Cardiac damage in hypertensive patients with inverse white coat hypertension. Hospitalet study

BACKGROUND: Few studies have assessed the relationship between ambulatory blood pressure (BP) and cardiac damage in essential hypertensive patients with inverse white coat hypertension (IWCH). OBJECTIVES: To determine the frequency of IWCH in untreated grade 1-2 hypertension and to assess possible differences in cardiac damage among patients with IWCH, white coat hypertension (WCH) and the rest of patients with grade 1-2 hypertension. PATIENTS AND METHODS: Two hundred and eleven patients with grade 1-2 hypertension were sequentially included. A good quality 24-h ambulatory BP monitoring was obtained in 204 patients (age: 41 +/- 12 years, 56% males). IWCH was defined as a daytime systolic and/or diastolic BP higher than diagnostic office systolic and/or diastolic BP, respectively. WCH was defined as a daytime BP < 135/85 mmHg. A good quality echocardiogram was obtained in 174 patients. We considered left ventricular hypertrophy a left ventricular mass index (LVMI) > or = 125 g/m2. RESULTS: We found IWCH in 29 subjects (14%), and WCH in 68 (33%). Office BP in patients with IWCH was in an intermediate position between WCH and the rest of grade 1-2 hypertension patients. The IWCH patients showed 24-h, daytime and night-time BP higher than the other groups. Left ventricular mass was significantly greater in patients with IWCH than in the other grade 1-2 hypertension patients after adjusting for age, gender, body mass index, smoking and office BP (regression coefficient 28.14, 95%CI: 7.36-48.91). CONCLUSION: IWCH is independently associated with higher values of left ventricular mass in patients with grade 1-2 hypertension.     

Population-derived comparisons of ambulatory and office blood pressures. Implications for the determination of usual blood pressure and the concept of white coat hypertension.

BACKGROUND--Ambulatory blood pressures (BPs) have generally been reported to be lower than office blood pressures, but population-based data are lacking. METHODS--To better characterize ambulatory and office BP relationships, we explored the interrelationships of BPs measured in the office by mercury sphygmomanometry, 24-hour ambulatory BP measured with a portable device, and echocardiographic left ventricular mass in a random sample of 50 men aged 51 to 72 years drawn from a much larger pool. Office BP was based on the mean of 10 measurements performed over five visits. RESULTS--Among all participants, mean 24-hour ambulatory and mean office BPs were highly correlated: r (systolic/diastolic) = .90/.79; and both mean 24-hour and mean awake ambulatory BPs were significantly higher than mean office BPs. For the subsample not receiving antihypertensive therapy, mean ambulatory and office BPs were similar in terms of their associations with Penn left ventricular mass index (LVMI). No association between BP and left ventricular mass was observed among the subjects receiving antihypertensive medication. CONCLUSIONS--We conclude that a single session of 24-hour ambulatory BP monitoring is unlikely to improve the determination of usual BP in older white men beyond that achievable with BP carefully measured over five separate office visits; and that white coat hypertension is rare in this population.     

Relationship between aortic stiffness and cardiovascular risk factors in a population of normotensives, white-coat normotensives, white-coat hypertensives, sustained hypertensives and diabetic patients.

