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.     

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.     

White coat hypertension in patients with obstructive sleep apnea-hypopnea syndrome

BACKGROUND: The strength of the association between obstructive sleep apnea-hypopnea syndrome (OSAHS) and systemic hypertension could be affected by methodologic problems in the definition of hypertension. STUDY OBJECTIVES: To determine the frequency of white coat hypertension (WCH) in patients with OSAHS, and to analyze the characteristics of patients with OSASH and WCH. PATIENTS AND INTERVENTIONS: Ninety-nine consecutive patients with OSAHS and 20 healthy control subjects were included into the study. Twenty-four-hour ambulatory BP monitoring (ABPM) and urinary catecholamines were determined simultaneously with the polysomnographic study. Arterial blood gases and lung volumes were also measured. RESULTS: Office hypertension was diagnosed in 45 patients, while the control group included 54 normotensive patients with OSAHS. After ABPM, hypertension was confirmed in 30 patients with OSAHS and office hypertension. WCH was diagnosed in the remaining 15 patients (33%). Patients with WCH presented higher values of sleep onset latency and wake after sleep onset than normotensive and sustained hypertensive patients. No other differences in sleep parameters, function tests, or urinary catecholamines were found between the OSAHS groups. CONCLUSION: The results indicate that WCH is a frequent phenomenon in patients with OSAHS, and that it is not predictable by clinical variables.     

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.     

White coat hypertension in type 1 diabetic patients without nephropathy

The aim of our study was to determine the prevalence of white coat hypertension (WCH) in type 1 diabetic patients. Therefore, ambulatory blood pressure monitoring (ABPM) and 24-h urinary albumin excretion (UAE) were determined in 47 patients with type 1 diabetes mellitus (27 with new diagnosis of hypertension by office blood pressure (BP) measurement and 20 with normotension). WCH was diagnosed in 20 patients (74%). Patients with WCH presented higher values of systolic and diastolic BP and UAE than normotensive patients. The results indicate that in type 1 diabetes mellitus WCH is very frequent. Thus, WCH may represent a potential risk for the development of diabetic complications, mainly diabetic nephropathy.     

White coat effect in treated and untreated patients with high office blood pressure. Relationship with pulse wave velocity and left ventricular mass index.

OBJECTIVE: To evaluate in hypertensive patients whether the white coat effect is associated with target-organ damage and whether it is modified by anti-hypertensive therapy. METHODS: In a cross-sectional study we evaluated blood pressure (BP) measured in the office and by 24-h ambulatory blood pressure monitoring (ABPM), carotid-femoral pulse wave velocity (PWV) as an index of aortic stiffness, and left ventricular mass index (LVMI) in 88 subjects (aged 49 +/- 2 years) with white-coat hypertension (WCH, office BP > 140/90, daytime BP < 130/84 mmHg), 31 under antihypertensive therapy, 57 untreated, and in 115 patients with office and ambulatory hypertension (HT, aged 51 +/- 2 years, office BP > 140/90, daytime BP > 135/85), 65 under antihypertensive therapy, 50 untreated. In a longitudinal study in 15 patients with HT and in 11 patients with WCH we evaluated the influence of antihypertensive therapy (> 6 months) on office and ambulatory BP and on PWV. RESULTS: The intensity of the white coat effect (office BP-daytime BP) was greater in WCH than in HT. Taking all subjects, the white coat effect did not correlate with PWV (r = 0.08, ns) or with LVMI (r = 0.01, ns), whereas daytime BP correlated significantly with PWV (r = 0.41, p < 0.01) and with LVMI (r = 0.32, p < 0.05). WCH subjects showed lower PWV and LVMI than HT subjects. Treated and untreated WCH, with similar office and daytime BP, showed similar values of PWV and LVMI. Treated and untreated HT showed similar office BP values but treated HT showed lower daytime BP and PWV values. In the longitudinal study, antihypertensive therapy significantly reduced daytime BP and PWV values in the 15 HTs, whereas in the 11 WCH it did not alter daytime BP or PWV values. CONCLUSIONS: 1. In both WCH and HT (treated and untreated) the intensity of the white coat effect does not reflect either the severity of hypertension measured by target organ damage or the efficacy of antihypertensive treatment. 2. In WCH antihypertensive therapy does not improve either ambulatory BP values or damage to target organs.     

