The challenge of white-coat hypertension screening

The 2025 American Heart Association/American College of Cardiology blood pressure guideline (2025-AHA/ACC-BP guideline) recommends out-of-office blood pressure (BP) assessment to exclude white-coat hypertension (WCH) in untreated and white-coat effect (WCE) in treated individuals among adults with office BP (OBP) ranging between 130/80-<160/100 mmHg, but its real-world diagnostic performance remains incompletely characterized.

We evaluated the performance of 2025-AHA/ACC-BP guideline-recommended OBP thresholds for screening WCH/WCE among 147,404 Brazilian adults with OBP ≥ 130/80mmHg, including 86,692 untreated (29.7% WCH) and 46,229 treated (29.2% WCE) individuals who underwent HBPM and 10,475 untreated (46.2% WCH) and 4,008 treated (49.4% WCE) individuals who underwent ABPM. OBP ranges combining ≥130/80mmHg with progressively lower upper limits (<160/100, <150/95, <150/90, and <140/90 mmHg) were evaluated. The performance of OBP intervals to detect WCH/WCE was assessed using sensitivity, specificity, and area under the receiver operating characteristic curve (AUC).

In the HBPM cohort, OBP ≥ 130/80-<160/100 mmHg yielded sensitivity, specificity, and AUC of 95%, 25%, and 0.600 in untreated and 94%, 28%, and 0.610 in treated participants. Narrower OBP ranges increased AUCs, peaking at OBP ≥ 130/80-<150/90 mmHg (0.682 and 0.677 in untreated and treated, respectively). In the ABPM cohort, the corresponding values for OBP ≥ 130/80-<160/100 mmHg were 94%, 34%, and 0.641 (untreated) and 91%, 41%, and 0.662 (treated), AUC's were highest at OBP ≥130/80-<150/90 mmHg (0.722 in both groups).

This real-world analysis shows that OBP thresholds recommended by the 2025-AHA/ACC-BP guideline for WCH/WCE screening are highly sensitive but have low specificity, resulting in referral of the majority of patients for out-of-office BP assessment.