Long-Term Risk of Sustained Hypertension in White-Coat or Masked Hypertension

Abstract

Abstract-It is debated whether white-coat (WCHT) and masked hypertension (MHT) are at greater risk of developing a sustained hypertensive state (SHT). In 1412 subjects of the Pressioni Arteriose Monitorate e Loro Associazioni Study, we measured office blood pressure (BP), 24-hour ambulatory BP, and home BP. Key Words: masked hypertension Ⅲ white-coat hypertension Ⅲ ambulatory blood pressure monitoring Ⅲ prognosis N o conclusive evidence exists as to whether isolated office or white-coat hypertension (HT; WCHT) and masked HT (MHT), ie, the conditions in which, respectively, only office or out-of-office blood pressure (BP) is elevated, are clinically innocent or rather associated with an increase in cardiovascular (CV) risk. [1][2][3] This is because in white-coat and masked hypertensive individuals, the prevalence of structural organ damage has not invariably been found to be greater than in "truly" normotensive individuals. [3][4][5][6][7] It is also because the longitudinal studies that have addressed this issue by assessing the incidence of morbidity and mortality have been based on a small number of CV events and/or a relatively short observation period. 8 -14 Information on the clinical significance of WCHT and MHT can also be obtained by investigating whether, compared with "true" normotension, these conditions are accompanied by a greater rate of development of a "sustained" hypertensive state, ie, HT both in and outside the clinical environment. We have addressed this issue in the Pressioni Arteriose Monitorate e Loro Associazioni (PAMELA) population by identifying subjects with WCHT and MHT through in-office and out-of-office BP measurements and by detecting the development of sustained HT (SHT) over a 10-year time interval, ie, a long follow-up that allowed a large number of cases to occur. A peculiar aspect of the study was that out-of-office BP was measured both at home and over 24 hours, which allowed us to obtain 2 separate identifications of WCHT and MHT. MethodsThe methodology used in the PAMELA Study has been reported in detail elsewhere. 12,15 Briefly, 3200 individuals were randomly selected from the white residents of Monza (a town in the northeast outskirts of Milan), to be representative of its residents for sex, age (25 to 74 years), and socioeconomic characteristics, according to the criteria used by the World Health Organization Monitoring Diseases Project 16 conducted in the same geographic area. 6 Data were collected in 2051 subjects (64% of the original sample), and survivors were contacted 10 years later to be re-examined. All of the subjects agreed to participate in the study after explanation of its nature and purpose the study, and protocol was approved by the ethics committee of the institutions involved.Continuing medical education (CME) credit is available for this article. Go to http://cme.ahajournals.org to take the quiz.

Association of resistin and adiponectin with different clinical blood pressure phenotypes

“…[37][38][39][40] In the Pressioni Arteriose Monitorate e Loro Associazioni (PAMELA) study, the independent contributor to worsening of hypertension status, apart from the baseline BP and age, was plasma glucose, and subjects with masked hypertension were at increased risk for developing sustained hypertension. 41 On the basis of the results of the PAMELA study, our findings further suggest that Res and Adp may have a role in the relentless progression from normal BP toward out-of-clinic hypertensive states, because they were correlated with 24-h BP levels, haemodynamic postural reactions to standing (clinical measure of sympathetic overdrive), metabolic parameters and waist circumference as components of the metabolic syndrome and finally left ventricle mass. The missing association of white-coat hypertension with inappropriate levels of the studied adipokines, even after adjustment for confounders including postural reactions to standing, suggests that these molecular signals might not be implicated on the association of isolated clinic hypertension with target organ damage.…”

Brachial artery hyperaemic blood flow velocity and left ventricular geometry

“…1,12 In a recently published article, 13 a 10% increase in LVMI was associated with a significant increase in cardiovascular risk (arrhythmias, stroke, congestive heart failure, coronary heart disease) and all-cause mortality. 14 An increased SDFV ratio might thus signal an increased risk of concentric remodelling of the LV, eventually leading to overt concentric LVH.…”

The role of blood pressure variability in misdiagnosed clinic hypertension

“…[11][12][13] Recently, both WCH and MH have been shown to predict sustained hypertension in subsequent ambulatory monitoring. 14 Our hypothesis in this study was that large differences between clinic and ambulatory BP, found among patients with both MH and WCH, can be associated with increased ambulatory BP variability. In addition, we aimed to quantify the risk of inaccurate assessment of BP control in the clinic (under-or overestimation) in patients with high BP variability.…”