White-coat hypertension and carotid artery atherosclerosis: a matching study

BACKGROUND: Blood pressure (BP) measurements obtained in the clinic have long served as the basis for determining risk of hypertensive vascular disease, yet many patients with high BP in the physician's office are normotensive elsewhere. It remains unclear whether such patients with "white coat" hypertension elude the risk of atherosclerosis. METHODS: Community residents 40 to 70 years of age and not receiving any cardiovascular medications were recruited to participate in a study of cardiovascular risk factors. On the basis of clinic and daytime ambulatory BP and a threshold criterion of 140/90 mm Hg, subjects were classified as having persistent hypertension, white-coat hypertension, or persistent normotension. One-to-one matching was conducted in male participants on the basis of race and BP. Subjects with persistent hypertension and white-coat hypertension were matched on clinic BP, and those with white-coat hypertension and normotension were matched on daytime ambulatory BP. RESULTS: The 3 matched groups of men (n=40 in each group) were similar in age, smoking status, and fasting glucose and lipid levels. Compared with the normotensive subjects, subjects with either persistent or white-coat hypertension had greater mean body mass index, waist-hip ratio, and fasting insulin concentration. On the basis of standardized duplex ultrasound examination of the carotid arteries, mean maximal intimal-medial thickness and plaque index in subjects with white-coat hypertension were greater than among normotensive subjects and equal to that of the subjects with persistent hypertension. CONCLUSION: When compared with unmedicated individuals with comparable elevations in clinic BP, individuals with white-coat hypertension appear not to be protected from the atherosclerotic sequelae of hypertension.     

The impact of apelin and relaxin plasma levels in masked hypertension and white coat hypertension

Masked hypertension (HTN) and white coat hypertension represent two reverse forms of clinical HTN with questionable prognostic significance. Recent evidence supports that low apelin and relaxin plasma levels contribute to vascular damage accelerating atherogenesis and predisposing to HTN and cardiovascular (CV) events. The aim of this study was to compare apelin and relaxin plasma levels between patients with masked hypertension (MH) and those with white coat HTN (WCH). Overall, 130 patients not receiving antihypertensive therapy were studied. All patients underwent 24‐hour ambulatory BP monitoring (ABPM) and office BP measurements. Plasma apelin and relaxin levels were measured by ELISA method. According to BP recordings, 24 subjects had MH (group A) and 32 had WCH (group B). Apelin (200 ± 111 pg/mL vs 305 ± 127 pg/mL, P < 0.01) and relaxin (35.2 ± 6.7 pg/mL vs 46.8 ± 23.6 pg/mL, P < 0.01) plasma levels were significantly lower in patients with MH compared to those with WCH, respectively. In conclusion, our findings showed that patients with MH had significantly lower apelin and relaxin levels compared to those with WCH. This observation implies an additional prognostic role for adipokines supporting the concept that MH is closer to essential HTN whereas WCH is a more benign condition.     

Gender difference in the relation blood pressure-left ventricular mass and geometry in newly diagnosed arterial hypertension

Much evidence suggests sexual dimorphism in the relationship linking blood pressure (BP) to both left ventricular mass (LVM) and geometry in hypertension. To better evaluate gender-associated characteristics in the relation BP-LVM among newly diagnosed hypertension (24-h average ambulatory BP monitoring, ABPM, >?125/80 mmHg), we measured indexed LVM and relative wall thickness (RWT) by standardized echographic methods in 209 Caucasian drug-na?ve subjects, of whom 162 (100M/62F) were recognized to be hypertensive. Mean office systolic (SBP)/diastolic (DBP), 24-h average and night-time BP values were similar between sexes and significantly related to indexed LVM in both genders. Daytime SBP was significantly related to indexed LVM only in females (r =0.41; p =0.0008 in women; r =0.11; p = NS in males), while LVM was more sensitive to day-to-night SBP change in females. RWT was, on the contrary, significantly related to ABPM values only in males. All these findings were confirmed after adjusting for possible confounders. Percentage of LVM variance explained by 24-h average, daytime or night-time SBP values were higher in females than in males (17% vs 3%; 11% vs 1%; and 17% vs 8%). In conclusion, in early hypertension, LVM was significantly associated with daytime BP and more sensitive to reduced percentage of night BP fall in females. LVM variance explained by ABPM SBP was much higher in females than in males. RWT, expressing concentric LVM remodelling was, conversely, more related to BP increase in males.     