OBJECTIVE: To evaluate the relationship between carotid-femoral pulse wave velocity (PWV) and office and ambulatory blood pressure (ABP) and other cardiovascular risk factors and to determine the discriminatory value of PWV in a large population including normotensive subjects (NT), white-coat normotensives (masked hypertension) (WCNT), and white-coat hypertensives (WCHT) compared to a group of treated and untreated hypertensive patients. METHODS: The study population included a total of 688 subjects aged from 18 to 80 years, with no previous cardiovascular events, who underwent 24 h ABP monitoring, biochemical evaluation and determination of PWV and left ventricular mass index (LVMI). Subjects were classified as true normotensives (NT, n=132; normal office and ABP values), WCNT (n=39; office BP < 140/90 and daytime BP > or =135 or > or =85 mmHg), WCHT (n=87; office BP > or =140 or > or =90 and daytime BP < 135/85 mmHg). Untreated (UT-HT, n=154) and treated (T-HT, n=171) hypertensive patients and type 2 diabetic patients (DM, n=102) were also studied. RESULTS: Values of PWV (m/s) in all groups were, in ascending order: NT (8.9 +/- 0.2) < WCHT (9.9 +/- 0.2) < T-HT (11.4 +/- 0.2) = WCNT (11.5 +/- 0.4) < UT-HT (11.9 +/- 0.3) < DM (12.6 +/- 0.4) (ANOVA, p = 0.043), and of LVMI (g/m2): NT (59 +/- 2) = WCHT (63 +/- 2) < WCNT (73 +/- 3) = T-HT (75 +/- 3) = UT-HT (77 +/- 3) < DM (84 +/- 4) (ANOVA, p < 0.05). The percentage of subjects with PWV values below the median (10.7 m/s) was higher (p < 0.02) in NT (81.8%) and WCHT (72.6%) than in UT-HT (49.2%), T-HT (43.6%), WCNT (47.6%) and DM (27.7%). In multiple regression analysis, taking PWV as the dependent variable, age (all groups), 24h systolic BP (UT-HT, T-HT, WCNT and DM) and 24h diastolic BP (NT and WCHT) were the variables that independently influenced the PWV value. CONCLUSIONS: Higher values of PWV occur in clinical situations associated with higher cardiovascular risk. This is in agreement with risk stratification based on ABP values but not on office BP values. Lower PWV and LVMI values occur in NT and WCHT subjects, supporting a low cardiovascular risk in these groups. By contrast, higher PWV values were associated with higher ABP values in DM, hypertensive patients and white-coat normotensives, i.e. clinical situations that are associated with higher cardiovascular risk, who in the present study also exhibited higher LVMI than subjects with normal ABP values.     

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.     

The importance of using 24‐hour and nighttime blood pressure for the identification of white coat hypertension: Data from the Jackson Heart Study

We calculated the prevalence of white coat hypertension (WCH) using out‐of‐clinic blood pressure (BP) in the daytime period; daytime and 24‐hour periods; and daytime, 24‐hour, and nighttime periods among 199 African Americans with clinic‐measured systolic/diastolic BP ≥140/90 mm Hg in the Jackson Heart Study. Left ventricular mass index (LVMI) was measured among participants with WCH and 374 participants with sustained normotension (ie, non‐hypertensive clinic, daytime, 24‐hour, and nighttime BP). The prevalence of WCH was 29.6%, 21.1%, and 10.6% using daytime BP; daytime and 24‐hour BP; and daytime, 24‐hour, and nighttime BP, respectively. Compared with sustained normotension, LVMI was higher when WCH was defined using daytime BP (adjusted mean difference [95% CI] 5.0 [?0.2, 10.1] g/m²), but not when defined using daytime and 24‐hour BP or daytime, 24‐hour, and nighttime BP (adjusted mean difference [95% CI] 3.9 [?1.9, 9.7] and 0.4 [?7.3,8.2] g/m², respectively). Using only daytime BP overestimates the prevalence of WCH among African Americans.     

Morning rise, morning surge and daytime variability of blood pressure and cardiovascular target organ damage. A cross-sectional study in 743 subjects.

