Cardiovascular Outcome in White-Coat Versus Sustained Mild Hypertension

Abstract

Background-The aim of this study was to compare the risk conferred by white-coat versus sustained mild hypertension for the development of cardiovascular disease. Methods and Results-Patients (nϭ479) who underwent 24-hour intra-arterial ambulatory blood pressure monitoring on the basis of a persistently elevated clinic systolic blood pressure of 140 to 180 mm Hg were followed up for the development of subsequent cardiovascular events during a 9.1Ϯ4.2-year period. White-coat hypertension, defined as a clinic systolic blood pressure of 140 to 180 mm Hg associated with a 24-hour ambulatory systolic blood pressure Ͻ140 mm Hg and diastolic blood pressure Ͻ90 mm Hg, was present in 126 patients, and the remainder had sustained mild hypertension. A subgroup of patients without complications underwent follow-up echocardiography and carotid ultrasound. White-coat hypertensives were younger (44Ϯ12 versus 52Ϯ10 years, respectively; PϽ0.001) and had a significantly lower incidence of cardiovascular events (1.32 versus 2.56 events per 100 patient-years, respectively; PϽ0.001) than sustained hypertensives. Multivariate analysis revealed age (Pϭ0.002), sex (Pϭ0.007), race (Pϭ0.001), smoking (Pϭ0.005), and the presence of white-coat hypertension (hazard ratio, 0.29; 95% CI, 0.09 to 0.90; Pϭ0.04) to be independent predictors of subsequent cardiovascular events. Subgroup analysis in patients without complications revealed a lower incidence of left ventricular hypertrophy and lesser degrees of carotid hypertrophy in the white-coat group. Conclusions-These findings indicate a relatively benign outcome in white-coat hypertension compared with sustained mild hypertension. (Circulation. 1998;98:1892-1897.)

White coat hypertension is a cardiovascular risk factor: a 10-year follow-up study

“…This finding of an increased risk in the WCH patients is surprising and in contrast with the previously mentioned prognostic studies on WCH. [5][6][7][8] In the study by Verdecchia et al, 5 there were similar survival curves for WCHs and the control group, whereas the EHs separated almost immediately to a higher event rate. However, there have been some discussions of these results because a low ABP cutoff level was used in this study and because a substantial fraction of the patients had been treated with antihypertensive drugs.…”

“…The phenomenon was decribed by Riva-Rocci 2 more than 100 years ago and has further been studied and illustrated by Ayman and Goldshine 3 in the 1940s and by Sokolow et al 4 in the 1960s. However, despite this long awareness the knowledge of the adverse effects of WCE is only sparse and particularly the prognosis of WCH remains unsettled; only a few longitudinal studies have been performed in this field [5][6][7][8] and so far the prospective data imply that WCH is a low-risk condition. In all the studies, white coat hypertensives (WCHs) developed fewer cardiovascular events than the established hypertensives (EHs), and in the two studies that included control individuals, these were found to have the same event rate as the WCH patients.…”

Metabolic syndrome in subjects with white-coat hypertension: impact on left ventricular structure and function

“…29 Other potential biologic mediators of LV hypertrophy in subjects with MetS may be certain peptide hormones, such as angiotensin II and leptin, which are secreted by white adipose tissue. 20 Our findings also suggest that the clustering of features of MetS, frequently described in WCHs, may be at least in part responsible for the cardiac abnormalities, and probably for the increased cardiovascular risk displayed in some, but not all, series regarding subjects with WCH [3][4][5][6][7][8][9][10][11][12][13][14][15][16][17] . On the other hand, the greater values of both LV mass and LV chamber diameter that we observed in WCHs without MetS when compared to those of normotensive controls, seem to indicate that WCH per se, independently of MetS, may not be innocuous for the heart.…”

“…1,2 Indeed, the studies that evaluated the effects of WCH on hypertensive target organ damage and on the occurrence of future cardiovascular events yielded conflicting results. [3][4][5][6][7][8][9][10][11][12][13][14][15][16][17] It has long been recognized that hypertension tends to cluster with various anthropometric and metabolic abnormalities, including elevated triglycerides, reduced high-density lipoprotein (HDL) cholesterol, glucose intolerance, abdominal obesity and insulin resistance, which are the main features of the metabolic syndrome (MetS). MetS, which may precede the appearance of sustained hypertension, contributes to the development of hypertensive target organ damage and atherosclerotic diseases.…”

White coat hypertension: not so benign after all?

“…11 Similarly, a study of 958 older Japanese patients with a mean follow-up of 42 months reported that the incidence of stroke in WCH is similar to that of normotensives and onefourth the risk in sustained hypertensives. 12 The longest follow-up study of 9.1 years was that of Khattar et al, 13 which reported cardiovascular outcomes in 479 patients with WCH compared to those with sustained mild hypertensionFand found that patients with WCH were younger (44 vs 52 years old) and had a significant lower incidence of cardiovascular events.…”