The clinical significance of white-coat and masked hypertension

OBJECTIVE: Self-measured blood pressure (BP) and 24-hour ambulatory blood pressure (ABP) monitoring are used to define the arbitrary clinical categories of masked hypertension (MH) and white-coat hypertension (WCH). Severity of target organ damage and incidence of major cardiovascular events are greater in patients with MH than in patients whose BP is normal both inside and outside the doctor's office. METHODS: We reviewed studies that addressed the prognostic impact of MH and WCH. RESULTS: Overall, WCH was associated with a better outcome and MH to a poor outcome. We, however, need the criteria to identify the clinically normotensive patients at elevated pretest probability of MH in whom a broad use of self-measured home BP and 24-hour ambulatory BP as screening tests may be appropriate and cost effective. Clinical management of patients with MH should continue to be based on current guidelines and mostly related to target organ damage and associated clinical conditions because of the normal values of clinic BP in these patients. WCH is generally defined by the coexistence of persistently high office BP with normal daytime or 24-hour ABP. Daytime ABP normalcy has been defined by values<135/85 mmHg. Data, however, suggest that incidence of cardiovascular events tends to increase consistently above the cut-off value of 130/80 mmHg for daytime BP. CONCLUSION: The long-term outcome of patients with WCH remains uncertain. Data suggesting an increased risk of stroke need to be confirmed in wide-scale studies.     

Target organ damage in "white coat hypertension" and "masked hypertension"

BACKGROUND: In this study we investigated (i) the prevalence of white coat hypertension (WCH) and masked hypertension (MH) in patients who had never been treated earlier with antihypertensive medication, and (ii) the association of these conditions with target organ damage. METHODS: A total of 1,535 consecutive patients underwent office blood pressure (BP) measurements, 24-h ambulatory BP monitoring (ABPM), echocardiography, and ultrasonography of the carotid arteries. Subjects who showed normotension or hypertension on the basis of both office and ambulatory BP (ABP) measurement were characterized as having confirmed normotension or confirmed hypertension, respectively. WCH was defined as office hypertension with ambulatory normotension, and MH as office normotension with ambulatory hypertension. RESULTS: WCH was found in 17.9% and MH in 14.5% of the subjects. The prevalence of WCH was significantly higher in subjects with obesity, while the prevalence of MH was significantly higher in normal-weight subjects. The confirmed hypertensive subjects as well as the masked hypertensive subjects had significantly higher left ventricular mass (LVM) (corrected for body surface area) and carotid intima media thickness (cIMT) than the confirmed normotensive subjects did (108.9 +/- 30.6, 107.1 +/- 29.1 vs. 101.4 +/- 29.9 g/m(2) and 0.68 +/- 0.16, 0.68 +/- 0.21 vs. 0.63 +/- 0.15 mm, respectively, P < 0.005). White coat hypertensive subjects did not have a significantly higher LVM index than confirmed normotensive subjects (101.5 +/- 25.9 vs. 101.4 +/- 29.9 g/m(2)); they tended to have higher cIMT than the confirmed normotensive subjects, but the difference was not statistically significant (0.67 +/- 0.15 vs. 0.63 +/- 0.15 mm). CONCLUSIONS: WCH and MH are common conditions in patients who visit hypertension outpatient clinics. Confirmed hypertension and MH are accompanied by increased LVM index and cIMT, even after adjusting for other risk factors.     

Examination of Several Physiological and Psychosocial Factors Potentially Associated With Masked Hypertension Among Low‐Risk Adults

The authors examined the association of factors, in addition to prehypertensive office blood pressure (BP) level, that might improve detection of masked hypertension (MH), defined as nonelevated office BP with elevated out‐of‐office BP average, among individuals at otherwise low risk. This sample of 340 untreated adults 30 years and older with average office BP <140/90 mm Hg all had two sets of paired office BP measurements and 24‐hour ambulatory BP monitoring (ABPM) sessions 1 week apart. Other than BP levels, the only factors that were associated (at P<.10) with MH at both sets were male sex (75% vs 66%) and working outside the home (72% vs 59% for the first set and 71% vs 45% for the second set). Adding these variables to BP level in the model did not appreciably improve detection of MH. No demographic, clinical, or psychosocial measures that improved upon prehypertension as a potential predictor of MH in this sample were found.     