OBJECTIVE: To evaluate in a large population the relationship between cardiovascular target organ damage and values of the night-to-morning rise of systolic blood pressure (MR-BP), the morning surge of BP at the moment of rising (BP surge) and daytime BP variability (standard deviation [SD] of daytime BP). METHODS: This was a cross-sectional study, evaluating 743 subjects, aged 30-75 years, 416 female, with normal renal function and no previous cardiovascular events. The population included: I-174 patients with type 2 diabetes, II-317 hypertensive patients with ongoing treatment over at least the previous 6 months, III-127 hypertensive patients untreated in the last 6 months, IV-125 healthy normotensive subjects. All underwent 24-hour ambulatory BP monitoring to calculate MR-BP, BP surge and SD of daytime BP. Target organ evaluation included: pulse wave velocity (PWV) (an indicator of aortic stiffness) in 711 subjects, left ventricular mass index (LVMI) in 185 subjects and 24-hour albuminuria in 239 subjects. RESULTS: In the population as a whole, BP surge, MR-BP and SD of daytime BP correlated significantly with PWV (r = 0.434, p < 0.0001; r = 0.126, p < 0.001; 0.337, p < 0.001, respectively), with LVMI (r = 0.447, p < 0.0001; r = 0.307, p < 0.001; 0.162, p < 0.05, respectively) and to a lesser degree with albuminuria (r = 0.126, p < 0.05; r = 0.083, NS; 0.082, NS, respectively). In the upper quintile of distribution of BP surge, the percentage of cases with abnormal PWV (>12 m/s) (21%), cardiac hypertrophy (53 %) and microalbuminuria (47 %) was significantly greater (p < 0.03) than that observed in the lower quintile (1%, 14% and 27%, respectively). BP surge correlated more strongly with indices of target organ damage than did MR-BP or SD of daytime BP, independently of night-time BP and nocturnal BP fall. CONCLUSIONS: In this large population, MR-BP, BP surge and daytime BP variability are strongly correlated with target organ damage severity, and are probably related to organ deterioration. Of the three, morning surge of BP at the moment of rising is more strongly related to organ damage than MR-BP, perhaps because unlike MR-BP, BP surge is independent of night-time BP values.     

Prevalence and clinical significance of a greater ambulatory versus office blood pressure ('reversed white coat' condition) in a general population

BACKGROUND: Attention has recently been directed to a condition termed 'reversed white coat' because of an average 24 h ambulatory blood pressure (BP) uncharacteristically greater than office BP. No data are available, however, on the prevalence of this condition in the general population, as well as on its relationship to BP, age, gender, antihypertensive treatment and cardiac organ damage. METHODS: In 3200 individuals (participation rate 64%), randomly selected to be representative of the residents of Monza (Milan, Italy) for sex and decades of age (25 to 74 years), we measured office BP (average of three measurements, sphygmomanometry), ambulatory BP (automatic readings every 20 min, Spacelabs 90207) and left ventricular mass (echocardiography). RESULTS: A 'reversed white coat' condition (identified when 24-h average ambulatory systolic, diastolic or mean were higher than the corresponding office values) was seen in 15% (diastolic) to 26% (systolic) of the population as a whole. Prevalence was greater (34-40%) when the difference between office and daytime BP was considered but in both instances it remained less than the prevalence of the white-coat phenomenon. A reversed white-coat condition was similarly frequent in males and females and showed a steep reduction with age and increasing office BP values. Prevalence was greater in hypertensive subjects in whom treatment achieved BP control than in untreated or unsatisfactorily treated individuals. Within each quartile of 24-h or office BP, left ventricular mass index adjusted for demographic and biochemical values was similar in reversed white coat versus the remaining subjects. The absence of any association with left ventricular hypertrophy scores against the clinical significance of this phenomenon.     

Increased circulating concentrations of asymmetric dimethylarginine (ADMA) in white coat hypertension

