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White Coat & Masked Hypertension Can Equal Heart Disease

Myocardial infarctions, heart failure, and ischemia more common in these patients.

“White coat” hypertension is typically defined as an increase in blood pressure in a healthcare setting. It may be explained by the nervousness patients may feel when in a healthcare setting such as a physician’s office. Masked hypertension is the opposite effect: blood pressure readings that are typically lower in healthcare settings but elevated at home. This phenomenon may be explained by outside factors at home that raise blood pressure but are not present at the physician’s office, such as stress. Previous studies have been contradictory on the clinical significance of these phenomena.

A new study published in the Journal of the American College of Cardiology suggests that both white coat hypertension and masked hypertension are associated with heart disease. The study authors examined over 3,000 subjects, half of whom were African-American. The subjects came from the Dallas Heart Study, which is a longitudinal study based in Dallas County, Texas. Prevalence of white coat hypertension was 3.3%, and prevalence of masked hypertension was 17.8%. The subjects were looked at over a period of nine years.

Both conditions were associated with increased cardiovascular events. Such events included heart attack, heart failure, atrial fibrillation, angina, and stroke. For white coat hypertension, the risk was larger, with an adjusted hazard ratio of 2.09 (95% CI, 1.05 to 4.15). Masked hypertension had an adjusted hazard ratio of 2.03 (95% CI, 1.36 to 3.03). Markers of hypertension-associated end organ damage also increased with both types of hypertension, including albumin-to-creatinine ratio, crystatin C, and aortic pulsed wave velocity.

This study revealed several important things. First of all, masked hypertension was very prevalent in this population. This suggests that masked hypertension may have a greater than suspected incidence in the general populace. Second of all, it confirms that both of these phenomena are clinically significant. The results may encourage clinicians to treat patients with white coat hypertension; the decision should be made based on a variety of factors. As for masked hypertension, clinicians should encourage their normotensive patients to confirm their good blood pressures at home to rule out masked hypertension.

We found that in participants in the Dallas Heart Study, a multiethnic populational-based study in the Dallas County, both White Coat Hypertension and MH are associated with increased aortic stiffness and markers of kidney damage when compared to the group with normal blood pressure both at home and in the clinic. Furthermore, both white coat hypertension and masked hypertension are associated with increased risk of cardiovascular events, including coronary heart disease, stroke, atrial fibrillation, heart failure, and cardiovascular death over a median follow-up period of nine years.

Practice Pearls:

  • Data from a longitudinal study shows that white coat hypertension and masked hypertension are both associated with increased risk of cardiovascular events.
  • They are also associated with increased incidence of end organ damage, such as renal injury.
  • Clinicians should consider having normotensive patients in the office screen blood pressure at home.

Tientcheu D, Ayers C, Das SR, et al. “Target Organ Complications and Cardiovascular Events Associated With Masked Hypertension and White-Coat Hypertension: Analysis From the Dallas Heart Study.” J Am Coll Cardiol. 2015;66(20):2159-2169. doi:10.1016/j.jacc.2015.09.007.