Long-Term Prognostic Value of White Coat Hypertension

Abstract

Abstract-The prognostic value of white coat hypertension (WCH) is still debated. In 2051 subjects representative of the general population of Monza, we measured office, ambulatory, and home blood pressure (BP). The risk of cardiovascular and allcause mortality was assessed over 16 years in normotensive, sustained hypertensive, and WCH subjects, the last group being defined as usually done in clinical practice (ie, by normality of 1 out-of-office [ambulatory or home] BP with an office BP elevation). Compared with normotensive subjects, the risk of cardiovascular mortality, as adjusted for potential confounders, showed a progressive significant increase in WCH and sustained hypertensive subjects (2.04 and 2.94; P=0.006). In either group, a significant increase in adjusted risk was also seen for all-cause mortality. However, when the WCH group was subdivided into 2 subgroups, that is, subjects in whom both out-of-office BPs were normal (true WCH, 42%) or one BP was normal whereas the other was elevated (partial WCH, 58%), only the latter showed a significantly greater adjusted risk of cardiovascular and all-cause mortality (2.76 and 1.58; P<0.03). Compared with normotensive subjects, the partial WCH group also exhibited a marked increase in adjusted risk of developing sustained hypertension over a 10-year time period (2.58; P<0.0001), but in this case the risk was also increased in true WCH subjects (2.89; P<0.0001). Thus, WCH includes subjects with a widely different long-term risk of a cardiovascular event. To identify those at higher risk, measurements of

Closer look at white-coat hypertension

“…No difference in renal function between WCHT and HT patients was noted by Pierdomenico et al [26] . In the PAMELA study, Cardillo, Weber, Mancia and Mulè reported that LVMI was increased in WCHT patients compared with NT patients (P < 0.01), whereas Pierdomenico and Hoeghelm found no difference in LVMI [5,[26][27][28][29][30][31] . Arterial compliance was lower in WCHT patients than in the NT group in studies by Karter's (P < 0.001) and Gomez [25,32] .…”

Definition of White Coat Hypertension

“…There may not be a significant effect on reducing clinical (the magnitude of the white coat effect remains) or self-measured or ambulatory BP values (if they were already within normal limits). In this respect, the study by Mancia et al 8 could help to establish a pattern. According to the study, a diagnosis of white coat hypertension would require both measurements (at home and in an ambulatory setting) to be taken and to be normal.…”

“…9 The second important aspect refers to the artificial categorization of continuous variables with a continuous relationship to the incidence of complications. In this respect, the data provided by Mancia et al 8 show that patients classified as presenting with white coat hypertension have BP values that are midway between hypertensive and normal. This is true for clinical and also for self-measured and 24-hour values.…”

Capsule Commentary on Johnson et al., Antihypertensive Medication Initiation Among Young Adults with Regular Primary Care Use

“…In addition, studies have shown that white coat hypertension may not be "benign" and is associated with increased longterm risk of cardiovascular morbidity. 3,4 Home and 24-hour ambulatory BP monitoring in young adults with mildly elevated office BP may contribute to the early identification and treatment of hypertension.Future studies on designing health care interventions for timely and improved management of hypertension in young adults should focus on the use and effectiveness of life-style modifications; and the patients' and providers' knowledge, attitudes, beliefs and practices toward management of office readings of high BP. Patient and provider education; practice-specific design algorithms for the management of hypertension, including use of ambulatory BP monitoring; and computer alerts targeting multiple high BP readings on a given patient across different practice contact points such as primary or specialty care, have the potential to improve hypertension management in general, as well as in young adults in particular.…”

“…In addition, studies have shown that white coat hypertension may not be "benign" and is associated with increased longterm risk of cardiovascular morbidity. 3,4 Home and 24-hour ambulatory BP monitoring in young adults with mildly elevated office BP may contribute to the early identification and treatment of hypertension.…”