Elevated plasma levels of the endogenous nitric oxide (NO) synthase inhibitor asymmetric dimethylarginine (ADMA) contribute to endothelial dysfunction and seem to be a predictor for cardiovascular mortality. Elevated ADMA plasma concentrations have been demonstrated in patients with hypertension. However, the plasma concentrations of ADMA in white coat hypertension (WCH) has not been previously studied. The aim of this study was to evaluate ADMA in WCH and compare with normotensive (NT) and hypertensive (HT) patients. We also evaluated the relation between ADMA and NO in these three groups. For this purpose, 34 NT, 34 white coat hypertensive (clinical hypertension and ambulatory daytime blood pressure <135/85 mmHg) and 34 HT patients were recruited in this study. The subjects were matched for age, gender, body mass index (BMI) and the patients with smoking habit, dyslipidaemia and diabetes mellitus were excluded. The ADMA levels were determined by high performance liquid chromatography. Plasma ADMA levels were significantly higher in WCH group than in the NT group (3.21+/-0.49 micromol/l vs 2.84+/-0.58 micromol/l, P=0.046). It was significantly higher in the HT group than in the NTs (4.24+/-0.38 micromol/l, P<0.001). There was also a significant difference between the HT and WCH groups (P<0.001). The WCH subjects had significantly higher levels of NO than the HTs (41.68+/-2.23 vs 32.18+/-2.68 micromol/l; P<0.001) and significantly lower values than the NTs (48.24+/-4.29 micromol/l; P<0.001). In WCH and HT group, there was a negative correlation between ADMA and NO (r=-0.515, P=0.003 and r=-0.389, P=0.034, respectively). In NT subjects, there was no correlation between these two parameters (r=-0.287, P=0.124). The correlation between ADMA and NO was stronger in WCH group than in HT group. Although NO levels in HT patients were lower than WCHs and ADMA levels were higher in HT patients than WCHs, the negative correlation of these two parameters were more pronounced in WCH group. Decreased NO and increased ADMA levels in WCH may indicate endothelial dysfunction. Our data indicate also that WCH represent an intermediate group between NT and HT when endothelial dysfunction is concerned.     

Treated hypertension and the white coat phenomenon: Office readings are inadequate measures of efficacy

To better define the prevalence of white coat hypertension (WCH) among patients with type 2 diabetes mellitus and to estimate the magnitude of white coat effect (WCE), before and after antihypertensive therapy, we gathered data from an open-label forced-titration study of a combination of antihypertensive drugs that was titrated sequentially, in the order amlodipine, olmesartan, and hydrochlorothiazide, over an 18-week period among 187 patients with type 2 diabetes mellitus. WCH was defined as daytime ambulatory blood pressure (BP) of 135/85 mm Hg or less, but clinic BP of 140/90 mm Hg or more. WCE was obtained as the mean difference between clinic and daytime ambulatory BP. At baseline, the prevalence of WCH was 12%; all but one subject had WCE of >10/5 mm Hg. After treatment, the prevalence of WCH had increased to 39% (P < .001). In the overall population, at baseline, the mean (±SD) WCE for systolic BP was 10.4 ± 10.9 mm Hg and 3.7 ± 8.6 mm Hg for diastolic BP. After treatment, the reduction in systolic WCE was 3.01 ± 0.93 (SE; P < .0001); no reduction was seen for diastolic WCE. Among patients treated with amlodipine-olmesartan combination, WCE at baseline was 11 mm Hg systolic and was attenuated to -0.9 mm Hg. Among patients treated with amlodipine-olmesartan-hydrochlorothiazide combination, systolic WCE was similar at baseline (10.1 mm Hg) and at end of therapy (8.1 mm Hg). Mean systolic difference between dual and triple therapy of 9.9 mm Hg, SE 2.98 was significant (P < .001). The drop in diastolic WCE from 6.4 with dual therapy to -1.2 with triple therapy was also significant (mean difference 7.6, SE 2.2; P < .001). In conclusion, the prevalence of WCH increases three-fold with treatment as a result of fewer patients having sustained hypertension. Thus, out-of-office BP monitoring especially among treated hypertensive patients with type 2 diabetes is necessary to provide better assessment of overall BP and response to treatment.     