Impact of prehypertension on carotid artery intima–media thickening: Actual or masked?

BackgroundRecent studies have reported that prehypertension is associated with increased values of common carotid artery intima–media thickness (CCA-IMT). The aim of this study was to assess the impact of daytime ambulatory blood pressure (BP) levels on the association of prehypertension with CCA intima–media thickening in prehypertensive subjects.MethodsA total of 807 subjects with office systolic BP < 140 and diastolic BP < 90 mmHg, underwent 24 h ambulatory BP (ABP) monitoring and carotid artery ultrasonographic measurements. The study population was divided into 3 groups according to office and daytime ABP levels: (1) normotensives: subjects with office BP < 120/80 mmHg and daytime ambulatory BP values within the normal range, (2) actual prehypertensives: individuals with office SBP (120–139 mmHg) and/or DBP (80–89 mmHg) and daytime ambulatory BP values within the normal range and (3) prehypertensives with masked hypertension (MH): patients with office SBP (120–139 mmHg) and/or DBP (80–89 mmHg) and elevated daytime ambulatory BP values.ResultsPrehypertensive patients with MH had higher (p < 0.01) CCA-IMT values (0.712 mm; 95%CI: 0.698–0.725) than actual prehypertensives (0.649 mm; 95%CI: 0.641–0.656) and normotensives (0.655 mm; 95%CI: 0.641–0.670) even after adjustment for baseline characteristics. Normotensives and actual prehypertensives did not differ significantly regarding CCA-IMT values (p > 0.05). After adjusting for potential confounders, (including demographic characteristics, vascular risk factors, and office BP) prehypertension with MH was independently (p < 0.01) associated with a 0.06 mm increment in CCA-IMT (95%CI: 0.03–0.09).ConclusionsPatients with office BP levels in the prehypertensive range, who also have elevated daytime ABP levels, had higher CCA-IMT values than patients with prehypertension with normal daytime ABP values and normotensive individuals.     

Predictors of controlled ambulatory blood pressure in treated hypertensive patients with uncontrolled office blood pressure.

Although some treated hypertensive patients have controlled 24-h ambulatory blood pressure (ABP) despite their uncontrolled office blood pressure (BP), the factors relating to the control of 24-h ABP remain unknown. We conducted a study to assess 24-h ABP and its association with other cardiovascular risk factors, including echocardiographic left ventricular hypertrophy (LVH), in elderly hypertensive patients (n =41) with uncontrolled office BP (>140/90 mmHg) during long-term medication. Although a majority of the patients had isolated elevation of office systolic BP (SBP), there was no significant relationship between office SBP and 24-h SBP, and about half of the patients had controlled 24-h ABP (125+/-8/69+/-6 mmHg). Patients with controlled 24-h ABP (125+/-8/69+/-6 mmHg) had similar office BP (150+/-6/77+/-5 vs. 150+/-7/79+/-7 mmHg), but lower left ventricular mass index (LVMI) (123+/-34 vs. 156+/-34 g/m(2)) and body mass index (BMI) (24.4+/-2.1 vs. 26.4+/-3.6 kg/m(2)) compared with those with uncontrolled 24-h ABP (149+/-13/78+/-7 mmHg). Multivariate analysis showed that LVMI and BMI were independently associated with controlled 24-h ABP, and the control status of 24-h ABP was highly dependent on the presence of LVH and obesity. Therefore, absence of LVH and obesity may be useful for predicting the level of control of 24-h ABP in treated patients whose office BP is uncontrolled without ABP measurements.     

