology, School of Medicine, University of California-Irvine, Irvine, California.
Insights
White-coat hypertension (WCH) and its associated white-coat effect (WCE) do not increase cardiovascular disease (CVD) risk in most individuals. However, older, high-risk WCH patients show a heightened risk for CVD events.
Area of Science:
- Cardiology
- Hypertension Research
- Epidemiology
Background:
- The prognostic significance of white-coat hypertension (WCH) and the white-coat effect (WCE) for cardiovascular disease (CVD) development is not fully understood.
- Existing research lacks comprehensive data on the long-term CVD outcomes associated with WCH.
Purpose of the Study:
- To investigate the association between WCH, WCE, and the incidence of CVD events.
- To compare CVD risk in individuals with WCH versus normotensive controls using ambulatory blood pressure monitoring.
Main Methods:
- Utilized data from the International Database on Ambulatory Blood Pressure Monitoring in Relation to Cardiovascular Outcomes (IDACO) across 11 cohorts.
- Compared 653 untreated WCH subjects with 653 age- and cohort-matched normotensive controls, assessing CVD risk using European Society Hypertension guidelines.
- Employed stepwise linear regression and Cox proportional hazards models for analysis, with a median follow-up of 10.6 years.
Main Results:
- Systolic WCE increased with age (3.8 mm Hg per decade) but was independent of CVD risk status.
- High-risk WCH subjects (≥3 risk factors, diabetes, or prior CVD) had a significantly higher incidence of CVD events (adjusted HR: 2.06) compared to matched controls.
- This elevated risk was primarily observed in older (≥60 years) high-risk WCH individuals (adjusted HR: 2.19), with no significant increase in low-risk WCH or older low-risk WCH groups.
Conclusions:
- The white-coat effect's magnitude is linked to aging, not directly to cardiovascular risk.
- For the majority of individuals, WCH does not confer increased CVD risk compared to age- and risk-adjusted normotensive individuals.
- Older, high-risk individuals with WCH represent a specific subgroup with a potentially elevated risk for cardiovascular events.
Background:
The role of white-coat hypertension (WCH) and the white-coat-effect (WCE) in development of cardiovascular disease (CVD) risk remains poorly understood.
Objectives:
Using data from the population-based, 11-cohort IDACO (International Database on Ambulatory Blood Pressure Monitoring in Relation to Cardiovascular Outcomes), this study compared daytime ambulatory blood pressure monitoring with conventional blood pressure measurements in 653 untreated subjects with WCH and 653 normotensive control subjects.
Methods:
European Society Hypertension guidelines were used as a 5-stage risk score. Low risk was defined as 0 to 2 risk factors, and high risk was defined as ≥3 to 5 risk factors, diabetes, and/or history of prior CVD events. Age- and cohort-matching was done between 653 untreated subjects with WCH and 653 normotensive control subjects.
Results:
In a stepwise linear regression model, systolic WCE increased by 3.8 mm Hg (95% confidence interval [CI]: 3.1 to 4.6 mm Hg) per 10-year increase in age, and was similar in low- and high-risk subjects with or without prior CVD events. Over a median 10.6-year follow-up, incidence of new CVD events was higher in 159 high-risk subjects with WCH compared with 159 cohort- and age-matched high-risk normotensive subjects (adjusted hazard ratio [HR]: 2.06; 95% CI: 1.10 to 3.84; p = 0.023). The HR was not significant for 494 participants with low-risk WCH and age-matched low-risk normotensive subjects. Subgroup analysis by age showed that an association between WCH and incident CVD events is limited to older (age ≥60 years) high-risk WCH subjects; the adjusted HR was 2.19 (95% CI: 1.09 to 4.37; p = 0.027) in the older high-risk group and 0.88 (95% CI: 0.51 to 1.53; p = 0.66) in the older low-risk group (p for interaction = 0.044).
Conclusions:
WCE size is related to aging, not to CVD risk. CVD risk in most persons with WCH is comparable to age- and risk-adjusted normotensive control subjects.
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