Diagnostic criteria of white coat hypertension (WCH): consequences for the implications of WCH for target organs

In a sample comprising 51 normotensive subjects and 51 subjects with in-clinic arterial hypertension [blood pressures (BPs) > or = 140/90 mmHg), we investigated the prevalence of target organ damage [left ventricular hypertrophy (LVH) and retinal vasculopathy] in white coat hypertension (WCH) groups defined using: (a) the "optimal ambulatory BP" criterion of the Seventh International Consensus Conference (in-clinic BPs >140/90 mmHg, daytime mean BPs < 130/80 mmHg) and (b) the "normal ambulatory BP" criterion proposed in 1997 by Verdecchia and co-workers (in-clinic BPs >140/ 90 mmHg, daytime mean BPs < 135/85 mmHg), and we compared the results with those obtained for the normotensive group and for a WCH group defined as in a 1996 study of the same data. We found that the newer criteria did not alter the conclusions reached in 1996: namely, that WCH constitutes a state of risk intermediate between normotension and sustained hypertension, which demands in-depth evaluation and active monitoring, if not immediate therapy. We also found that when the WCH group was defined as those patients with in-clinic BPs > or = 140/90 mmHg and 24-h mean BPs < 121/78 mmHg, the prevalence of target organ damage was similar to that found in the control group. We conclude that if WCH status is to imply absence of elevated risk of target organ damage, then the ambulatory BP threshold defining WCH should be lower than the upper limit of ambulatory BPs among subjects who are normotensive in the clinic. The desirability of predicting target organ damage in both hypertensive and normotensive subjects using criteria combining in-clinic BPs, daytime mean ambulatory BPs and night-time mean ambulatory BPs is suggested.     

Subclinical Organ Damage in White‐Coat Hypertension: The Possible Role of Cystatin C

The authors investigated the relationship of white‐coat hypertension (WCH) with subclinical organ damage and potential relevant mechanisms. A total of 386 untreated patients were enrolled and divided into 204 patients with WCH and 183 with normotension. Flow‐mediated dilation (FMD), pulse wave velocity (PWV), intima‐media thickness, left ventricular mass index (LVMI), and cystatin C levels were measured. All tests were two‐sided, and a P value <.05 was considered statistically significant. The WCH group exhibited higher LVMI and PWV values, decreased E/A ratio and FMD values, and increased prevalence for left ventricular hypertrophy compared with controls (P<.001 for all). Cystatin C was significantly higher in the WCH group compared with controls (P=.035) and was positively associated with LVMI (P<.05 for both). The presence of WCH is associated with more pronounced subclinical organ damage compared with normotension. Cystatin C may play a significant role and therefore warrants further investigation.     

24-h Ambulatory blood pressure in patients with ECG-determined left ventricular hypertrophy: left ventricular geometry and urinary albumin excretion-a LIFE substudy

This study was undertaken to evaluate the relationships among left ventricular (LV) geometric patterns and urinary albumin excretion in patients with hypertension and electrocardiographic (ECG) LV hypertrophy. In 143 patients with stage II-III hypertension, 24-h ambulatory blood pressure (BP) monitoring, single urine albumin determination, and echocardiography were performed after 14 days of placebo treatment. Mean age was 68+/-7 years, 35% were women, body mass index was 28+/-5 kg/m(2), LV mass index (LVMI) was 125+/-26 g/m(2), and 24% had microalbuminuria. The mean office BP was 176+/-15/99+/-8 mmHg and the mean daytime ambulatory BP was 161+/-18/92+/-12 mmHg. Ambulatory BP, but not office BP, was higher among albuminuric compared to normoalbuminuric patients. In patients with established hypertension, daytime pulse pressure and office BP were different in the four patterns of LV geometry, with the highest pressure in those with abnormal geometry. Furthermore, microalbuminuria was more frequent in hypertensive patients with LV hypertrophy than in those with either normal geometry or concentric remodelling. White coat hypertensives (10%) showed lower LVMI and no microalbuminuria compared to patients with established hypertension. There were no differences in the prevalence of nondippers (26%) among the four LV geometric patterns or in microalbuminuria. In conclusion, increased daytime pulse pressure and office BP were associated with increased prevalence of abnormal LV geometry. Microalbuminuria was more frequent in groups with concentric and eccentric LV hypertrophy. Ambulatory BP, but not office BP, was higher in albuminuric than normoalbuminuric patients. With regard to the relationship among BP, LV geometric patterns, and urine albumin excretion in this population, 24-h ambulatory BP did not provide additional information beyond the office BP.     