Endothelium and angiogenesis in white coat hypertension

Hypertensive patients are at particular risk of cardiovascular complications, possibly related to endothelial damage or dysfunction, or to abnormal angiogenesis. The aim of this study was to compare the risk conferred by white coat hypertension (WCH) vs sustained hypertension in the development of the endothelial dysfunction and abnormal angiogenesis by evaluating nitric oxide (NO=NO2+NO3), endothelin-1 (ET-1), vascular endothelial growth factor (VEGF), and E-selectin levels in plasma. The study group included 102 subjects, 34 with WCH (17 male and 17 female patients) aged 49+/-11 years, 34 sustained hypertensives (HT) (15 male and 19 female patients) aged 47+/-11 years and 34 normotensive control subjects (NT) (16 male and 18 female patients) aged 48+/-10 years. WCH was defined as clinical hypertension and daytime ambulatory blood pressure less than 135/85 mmHg. The subjects were matched for age, gender, body mass index and the patients with smoking habit, dyslipidaemia, and diabetes mellitus were excluded from the study. The NO, ET-1, VEGF and E-selectin levels were analysed by ELISA technique. The WCH subjects had significantly higher levels of NO than the HT (41.68+/-2.23 vs 32.18+/-2.68 micromol/l; P<0.001) and significantly lower values than the NT (48.24+/-4.29 micromol/l; P<0.001). ET-1 levels of the WCH group were significantly higher than the NT (8.10+/-0.92 vs 5.95+/-0.26 ng/ml; P<0.001) and significantly lower than the HT (11.46+/-0.59 ng/ml; P<0.001). Considering with VEGF, the WCH group had significantly higher levels than the NT (195.88+/-11.84 vs 146.26+/-18.67 pg/ml; P<0.001), but the difference from the HT group was not significant (203.35+/-7.48 pg/ml; P=0.062). E-selectin in the WCH group was significantly lower than the HT (4.77+/-0.52 vs 8.49+/-2.85; P<0.001), but the difference from the NT group was not significant (3.86+/-0.67; P=0.077). Our data demonstrate that WCH is associated with endothelial dysfunction and abnormal angiogenesis. The degree of these changes is not as severe as observed in hypertensive population.     

Hyperhomocysteinemia: an additional risk factor in white coat hypertension

The association between homocysteine and sustained hypertension (HT) has been studied. The aim of this study was to assess homocysteine levels in white coat hypertension (WCH) as an indicator of increased risk in the development of cardiovascular diseases. WCH was defined as clinical hypertension and a daytime ambulatory blood pressure of < 135/85 mmHg. Plasma levels of homocysteine were determined in patients with WCH, hypertension, and normotension (NT). The study group included 100 subjects, 33 with WCH (16 males, 17 females) aged 49.1 +/- 1.9; 35 sustained hypertensives (17 males,18 females) aged 48.5 +/- 1.7 and 32 normotensive control subjects (15 males, 17 females) aged 48.8 +/- 2.2. The subjects were matched for age, gender, and body mass index. Patients with a smoking habit, dyslipidemia, or diabetes mellitus were not included in the study. Homocysteine levels were analyzed by ELISA. Plasma homocysteine levels were significantly higher in the WCH group compared to the controls (12.32 +/- 1.07 versus 5.35 +/- 1.38 micromol/L; P < 0.001) and the WCH group had significantly lower homocysteine values than the hypertensives (19.03 +/- 0.76 micromol/L P < 0.001). Total cholesterol and tri-glycerides were not different among the groups. There were no statistically significant differences in urinary albumin excretion (UAE) or creatinine clearance between the three groups. Hypertensive retinopathy was observed in the WCH group, but was less severe and less frequent compared to HTs. LVMI was greater in the WCH group compared to the NTs, but significantly less than HTs. The data demonstrate that WCH is associated with high levels of homocysteine. The increase in homocysteine level in WCH is not as high as in SHT. Since an elevated plasma homocysteine level is a strong risk factor for coronary artery disease and there was target organ damage in our WCH group, we conclude that WCH should not be considered to be an innocent trait.     