Isolated ambulatory hypertension is common in outpatients referred to a hypertension centre

The present investigation was aimed at determining the prevalence and the blood pressure (BP) profile of isolated ambulatory hypertension, defined as an elevated ambulatory BP with normal office blood pressure, in a series of 1488 consecutive outpatients referred for routine clinical evaluation of suspected or established arterial hypertension. All patients underwent both office BP (OBP) measurement by a physician and 24-h ambulatory blood pressure monitoring (ABPM). Using OBP values (cutoff for diagnosis of hypertension >/=140/90 mmHg) and daytime ABPM (cutoff for diagnosis of hypertension >/=135/85 mmHg), patients were classified into eight subgroups. In the whole series we found that, independent of treatment status, the prevalence of isolated ambulatory hypertension exceeded 10%. More importantly, 45.3% of individuals who presented with normal OBP values, showed elevated BP at ABPM. Night-time BP, 24-h pulse pressure, and BP variability were significantly higher in isolated ambulatory hypertensives than in normotensive or in white-coat hypertensive individuals. Therefore, isolated ambulatory hypertension is characterized by a blood pressure profile that is similar to that observed in sustained hypertension. These findings suggest that isolated ambulatory hypertension is very common and probably the indications for ABPM should be more extensive in outpatients referred to hypertensive centre.     

Algorithm for diagnosing hypertension using out‐of‐office blood pressure measurements

The authors developed and validated a diagnostic algorithm using the optimal upper and lower cut‐off values of office and home BP at which ambulatory BP measurements need to be applied. Patients presenting with high BP (≥140/90 mm Hg) at the outpatient clinic were referred to measure office, home, and ambulatory BP. Office and home BP were divided into hypertension, intermediate (requiring diagnosis using ambulatory BP), and normotension zones. The upper and lower BP cut‐off levels of intermediate zone were determined corresponding to a level of 95% specificity and 95% sensitivity for detecting daytime ambulatory hypertension by using the receiver operator characteristic curve. A diagnostic algorithm using three methods, OBP‐ABP: office BP measurement and subsequent ambulatory BP measurements if office BP is intermediate zone; OBP‐HBP‐ABP: office BP, subsequent home BP measurement if office BP is within intermediate zone and subsequent ambulatory BP measurement if home BP is within intermediate zone; and HBP‐ABP: home BP measurement and subsequent ambulatory BP measurements if home BP is within intermediate zone, were developed and validated. In the development population (n = 256), the developed algorithm yielded better diagnostic accuracies than 75.8% (95%CI 70.1–80.9) for office BP alone and 76.2% (95%CI 70.5–81.3) for home BP alone as follows: 96.5% (95%CI: 93.4–98.4) for OBP‐ABP, 93.4% (95%CI: 89.6–96.1) for OBP‐HBP‐ABP, and 94.9% (95%CI: 91.5–97.3%) for HBP‐ABP.  In the validation population (n = 399), the developed algorithm showed similarly improved diagnostic accuracy. The developed algorithm applying ambulatory BP measurement to the intermediate zone of office and home BP improves the diagnostic accuracy for hypertension.     

Masked hypertension definition, impact, outcomes: a critical review

The phenomenon of masked hypertension (MH) is defined as a clinical condition in which a patient's office blood pressure (BP) level is <140/90 mm Hg but ambulatory or home BP readings are in the hypertensive range. The prevalence in the population is about the same as that of isolated office hypertension; about 1 in 7 or 8 persons with a normal office BP level may fall into this category. The high prevalence of MH would suggest the necessity for measuring out-of-office BP in persons with apparently normal or well-controlled office BP. Reactivity to daily life stressors and behavioral factors such as smoking, alcohol use, contraceptive use in women, and sedentary habits can selectively influence MH. MH should be searched for in individuals who are at increased risk for cardiovascular complications including patients with kidney disease or diabetes. Individuals with MH have been shown to have a greater-than-normal prevalence of organ damage, particularly with an increased prevalence of metabolic risk factors, left ventricular mass index, carotid intima-media thickness, and impaired large artery distensibility compared with patients with a truly normal BP level in and out of the clinic or office. Also, outcome studies have suggested that MH increases cardiovascular risk, which appears to be close to that of in-office and out-of-office hypertension. The aim of this review was to define the entity of MH, to describe its prevalence in the general population, and to discuss its correlation with cardiovascular events.     