Prevalence of the white-coat effect at multiple visits before and during treatment

OBJECTIVE: To investigate the prevalence and persistence of the white-coat effect (WCE) and white-coat hypertension (WCH) on multiple blood pressure measurement occasions in hypertensive patients with and without treatment. DESIGN: Essential hypertensive patients in whom we took office blood pressure measurements (OBPM) at eight visits (three readings per visit) performed self blood pressure measurements (SBPM) for 1 week prior to each visit (42 readings per week) over a period of 1 year. All measurements were performed with the same automatic device (Omron 705CP). In addition, 24-h ambulatory blood pressure monitoring (ABPM) was performed at the start and at the end of the study. At the start, patients did not use any medication but on subsequent visits they were treated on the basis of their SBPM values. WCH was defined as an OBPM-value > or = 140 and/or 90 mmHg and a SBPM or daytime ABPM value < 135/85 mmHg. This definition was used irrespective of treatment. We also determined the prevalence of a substantial WCE (OBPM 20 mmHg systolic or 10 mmHg diastolic higher than SBPM or daytime ABPM). SETTING: Patients were recruited at hospital or general practice. PATIENTS: A total of 163 mild-to-moderate essential hypertensive patients with a mean age of 56 years (56% males). RESULTS: At eight blood pressure (BP) measurement occasions, 75% of all patients had a substantial WCE at least once, while 57% had WCH at least once. One-third of the patients consistently had a substantial WCE and 14% consistently had WCH on three or more occasions The magnitude of the WCE was significantly related to the height of blood pressure in treated but not in untreated patients. CONCLUSION: In some patients, WCH or a substantial WCE occurs consistently on multiple OBPM visits. Especially in untreated patients, the magnitude of the WCE varies widely among individuals. These results support the incorporation of SBPM and/or ABPM into optimal management of hypertension, not only to prevent misdiagnosis in untreated patients but also to determine the need for adjusting antihypertensive therapy in treated subjects.     

Ambulatory blood pressure monitoring to study white coat syndrome in patients with hypertension seen in primary care

INTRODUCTION AND OBJECTIVES: The white coat phenomenon is said to occur when the difference between systolic/diastolic blood pressure measured during visits to the doctor's office and in ambulatory recordings is greater than 20/10. These absolute differences, known as the white coat effect, may lead to normotensive patients being classified as having white coat hypertension (WCH). We used ambulatory blood pressure monitoring (ABPM) to monitor the prevalence and response (white coat effect, white coat hypertension or white coat phenomenon) in patients during pharmacological treatment for grade 1 or 2 hypertension, and 4 weeks after treatment was suspended under medical supervision. PATIENTS AND METHOD: Ambulatory blood pressure monitoring was used in 70 patients with hypertension that was well controlled with treatment. Blood pressure was recorded during treatment (phase 1) and 4 weeks after treatment was stopped (phase 2). RESULTS: 18 (26%) of the 70 patients did not participate in phase 2 because when medication was withdrawn, their blood pressure values became unacceptable and it was necessary to restart treatment. The white coat effect was significantly stronger in phase 1, and the prevalence of white coat phenomenon and white coat hypertension did not differ significantly between phases. At the end of phase 2 the prevalence of white coat hypertension was 33%. CONCLUSIONS: Withdrawal of antihypertensive medication in patients with well controlled grade 1 or grade 2 hypertension did not significantly modify the prevalence of white coat phenomenon or white coat hypertension. The white coat effect was greater while patients were on pharmacological treatment. One third of our patients were considered to have been mistakenly diagnosed as having hypertension.     

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.     

