Ambulatory Blood Pressure Monitoring and Clinical Characteristics of the True and White-Coat Resistant Hypertension

Abstract

The resistant hypertension has been differentiated in true resistant hypertension and white-coat resistant hypertension by using ambulatory blood pressure monitoring. White-coat resistant hypertension was defined as high clinic blood pressure, despite triple treatment for at least 3 months, but day-time blood pressure values < 135/85 mmHg. The aim of this study was to evaluate the presence of different clinical characteristics between two types of resistant hypertension. The study group consisted of 49 patients with essential hypertension, resistant to an adequate and appropriate triple-drug therapy, that included a diuretic, with all 3 drugs prescribed in near maximal doses and that had persistently elevated clinic blood pressure (> 140/90 mm Hg), for at least 3 months. They represented the 2% of 2500 hypertensive outpatients that referred at our Hypertension Unit. Patients with white-coat resistant hypertension (n=19) were older (p<0.05) than those with true resistant hypertension (n=30). The sodium intake (p<0.05) and alcohol intake (p<0.05) were significantly higher in patients with true resistant hypertension than in those with white-coat resistant hypertension. The renin plasma activity and plasma aldosterone were higher (p<0.05) in patients with true resistant hypertension than in those with white-coat resistant hypertension with normal plasma electrolyte balance. There were no significant differences in mean values of office systolic and diastolic blood pressures between white coat resistant hypertensives and true resistant hypertensives (165+17 vs 172+28 and 98+12 vs 102+14 mmHg). Day-time and night-time ambulatory 24-h-systolic and diastolic blood pressures were significantly higher in the true resistant hypertensive patients when compared with white-coat resistant hypertensives (153+15 vs 124+10 mmHg and 97+9 vs 76+6 mmHg all p<0.001). Day-time and night-time ambulatory 24-h-heart rate were significantly higher in the true resistant hypertensive patients when compared with white-coat resistant hypertensives (79+11 vs 71+9 beats/min; p<0.01; 68+9 vs 60+6 beats/min, p<0.001). The ABP readings were analysed by a Fourier series with 4 harmonics. According to the runs test both two groups of patients showed a circadian rhythm for both systolic and diastolic blood pressure. The nocturnal fall in SBP, DBP and HR was not different in both groups of patients. In conclusion, our findings showed that true resistant hypertensive patients were characterized both by higher heart rate and higher plasma renin activity values as an expression of a possible increased sympathetic activity. Thus, the combination of ABPM with the assessment of the clinical characteristics allow to differentiate better the true drug-resistant hypertension from the white coat resistant hypertension.

The use of ambulatory blood pressure monitoring among Medicare beneficiaries in 2007–2010

“…In 2008, the American Heart Association (AHA) published a scientific statement [16] on a sub-class of hypertensive patients considered to have treatment-resistant hypertension, defined as having uncontrolled blood pressure despite the use of antihypertensive medications from three or more classes, or the use of four or more antihypertensive medication classes to achieve blood pressure control. ABPM is currently recommended for the evaluation of patients with treatment-resistant hypertension [3], as it can determine which patients have white coat resistant hypertension [17, 18]. In adjusted models, having more hypertension diagnoses and filling multiple (particularly 4 or more) classes of antihypertensive medication were associated with a significantly higher likelihood of having an ABPM claim.…”

Ambulatory Blood Pressure Monitoring in Resistant Hypertension

“…Apart from this, certain studies demonstrate that patients with true RH have also increased ambulatory pulse pressure in comparison with those with white coat RH [6, 16]. Interestingly ambulatory 24-hour, daytime, and nighttime heart rate is higher in true resistant hypertensives, supporting the notion that increased sympathetic activation may be present in true RH [16]. …”

Ambulatory Blood Pressure Monitoring in the Diagnosis, Prognosis, and Management of Resistant Hypertension: Still a Matter of our Resistance?

“…In another study, Veglio et al [32] performed ABPM in 49 patients with resistant hypertension (office BP > 140/ 90 mmHg for at least 3 months despite triple drug therapy in near maximal doses, including a diuretic). According to the cutoff values suggested by Pickering (135/85 mmHg for daytime ambulatory BP), the investigators identified 61 % of the study patients with true resistant hypertension (daytime ambulatory BP≥ 135/85 mmHg) and 39 % with white-coatresistant hypertension (daytime ambulatory BP < 135/ 85 mmHg).…”