Echocardiographic definition of left ventricular hypertrophy in the hypertensive: which method of indexation of left ventricular mass?

OBJECTIVES: It has been suggested that hypertensives at high risk of cardiovascular complications can be identified on the basis of their left ventricular mass as determined echographically. However, there is as yet a lack of consensus on the mode of indexation (body surface area, height, height 2.7) of left ventricular mass (LVM), and on the cut-off values for definition of left ventricular hypertrophy (LVH). The main objective of this study is to test the influence of the different modes of indexation for LVM on the prevalence of LVH in a population of never treated hypertensive patients on the basis of cut-offs for LVM based upon its relationship with ambulatory blood pressure (BP) measurement. METHODS: A population of 363 untreated hypertensives was investigated using a standardised procedure. The men and women were analysed separately. We studied the relationship between mean daytime ambulatory systolic BP and LVM and calculated the LVM cut-off for a BP of 135 mm Hg using three different methods of indexation. On the basis of these criteria, the population was divided into those with and those without LVH. RESULTS: The prevalence of LVH was found to be higher when LVM was indexed to height2.7 (50.4%) or height (50.1%). Prevalence was lowest when LVM was indexed to body surface area (48.2%), which tended to minimise the hypertrophy in obese individuals. Only indexation by height 2.7 fully compensates for relationships between height and ventricular mass in this population. CONCLUSIONS: Indexing LVM to height 2.7 thus appeared to give a more sensitive estimate of LVH by eliminating the influence of growth. Cut-offs of 47 g/m2.7 in women and 53 g/m2.7 in men corresponded to a cardiovascular risk indicated by a daytime systolic BP >/=135 mm Hg.     

Morning Hypertension Determined by Self‐Measurement at Home Predicts Left Ventricular Hypertrophy in Patients Undergoing Continuous Ambulatory Peritoneal Dialysis

This study aimed to clarify the relationship between blood pressure (BP, mm Hg) measured by patients in the morning at home and left ventricular hypertrophy (LVH), which is a strong predictor for morbidity and mortality due to cardiovascular disease in patients undergoing continuous ambulatory peritoneal dialysis (CAPD). We recorded self‐measured morning BPs and BPs measured at hospital check‐ups (hospital BPs) in 33 patients undergoing CAPD (mean age, 64.0 years) and compared them with left ventricular mass (LVM) derived from echocardiographic examinations. The mean morning BP was 137/75, the mean hospital BP was 140/80, and the mean LVM (g/m^2.7: corrected by height) was 61.8. Of the subjects, 72.7% had LVH (LVM > 51). The morning BP (systolic) was positively correlated with LVM (P = 0.0022, R = 0.508), and the hospital BP (systolic) was weakly correlated (P = 0.0534, R = 0.339). The adjusted odds ratio for LVH was significantly higher in patients with a morning BP (systolic) ≥ 135 (15.9; 95% CI, 1.3 to 198.5) than in patients with a morning BP (systolic) < 135. In conclusion, morning hypertension determined with self‐measured BP was positively correlated with LVH, therefore self BP monitoring could be a useful method to predict LVH in CAPD patients.     

Blood pressures values during evaluation of 24-h ambulatory blood pressure monitoring and left ventricular hypertrophy in patients with chronic renal failure treated with hemodialysis (HD)