Left ventricular systolic and diastolic function assessed with two-dimensional and Doppler echocardiography in “white coat” hypertension

Objectives. The aim of this study was to investigate left ventricular function in subjects with “white coat” hypertension, defined as office arterial diastolic pressure ≥90 and ambulatory daytime pressure < 140/90mm Hg.Background. The white coat arterial pressure response may, by influencing left ventricular function, have a confounding effect in studies of heart disease.Methods. Two-dimensional and Doppler echocardiography, combined with the calibrated subclavian arterial pulse tracing, were used to assess variables of left ventricular function in 26 subjects with white coat hypertension, as well as 22 subjects with previously untreated ambulatory hypertension (office arterial diastolic pressure ≥90 and <115 mm Hg and ambulatory daytime diastolic pressure ≥90 mm Hg) and 32 normotensive subjects.Results. In subjects with white coat hypertension, systolic arterial pressure during the echocardiographic examination was significantly higher than ambulatory daytime systolic pressure. This pressure response was positively related to the ratio of the systolic to diastolic pulmonary venous flow peak velocities and to the peak velocity of flow reversion during atrial systole; it was inversely related to the ratio of early to late mitral flow peak velocities. Left ventricular stroke volume, ejection fraction and velocity of circumferential fiber shortening did not differ in the study groups, but left ventricular external work and end-systolic wall stress were increased in the white coat group.Conclusions. The arterial pressure response in subjects with white coat hypertension is associated with increased left ventricular external work, increased end-systolic wall stress and alterations of left ventricular filling but normal ejection fraction and velocity of circumferential fiber shortening.     

Identification of subjects with white-coat hypertension and persistently normal ambulatory blood pressure

OBJECTIVE: To assess the spontaneous changes in clinic blood pressure, ambulatory blood pressure (ABP) and left ventricular structure in untreated subjects with white-coat hypertension (WCH). DESIGN: A prospective observational study. PATIENTS AND METHODS: In 83 untreated subjects with WCH, 24 h non-invasive ABP monitoring and echocardiographic studies of the left ventricle were repeated after 0.5-6.5 years (mean 2.5) in the absence of antihypertensive drug treatment. WCH was defined by an average daytime ABP < 131/86 mmHg in women and < 136/87 mmHg in men. Ambulatory hypertension was defined by higher ABP values. RESULTS: In the whole population, the clinic blood pressure, ABP and left ventricular mass did not change from baseline to the follow-up visit, whereas the peak A: peak E ratio (where A is the velocity of transmitral blood flow after atrial contraction and E is the velocity during passive left ventricle filling) increased from 0.86 to 0.93. Sixty-three per cent of subjects remained in the WCH category at follow-up study; the remaining 37% shifted to the ambulatory hypertension category. The former group showed no changes in clinic blood pressure, ABP, left ventricular mass and peak A: peak E ratio. The clinic blood pressure of those who developed ambulatory hypertension did not change, whereas their ABP and peak A: peak E ratio increased and their left ventricular mass increased slightly but not significantly. The left ventricular mass increased from baseline to follow-up study by 6.2% in those who developed ambulatory hypertension and decreased by 1.6% in those who remained in the WCH category. The changes in left ventricular mass were associated with the changes in average 24 h systolic blood pressure, but not with the changes in clinic blood pressure. In a stepwise logistic regression analysis, average daytime diastolic blood pressure was the sole variable to enter the model and the probability of ambulatory hypertension at follow-up study was 20.0%percnt; in those with basal daytime ABP <130/80 mmHg, versus 81% in those with higher basal daytime blood pressure levels. CONCLUSION: After 0.5-6.5 years, WCH spontaneously evolved into ambulatory hypertension in 37% of subjects, with an accompanying rise in left ventricular mass. The probability of ambulatory hypertension increased with the baseline values of ABP, rather than with those of clinic blood pressure. WCH might be a prehypertensive state (particularly in subjects with higher baseline ABP levels) and should be defined by low levels of daytime ABP, possibly lower than 130/80 mmHg.     

