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Mortality risks in different subtypes of white-coat hypertension: implications for the diagnosis of white-coat
Alejandro de la Sierra1, Luis M Ruilope2, Natalie Staplin3
1Hypertension Unit. Department of Internal Medicine. Hospital Mutua Terrassa. University of Barcelona, Terrassa.
Insights
White-coat hypertension is not a single condition. Some subtypes, particularly those with elevated 24-hour blood pressure, significantly increase mortality risk, while others do not.
Area of Science:
- Cardiology
- Hypertension Research
- Morbidity and Mortality Studies
Background:
- The prognostic significance of white-coat hypertension (WCH) remains debated.
- WCH is characterized by elevated clinic blood pressure (BP) with normal ambulatory BP.
- Subtypes of WCH based on circadian BP patterns may have differential risks.
Purpose of the Study:
- To investigate mortality risks associated with different subtypes of white-coat hypertension.
- To define WCH subtypes based on 24-hour, daytime, and nighttime blood pressure patterns.
- To compare risks against a normotensive reference group.
Main Methods:
- Analysis of 44,119 patients with elevated office BP.
- Classification of WCH into three subtypes based on circadian BP.
- Cox-regression models adjusted for confounders to assess all-cause and cardiovascular mortality.
Main Results:
- WCH with normal BP across all circadian periods showed no increased mortality risk.
- WCH with normal daytime BP but elevated 24-hour BP was linked to higher all-cause and cardiovascular mortality.
- WCH with normal 24-hour BP but elevated nocturnal BP had increased crude death rates, but not statistically significant after adjustment.
Conclusions:
- White-coat hypertension is a heterogeneous condition with varying mortality risks.
- Relying solely on daytime BP may obscure increased risks in patients with elevated 24-hour or nocturnal BP.
- Accurate classification of WCH subtypes is crucial for risk stratification.
Background:
The risk associated with white-coat hypertension is controversial. We evaluated mortality risks in white-coat hypertension subtypes defined according to the circadian pattern of blood pressure (BP) elevation over 24 h.
Methods:
In 44 119 patients with elevated office BP, white-coat hypertension subtypes were defined as normal BP in all circadian periods (day, night, and 24-h, 12 192 patients), normal 24-h, with nocturnal BP elevation (4368), and normal daytime, with 24-h BP elevation (3525). Associations of each subtype with all-cause and cardiovascular mortality were estimated by Cox-regression models, adjusted for clinical confounders, compared to a reference group of 7690 patients with normal both office and ambulatory (all periods) BP.
Results:
Compared to the reference group, white-coat hypertension defined by normal BP in all circadian periods was not associated with an increased risk of all-cause [hazard ratio, 0.94 [95% confidence interval, 95% CI,0.85-1.03]) or cardiovascular death (hazard ratio, 0.91 [95% CI,0.76-1.08]). In contrast, white-coat hypertension defined by normal daytime, but with elevated 24-h BP, was associated with increased risks of all-cause (hazard ratio, 1.27 [95% CI,1.13-1.42]) and cardiovascular death (hazard ratio, 1.37 [95% CI,1.12-1.68]). The group of white-coat hypertension defined by normal 24-h BP, but with nocturnal BP elevation had increased crude rates of death, but risks were not significantly increased after adjusting for confounders.
Conclusion:
White-coat hypertension is a heterogeneous condition in terms of associated risk of death. A definition based only on a normal daytime BP may mask a significant group of patients with increased 24-h or night BP, who exhibit an increased risk of mortality.
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