Left ventricular hypertrophy (LVH) is common and important predictor of risk of death in end-stage renal failure. In the present study we have analysed the relationship between 24-h ambulatory blood pressure (BP) profile and LVH. The effect of parathyroid hormone (PTH) on was also assessed. From a cohort of 85 patients with crf we selected for analysis 59 stable patients. Ambulatory BP 24-h monitoring, echocardiography (ECHO), body mass index (BMI), serum creatinine, hemoglobin, total protein, albumin, electrolytes and PTH concentrations were assessed in all patients. Concentric LVH was detected by ECHO in 46 patients, in 13 patients excentric LVH was observed. Mean 24-h ambulatory sBP, dBP, mean 24-h ambulatory day sBP, dBP as well as night sBP and dBP were significantly higher than in a control group 60 healthy subjects. It was a correlation between mean 24-h ambulatory sBP and left ventricular mas (LVM) r = 0.606 (p < 0.0001), between mean dBP and (LVM) r = 0.498 (p < 0.001), between mean day sBP and (LVM) r = 0.591 (p < 0.0001), between mean day dBP and (LVM) r = 0.479 (p < 0.001), between mean night dBP and (LVM) r = 0.548 (p < 0.0001), between left ventricular mass index (LVMI) and mean sBP r = 0.428 (p < 0.05), between LVMI and mean day sBP r = 0.442 (p < 0.05). The loss in physiological night-time BP was observed in all patients. It was also correlations between PTH and (LVM) r = 0.704 (p < 0.001), and between BMI and LVMI r = -0.451 (p < 0.05). LVH is common in crf patients. These results confirmed that strong correlations between BP values and LVH and between serum PTH concentrations and LVH indicate that both hypertension and hyperparathyroidism play an important role in the LVH development.     

Long-term risk of mortality associated with selective and combined elevation in office, home, and ambulatory blood pressure

In the Pressioni Arteriose Monitorate e Loro Associazioni (PAMELA) study, office, home, and ambulatory blood pressure (BP) values were measured contemporaneously between 1990 and 1993 in a large population sample (n=2051). Cardiovascular (CV) and non-CV death certificates were collected over the next 148 months, which allowed us to assess the prognostic value of selective and combined elevation in these 3 BPs over a long follow-up. There were 69 CV and 233 all-cause deaths. Compared with subjects with normal office and 24-hour BP, the hazard ratio for CV death showed a progressive increase in those with a selective office BP elevation (white-coat hypertension), a selective 24-hour BP elevation (masked hypertension), and elevation in both office and 24-hour BP. This was the case also when the above conditions were identified by office versus home BP values. Selective elevation in home versus ambulatory BP or vice versa also carried an increased risk. There was indeed a progressive increase in both CV and all-cause mortality risk from subjects in whom office, home, and ambulatory BP were all normal to those in whom 1, 2, or all 3 BPs were elevated, regardless of which BP was considered. The trends remained significant after adjustment for age and gender, as well as, in most instances, after further adjustment for other cardiovascular risk factors. Thus, white-coat hypertension and masked hypertension, both when identified by office and ambulatory or by office and home BPs, are not prognostically innocent. Indeed, each BP elevation (office, home, or ambulatory) carries an increase in risk mortality that adds to that of the other BP elevations.     

Comparison of Office, Ambulatory, and Home Blood Pressure Antihypertensive Response to Atenolol and Hydrochlorthiazide

J Clin Hypertens (Greenwich). 2010;12:14–21. ^© 2009 Wiley Periodicals, Inc.
Office, home, and ambulatory blood pressure (BP) demonstrate variable associations with outcomes. The authors sought to compare office BP (OBP), home BP (HBP), and ambulatory BP (ABP) for measuring responses to hydrochlorothiazide (HCTZ), atenolol, and their combination. After completing washout, eligible patients were randomized to atenolol 50 mg or HCTZ 12.5 mg daily. Doses were doubled after 3 weeks and the alternate drug was added after 6 weeks if BP was >120/70 mm Hg (chosen to allow maximum opportunity to assess genetic associations with dual BP therapy in the parent study). OBP (in triplicate), HBP (twice daily for 5 days), and 24-hour ABP were measured at baseline, after monotherapy, and after combination therapy. BP responses were compared between OBP, HBP, and ABP for each monotherapy and combination therapy. In 418 patients, OBP overestimated BP response compared with HBP, with an average 4.6 mm Hg greater reduction in systolic BP ( P <.0001) and 2.1 mm Hg greater reduction in diastolic BP ( P <.0001) across all therapies. Results were similar for atenolol and HCTZ monotherapy. ABP response was more highly correlated with HBP response ( r =0.58) than with OBP response ( r =0.47; P =.04). In the context of a randomized clinical trial, the authors have identified significant differences in HBP, OBP, and ABP methods of measuring BP response to atenolol and HCTZ monotherapy.     