White Coat Hypertension: to Treat or Not to Treat?

Definition of white coat hypertension (WCH) traditionally relies on elevated office blood pressure (BP) during repeated visits concomitant with normal out-of-office BP values, as assessed by home and/or 24-h ambulatory BP monitoring measurements. Accumulating evidence focusing on the association of WCH with target organ damage and, more importantly, with cardiovascular events indicates that the risk conveyed by this condition is intermediate between normotension and sustained hypertension. This article will review a number of issues concerning WCH with particular emphasis on the following: (1) prevalence and clinical correlates, (2) association with target organ damage and cardiovascular events, (3) therapeutic interventions. Data will refer to the original WCH definition, based on out-of-office BP determined by 24-h ambulatory BP monitoring; at variance from home BP measurement, this approach rules out the potentially confounding effect of a clinically relevant abnormal BP phenotype such as isolated nocturnal hypertension.     

Birth weight, hypertension and "white coat" hypertension: size at birth in relation to office and 24-h ambulatory blood pressure

We investigated the association of size at birth with hypertensive status defined by office blood pressure (BP) and 24-h ambulatory BP monitoring in a historical cohort study of 736 men born 1920-1924 and examined at age 70 years. Office BP was measured after 10-min supine rest with a sphygmomanometer, ambulatory BP was recorded with Accutracker 2, and anthropometric and other measurements were taken at a clinic. Birth weight and gestational age were abstracted from the men's birth records. A total of 24% of the men were treated for hypertension at the time of the study. Among not treated subjects, there was a weak positive association of birth weight with daytime and 24-h diastolic ambulatory BP. In subjects treated for hypertension, both office and ambulatory BP were inversely related to birth weight, although these associations were not statistically significant. Birth weight did not show significant association with sustained hypertension (elevated office and daytime ambulatory BPs) but showed a strong and statistically significant inverse association with "white coat" hypertension (elevated office BP and normal daytime ambulatory BP) when adjusted for concurrent body mass index (odds ratios 1.91, 1.59, 1 and 1.21 from lowest to highest quartile of birth weight, P-value for trend 0.035). We conclude that BP measured by 24-h-ambulatory monitoring is not related to birth weight in a pattern previously reported for office BP and that factors related to growth in utero are particularly related to higher risk of "white coat" hypertension.     

Prevalence of left ventricular hypertrophy in hypertensive patients without and with blood pressure control: data from the PAMELA population. Pressioni Arteriose Monitorate E Loro Associazioni

Previous studies have shown that in the population, only a minority of treated hypertensive patients achieve blood pressure (BP) control. Whether and to what extent this inadequate control has reflection on hypertension-related organ damage has never been systematically examined. In 2051 subjects belonging to the PAMELA (Pressioni Arteriose Monitorate E Loro Associazioni) Study population, we measured office, home, and 24-hour ambulatory BP values, together with echocardiographic left ventricular mass and wall thickness. Based on the fraction on antihypertensive treatment and on measurements of increased or normal office, home, or 24-hour ambulatory BP values, subjects were classified as normotensives, untreated hypertensives, treated hypertensives with inadequate BP control, and treated hypertensives with effective BP control. Compared with values in the normotensive group, left ventricular mass index, left ventricular wall thickness, and prevalence of left ventricular hypertrophy were markedly increased not only in untreated hypertensive patients but also in treated hypertensives with inadequate BP control. Echocardiographic abnormalities were less in treated hypertensives with BP control than in patients with inadequate BP control, but values were still clearly greater than in normotensive subjects. This was the case regardless whether BP control was assessed by office, home, and/or ambulatory values. Our data provide evidence that in the hypertensive fraction of the population, cardiac structural alterations can be frequently found in both the presence and absence of antihypertensive treatment. They also imply that even effective treatment of hypertension does not allow complete reversal of the cardiac organ damage characterizing high BP states.