Endothelial function in sustained and white coat hypertension

BACKGROUND: Endothelial dysfunction is a frequent finding in essential hypertension. The aim of this study was to assess endothelial function, by evaluating circulating nitric oxide metabolites, nitrate plus nitrite (NOx), and endothelium-dependent vasodilation (EDD), in white coat hypertension in comparison with sustained hypertension and normotension. METHODS: We selected 22 sustained hypertensive, 22 white coat hypertensive, and 22 normotensive subjects matched for age, gender, body mass index, and occupation. Women were also matched for menopausal status. Subjects with smoking habit, dyslipidemia, and diabetes mellitus were excluded from the study. White coat hypertension was defined as clinical hypertension and daytime ambulatory blood pressure (BP) <135/85 mm Hg. Groups received for 2 days a low-nitrate diet before obtaining blood samples for laboratory measurements. The NOx levels were measured by using the Griess reagent after enzymatic conversion of all nitrate to nitrite. Subjects also underwent brachial artery study by ultrasonography to evaluate EDD and endothelium-independent vasodilation. RESULTS: White coat hypertensive subjects had significantly higher levels of NOx than sustained hypertensive patients (30.8 +/- 12 v 22 +/- 8.5 micromol/L, P <.05) and significantly higher EDD (7.8% +/- 3.1% v 4.6% +/- 3.0%, P <.05). No significant difference was observed between white coat hypertensive and normotensive subjects regarding these parameters. Endothelium-independent vasodilation was not significantly different among sustained hypertensives, white coat hypertensives, and normotensives (18% +/- 4.2% v 18.3% +/- 3.9% v 18.6% +/- 4.8%, respectively, P = not significant). CONCLUSIONS: Our data suggest that middle-aged white coat hypertensive subjects without other cardiovascular risk factors do not show endothelial dysfunction in contrast with sustained hypertensive patients.     

白大衣高血压与被掩盖的高血压的分布特征

目的 观察白大衣高血压与被掩盖的高血压分布特征。方法 2011年1月~2014年6月在我院拟诊为高血压病患者300例,根据诊室血压和24小时动态血压,分为白大衣高血压组、被掩盖的高血压组与持续性高血压组。对比3组患者的患病构成比及收缩期高血压、舒张期高血压和双期高血压特征。结果 白大衣高血压(占16.0%)与被掩盖的高血压病（12.3%）占比类似,持续性高血压组占71.7%。白大衣高血压患者女性、年轻和单纯收缩期高血压占比较高。被掩盖的高血压患者的患病年龄较大,体质量指数大。结论 白大衣高血压与被掩盖的高血压占比相近,各约占七分之一。每种类型的高血压各有一定的分布特征。     