14例偶测血压正常动态血压升高病人临床分析

背景 长期以来,临床工作者常常只注意偶测血压高而动态血压正常者,即“自大衣高血压”(white coat hyperten-sion),而对偶测血压正常、动态血压升高的病人未予以重视。目的 探讨偶测血压正常、动态血压升高病人(masked hyper-tension)的临床特征与临床意义。方法 89例临床诊断为血压正常的受试者,由受过专门训练的护士在受试者家中测量血压二次,时间间隔为2～3周,二次测量共获得10个读数的平均值作为偶测血压。采用24小时动态血压监测仪记录动态血压。结果 该人群中偶测血压正常、动态血压升高的患病率为15．7％,以男性多见,其中64．3％为偶测血压正常高值者(血压13l～139／85～89mmHg);患者中饮酒的比例、体重指数、血清胆固醇及低密度脂蛋白胆固醇均高于偶测血压及动态血压均正常者。不同日二次测量共10个血压读数的均数与白昼动态血压的相关性好于同日测量、5个读数的均数。结论由于偶测血压的局限性,可使一部分白昼动态血压升高的患者漏诊,后者主要见于偶测血压正常高值者。应对偶测血压正常高值者予以随访检查。     

动态血压监测二级筛选诊断高血压的价值

选择上海人民出版社医务室管辖的７７０名职工中的１０８例高血压（确诊１０２例，临界６例）为对象，观察停服降压药２周以上后的２４ｈ动态血压（ＡＢＰ）参数。在１０１例（检测率９３．５％）受检患者中，ＡＢＰ各项参数均正常者占１９．８％，随年龄增大而减少，男性１５．２％，女性３６．４％（Ｐ＜０．０５）；各项参数均升高者占２５．７％，随年龄增大而增加，男性３０．４％，女性９．１％（Ｐ＜０．１）。高血压患病率根据随测血压的ＷＨＯ标准为１４．０％，按照ＡＢＰ参数则为１１．２％。结果提示动态血压监测可以作为高血压诊断的二级筛选手段，有助于识别＂诊所高血压＂和高危患者。     

Isolated ambulatory hypertension and changes in target organ damage in treated hypertensive patients

Isolated ambulatory hypertension is a condition characterized by elevated ambulatory but normal clinic blood pressure (BP), and has been reported to be associated with increased cardiovascular risk in untreated subjects. However, little is known about the relationship between this condition and intermediate end points such as target organ damage (TOD) in treated hypertensives. We investigated the impact of isolated ambulatory hypertension on left ventricular hypertrophy (LVH) and microalbuminuria (MA) in a selected sample of treated nondiabetic hypertensives with effective and prolonged clinic BP control (BP<140/90 mmHg). Clinic BP measurements, routine diagnostic procedures, echocardiography and 24-h urine collection for MA, were undertaken in 80 patients (mean age 53+/-8 years) with essential hypertension attending our hospital outpatient centre at baseline and after an average follow-up of 30 months. At follow-up evaluation BP status was assessed by self-measurement of BP and ambulatory BP monitoring (ABPM). At the follow-up visit, 51 out of 80 patients (63.7%) reached a BP control according to ABP (average daytime BP<132/85 mmHg) criteria (group I) whereas the remaining 29 did not (group II); home BP was controlled (BP<135/85 mmHg) in all members of group I and in 86% of group II. In the overall study population, mean Sokolow voltage, LV mass index (LVMI) and urinary albumin excretion (UAE) decreased compared to baseline from 24.1+/-5.0 to 18.9+/-5.1 mm (P<0.05), 115.6+/-24.1 to 97.7+/-21.6 g/m(2) (P<0.01), 11.8+/-23.7 to 5.8+/-14.9 mg/24 h (P<0.05), respectively. The prevalence of ECG LVH, altered LV patterns and MA fell from 7.5 to 2.5% (P=NS), from 45 to 25 (P<0.01) and from 13.7 to 5.1% (P<0.05), respectively. However, when data were analysed separately for the two groups a significant decrease of echo LVH and MA was found only in patients with controlled ABP. LVMI and MA decreased from 117.1+/-23.1 to 95.9+/-22.1 g/m(2) (P<0.01) and 12.8+/-24.7 to 4.1+/-5.7 mg/24 h (P<0.05) in group I, and from 114.1+/-24.8 to 102.3+/-20.3 (P=NS) and 11.9+/-22.1 to 6.3+/-18.1 mg/24 h (P=NS) in group II. In conclusion, in the present study isolated ambulatory hypertension in treated patients is associated with a lack of regression in cardiac and extracardiac TOD, suggesting that a tight BP control throughout the 24 h plays a key role in lowering hypertension-induced structural and functional alterations at cardiac and renal level.     

