Chronic hypertension differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Assistant Editor-In-Chief: Taylor Palmieri

Overview

Before the diagnosis of primary (essential) hypertension, secondary causes of hypertension should be ruled out. Additionally, other conditions that may elevate BP include: White coat hypertension, masked hypertension, and pseudo-hypertension.

Differerentiating Hypertension from other Diseases

White Coat Hypertension

Definition

White coat hypertension, more commonly known as white coat syndrome, is a phenomenon in which patients exhibit elevated blood pressure in a clinical setting but not in other settings. It is believed that this is due to the anxiety some people experience during a clinic visit. In studies, white coat hypertension can be defined as the presence of a defined hypertensive average blood pressure in an office setting but not at home.

Epidemiology and Demographics

In one Turkish study of 438 consecutive patients, 38% were normotensive, 43% had white coat hypertension, 2% had masked hypertension, and 15% had sustained hypertension. Even patients taking medication for sustained hypertension who are normotensive at home may exhibit white coat hypertension in the office setting.

Risk Factors

Patients with white coat hypertension do not exhibit the signs indicative of trepidation and their increased blood pressure is often not accompanied by tachycardia. This is supported by studies that repeatedly indicate that 15%–30% of those thought to have mild hypertension as a result of clinic or office recordings display normal blood pressure and no unusual response to pressure stimulus. These persons did not show any specific characteristics such as age that may be indicative of a higher susceptibility to white coat hypertension.

Natural History, Complications, Prognosis

In general, individuals with white coat hypertension have lower morbidity than patients with sustained hypertension, but higher morbidity than the clinically normotensive. Many cross sectional studies have shown that "target-organ damage (as exemplified by left ventricular hypertrophy) is less in white-coat hypertensive [patients] than in sustained hypertensive [patients] even after the allowance has been made for differences in clinic pressure".

Diagnosis

As the notion of "normal" is subjective and changes from individual to individual a reference measurement was necessary. As night-time and self measured values are often not subject to daily stress and clinical values are subject to unusual anxiety, daytime ambulatory blood pressure is used as a reference as it takes into account daily stress but not in excess. Due to specificity involved in diagnosis of white coat hypertension, many problems have been incurred in its diagnosis and treatment.

The diagnosis is made difficult as a result of the unreliable measurements taken from the office setting itself. These methods often involve an interface with health care professionals and frequently results are tarnished by a list of factors including variability in the individual’s blood pressure, technical inaccuracies, anxiety of the patient, recent ingestion of pressor substances, and talking, amongst many other factors. The most common measure of blood pressure is taken from a noninvasive instrument called a sphygmomanometer. "A survey showed that 96% of primary care physicians habitually use a cuff size too small," adding to the difficulty in making an informed diagnosis. For such reasons, white coat hypertension cannot be diagnosed with a standard clinical visit. It can be reduced (but not eliminated) with automated blood pressure measurements over 15 to 20 minutes in a quiet part of the office or clinic.

Ambulatory blood pressure monitoring and patient self-measurement using a home blood pressure monitoring device is being increasingly used to differentiate those with white coat hypertension or experiencing the white coat effect from those with chronic hypertension. This does not mean that these methods are without fault. Daytime ambulatory values, despite taking into account stresses of everyday life when taken during the patient's daily routine, are still susceptible to the effects of daily variables such as physical activity, stress and duration of sleep. Ambulatory monitoring has been found to be the more practical and reliable method in detecting patients with white coat hypertension and for the prediction of target organ damage. Even as such, the diagnosis and treatment of white coat hypertension remains controversial.

Recent studies showed that home blood pressure monitoring is as accurate as a 24-hour ambulatory monitoring in determining blood pressure levels. Researchers at the University of Turku, Finland studied 98 patients with untreated hypertension. They compared patients using a home blood pressure device and those wearing a 24-hour ambulatory monitor. Researcher Dr. Niiranen said that "home blood pressure measurement can be used effectively for guiding anti-hypertensive treatment". Dr. Stergiou added that home tracking of blood pressure "is more convenient and also less costly than ambulatory monitoring."

Use of breathing patterns has been proposed as a technique for identifying white coat hypertension.

Treatment

It should be remembered that all the established published trials on the consequences of high blood pressure and the benefits of treating are based on one-time measurement in clinical settings rather than the generally slightly lower readings obtained from ambulatory recordings. The debate and conflicting ideas revolve around whether or not it would be feasible to treat white coat hypertension, as there still is no conclusive evidence that a temporary rise in blood pressure during office visits has an adverse effect on health. Many believe that patients with "white coat" hypertension do not require even very small doses of antihypertensive therapy as it may result in hypotension.

Masked Hypertension

The term "masked hypertension" can be used to describe the contrasting phenomenon, where blood pressure is elevated during daily living, but not in an office setting.