Isolated nocturnal hypertension and arterial stiffness in a Chinese population

OBJECTIVE: We reported previously that normotensive Chinese had higher nighttime diastolic blood pressure (BP) compared with non-Chinese. We, therefore, studied the prevalence and characteristics of isolated nocturnal hypertension and its association with arterial stiffness, an intermediate sign of target organ damage. METHODS: We recorded ambulatory BP, the central and peripheral systolic augmentation indexes, the ambulatory arterial stiffness index, and brachial-ankle pulse wave velocity in 677 Chinese enrolled in the JingNing population study (53.6% women; mean age: 47.6 years). RESULTS: The prevalence of isolated nocturnal hypertension (> or = 120/70 mmHg from 22 : 00 to 4 : 00 h) was 10.9%. Patients with isolated nocturnal hypertension, compared with participants with ambulatory normotension (45.8%), were older (53.7 vs. 40.7 years), more often reported alcohol intake (68.9 vs. 51.0%), and had faster nighttime pulse rate (62.8 vs. 60.7 bpm), higher serum cholesterol (5.12 vs. 4.77 mmol/l), and higher blood glucose (4.84 vs. 4.38 mmol/l). They also had higher indexes of arterial stiffness (P<0.05) than participants with ambulatory normotension. Of 74 patients with isolated nocturnal hypertension, only four (5.4%) had hypertension on conventional office BP measurement (> or = 140/90 mmHg). CONCLUSION: Isolated nocturnal hypertension can only be diagnosed by ambulatory BP monitoring, is prevalent among Chinese, and is associated with increased arterial stiffness.     

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.     

Pulse pressure is more susceptible to the white coat effect than is systolic blood pressure: observations from real-life ambulatory blood pressure monitoring

BACKGROUND: Pulse pressure is a derivative of arterial stiffness. We have previously demonstrated ambulatory pulse pressure to be relatively independent from the blood pressure (BP) lowering during sleep, and thus of a neurogenic effect. On the other hand, white coat BP effects are thought to involve neurogenic activation. The aim of this work was to analyze white coat induced variability in pulse pressure. METHODS: Percent clinic-awake differences in systolic BP (SBP) and pulse pressure (white coat effects) were calculated for 688 consecutive subjects (mean age 60 +/- 16 years, 58% female). Of the subjects, 23% had controlled hypertension, 45% uncontrolled hypertension, 8% normotension, and 4% isolated office hypertension; all were referred to our unit for 24 h ambulatory BP monitoring. RESULTS: Pulse pressure highly correlated with SBP (r = 0.82, P <.00001). We found a larger white coat effect on pulse pressure than on SBP (8.3% and 5.2%, respectively, P < or =.0001). This was true in all subgroups except in normotensive subjects. Specifically, the magnitude of the white coat effect on pulse pressure was greater than on SBP in subjects with treated hypertension, untreated hypertension, and isolated office hypertension, and in young hypertensive subjects, older subjects, and those with diabetes. CONCLUSIONS: Although pulse pressure is related to the mechanical properties of large arteries, it is also influenced by the white coat effect, a neurogenic process. Furthermore, in hypertensive but not in normotensive subjects, the white coat effect on pulse pressure is significantly more pronounced than on SBP.     

Left ventricular hypertrophy in isolated and dual masked hypertension

Masked hypertension (MH) is defined as normal office blood pressure (BP) and elevated ambulatory BP (ABP) or home BP or both. This study assessed the association of MH (ie, isolated home, isolated ABP and dual MH) with echocardiographic left ventricular hypertrophy (LVH). The present analysis of the PAMELA study included 1087 untreated and treated participants with normal office BP and a measurable LV mass (LVM). A total of 193 individuals (17.7%) had any MH (ie, normal office BP, elevated ABP or home BP or both), 48 had dual MH (25%), 62 isolated ambulatory MH (32%), and 83 isolated home MH (43%). Average LVM indexed to body surface area was superimposable in the three MH phenotypes (being the largest difference between groups <3 g/m²) and significantly higher than in true normotensives. This was also for the LVH prevalence that varied across the MH subgroups in a narrow range (from 8.3% to 10.8%). In conclusion, individuals from the general population with isolated MH, in which either home or ABP was elevated, exhibited an increased risk of LVH similar to that entailed by dual MH. Our findings add the notion both home and ABP measurements are useful to more accurately assess the risk of LVH associated with MH in the community.     