Diagnostic accuracy of home vs. ambulatory blood pressure monitoring in untreated and treated hypertension

Several studies with relatively small size and different design and end points have investigated the diagnostic ability of home blood pressure (HBP). This study investigated the usefulness of HBP compared with ambulatory monitoring (ABP) in diagnosing sustained hypertension, white coat phenomenon (WCP) and masked hypertension (MH) in a large sample of untreated and treated subjects using a blood pressure (BP) measurement protocol according to the current guidelines. A total of 613 subjects attending a hypertension clinic (mean age 53±12.4 (s.d.) years, men 57%, untreated 59%) had measurements of clinic BP (three visits, triplicate measurements per visit), HBP (6 days, duplicate morning and evening measurements) and awake ABP (20-min intervals) within 6 weeks. Sustained hypertension was diagnosed in 50% of the participants by ABP and HBP (agreement 89%, κ=0.79), WCP in 14 and 15%, respectively (agreement 89%, κ=0.56) and MH in 16% and 15% (agreement 88%, κ=0.52). Only 4% of the subjects (27/613) showed clinically significant diagnostic disagreement with BP deviation >5?mm?Hg above the diagnostic threshold (for HBP or ABP). By taking ABP as reference, the sensitivity, specificity, positive and negative predictive value of HBP in detecting sustained hypertension were 90, 89, 89 and 90%, respectively, WCP 61, 94, 64 and 94% and MH 60, 93, 60 and 93%. Similar diagnostic agreement was found in untreated and treated subjects. HBP appears to be a reliable alternative to ABP in the diagnosis of hypertension and the detection of WCP and MH in both untreated and treated subjects.     

White-coat hypertension: a clinical review

White-coat hypertension (WCHT), also called 'isolated office or clinic hypertension', is defined as the occurrence of blood pressure (BP) values higher than normal when measured in the medical environment, but within the normal range during daily life, usually defined as average daytime ambulatory BP (ABP) or home BP values (<135 mm Hg systolic and <85 mm Hg diastolic). The prevalence of WCHT varies from 15% to over 50% of all patients with mildly elevated office BP (OBP) values. In untreated hypertensive patients, the probability of WCHT especially increases with female gender and a mildly elevated OBP level. The value of other possible determinants such as (non) smoking status, duration of hypertension, left ventricular mass, number of OBP measurements, educational level, etc. is less consistently shown. Although, for various reasons, studies evaluating the long-term effects of WCHT are not always easy to interpret, most data indicate that persons with WCHT have a worse or equal cardiovascular prognosis than normotensives, but a better one than those with sustained hypertension. WCHT is sometimes considered a prehypertensive state, but data on the long-term evolution of subjects with WCHT are scarce. Patients with WCHT and a high cardiovascular risk or proven target organ damage should be pharmacologically treated. Subjects with uncomplicated WCHT should probably not receive medical therapy, but a close follow-up, including regular assessment of other risk factors and measurement of OBP (every 6 months) and ABP (every 1 or 2 years), is warranted.     

Left ventricular hypertrophy in treated hypertensive patients with good blood pressure control outside the clinic,but poor clinic blood pressure control

OBJECTIVE: The aim of the study was to evaluate the prevalence of left ventricular hypertrophy (LVH) in treated patients with good blood pressure (BP) control during multiple home BP (HBP) measurements and during 24-h ambulatory BP monitoring (ABPM), but with unsatisfactory BP control in the clinic. These patients were compared with treated hypertensives whose BP was well controlled under the three circumstances. METHODS: Seventy-two treated consecutive patients (group I, age 56 +/- 10 years) with clinic BP values > or = 140/90 mmHg, and a difference between clinic and self-measured HBP > 10 mmHg for diastolic blood pressure (DBP) and/or > 20 mmHg for systolic blood pressure (SBP), underwent the following procedures: (1) clinic BP measurement; (2) routine diagnostic work-up; (3) HBP monitoring; (4) 24-h ABPM; (5) echocardiography. Thirty-five hypertensive patients with satisfactory BP control according to clinic (< 140/90 mmHg), HBP (< or = 131/82 mmHg) and ABP criteria (< or = 125/79 mmHg) were included as the control group (group II, age 55 +/- 9 years). RESULTS: In group I, 33 subjects out of the 72 (46%) with clinic BP > 140/90 mmHg had BP values controlled outside the clinic (23 according to HBP criteria and 22 according to ABP criteria). The prevalence of LVH (LV mass index > 134 g/m2 in men and > 110 g/m2 in women) was significantly higher in these patients (15.1 versus 2.8%, P < 0.01) than in group II (BP also controlled in the clinic), despite the fact that HBP and ABP were reduced to similar levels in the two groups. CONCLUSIONS Our data provide evidence that treated hypertensive patients with good BP control at home or during ambulatory monitoring, but incomplete BP control in the clinic, have more pronounced cardiac alterations than patients with both clinic and out of the clinic BP control. This finding offers a new piece of information about the diagnostic value of BP measurement in the clinic to assess BP control during antihypertensive treatment.     

Masked hypertension and target organ damage in treated hypertensive patients

BACKGROUND: Recent studies have shown that an elevated ambulatory or home blood pressure (BP) in the absence of office BP-a phenomenon called masked hypertension-is associated with poor cardiovascular prognosis. However, it remains to be elucidated how masked hypertension modifies target organ damage in treated hypertensive patients. METHODS: A total of 332 outpatients with chronically treated essential hypertension were enrolled in the present study. Patients were classified into four groups according to office (<140/90 or >or=140/90 mm Hg) and daytime ambulatory (<135/85 or >or=135/85 mm Hg) BP levels; ie, controlled hypertension (low office and ambulatory BP), white-coat hypertension (high office but low ambulatory BP), masked hypertension (low office but high ambulatory BP), and sustained hypertension (high office and ambulatory BP). Left ventricular mass index, carotid maximal intima-media thickness, and urinary albumin levels were determined in all subjects. RESULTS: Of the patients, 51 (15%), 65 (20%), 74 (22%), and 142 (43%) were identified as having controlled hypertension, white-coat hypertension, masked hypertension, and sustained hypertension, respectively. Left ventricular mass index, maximal intima-media thickness, and urinary albumin level in masked hypertension were significantly higher than in controlled hypertension and white-coat hypertension, and were similar to those in sustained hypertension. Multivariate regression analyses revealed that the presence of masked hypertension was one of the independent determinants of left ventricular hypertrophy, carotid atherosclerosis, and albuminuria. CONCLUSIONS: Our findings indicate that masked hypertension is associated with advanced target organ damage in treated hypertensive patients, comparable to that in cases of sustained hypertension.