Cardiac structure and function and arterial circulation in hypertensive patients with and without metabolic syndrome

High blood pressure (BP) is one of the crucial determinants of the metabolic syndrome (MS). The extent to which MS, diagnosed according to the criteria of the International Federation of Diabetes, impacts on cardiovascular organ damage, independently of BP, is debated. Three hundred and forty hypertensive patients and 100 normotensive controls underwent the following procedures: (1) physical examination and resting BP measurements, (2) 24 h ambulatory BP monitoring, (3) laboratory routine examination, (4) echocardiography, (5) carotid ultrasonography and (6) ankle-brachial BP index. The syndrome was found in 104 of the 340 hypertensive patients (30.6). In comparison to those without MS, those with MS had significantly higher prevalence of left ventricular (LV) hypertrophy by mass/height(2.7) criteria (46 vs 42%, P<0.01) but not by LV mass/body surface criteria (30 vs 31%); the ratio between early-to-late peak velocities of the LV filling waves (E/A) was higher (E/A=0.99+/-0.14 vs 0.89+/-0.15, P<0.01) and left atrium was larger (3.8+/-0.3 vs 3.5+/-0.5 cm, P<0.01). Both hypertensive groups had significantly greater LVM and carotid intima-media thickness than normotensives, without between-group-difference. In this hypertension outpatient clinic almost one-third hypertensive patients have MS. They show a deterioration in structure and function of the heart in comparison to hypertensive patients without MS, but no difference was detected in the carotid and peripheral arterial circulation.     

Masked hypertension in young patients after successful aortic coarctation repair: impact on left ventricular geometry and function

Life expectancy is still reduced in aortic coarctation (AoC) patients despite a successful repair because of late arterial hypertension and atherosclerosis. Masked hypertension (MH) consists of an elevated daytime or awake ambulatory blood pressure (BP) in the presence of a normal BP on conventional measurement at the office. To assess the prevalence of MH among AoC normotensive young patients successfully treated and to evaluate the impact of MH on left ventricular (LV) geometry and function.We studied 76 AoC patients (mean age 14.5±5.7 years, male 64%). According to 24?h ambulatory BP monitoring (ABPM) our sample was divided in real normotensive patients (Group RN, n=40) and MH patients (Group MH, n=36). There was an increased pressure gradient in the aortic arch (15?mm?Hg±4 vs 13?mm?Hg±4.7, P<0.05), increased LV mass (51?g?m(-2.7)±13 vs 46 g?m(-2.7)±12, P<0.05), in MH AoC patients. Regional longitudinal deformation properties of the basal septal segment (-15%±2.4 vs -20%±5, P<0.01) and LV twist values (14°±1.6 vs 12°±1.9, P<0.0001) were reduced in the MH group. There is a high prevalence of MH in young patients with repaired AoC, which is associated with abnormal LV structure and function. Clinicians should consider 24?h ABPM measurements in apparently normotensive patients followed up for AoC repair.     

Assessment of arterial stiffness from ambulatory blood pressure monitoring in children with diabetes mellitus type-1 (DMT1)

Pulse pressure (PP) and ambulatory arterial stiffness index (AASI) can be calculated from ambulatory blood pressure (BP) monitoring (ABPM) and have been suggested as markers of arterial stiffness and predictors of cardiovascular mortality. We retrospectively evaluated PP and AASI from ABPM records in 84 children (43 boys) with diabetes mellitus type-1 (DMT1) compared with 27 non-diabetic normotensive children. Based on office BP and ABPM, patients with DMT1 were divided into three groups: 24/84 (29%) had hypertension (DM HTN), 33/84 (39%) were normotensive (DM NT) and 27/84 (32%) had white-coat hypertension (DM WCH). DM WCH and DM HTN patients had significantly higher PP when compared with DM NT and NT patients alone (47.62 ± 7.31 and 47.43 ± 8.68 versus 41.45 ± 4.44 and 42.18 ± 5.97, respectively, P=0.0002). Similarly, AASI was significantly elevated in both DM WCH and DM HTN patients when compared with NT patients (0.35 ± 0.14 and 0.36 ± 0.15 versus 0.23 ± 0.15, respectively, P=0.007). In conclusion, children with DMT1 and hypertension, including WCH, had significantly higher PP and AASI levels when compared with normotensive patients. This suggests that these children may be at an increased risk for developing cardiovascular complications later on in life.