Chronic hypertension differential diagnosis: Difference between revisions

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==Differerentiating Hypertension from other Diseases==
==Differerentiating Hypertension from other Diseases==
Before the diagnosis of primary (essential) hypertension is made, ruling out secondary causes of hypertension is important. Additionally, other conditions that might reveal high blood pressure levels in the clinic or outside must be considered in the differential diagnosis of hypertension.
===White Coat Hypertension===
===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.<ref name="pmid24107724">{{cite journal| author=Mancia G, Fagard R, Narkiewicz K, Redán J, Zanchetti A, Böhm M et al.| title=2013 Practice guidelines for the management of arterial hypertension of the European Society of Hypertension (ESH) and the European Society of Cardiology (ESC): ESH/ESC Task Force for the Management of Arterial Hypertension. | journal=J Hypertens | year= 2013 | volume= 31 | issue= 10 | pages= 1925-38 | pmid=24107724 | doi=10.1097/HJH.0b013e328364ca4c | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24107724 }} </ref> The prevalence of white coat hypertension is approximately 13%.<ref name="pmid17921809">{{cite journal| author=Fagard RH, Cornelissen VA| title=Incidence of cardiovascular events in white-coat, masked and sustained hypertension versus true normotension: a meta-analysis. | journal=J Hypertens | year= 2007 | volume= 25 | issue= 11 | pages= 2193-8 | pmid=17921809 | doi=10.1097/HJH.0b013e3282ef6185 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17921809 }} </ref> Risk factors based on observational studies include age, female sex, and non-smoking. Nonetheless, as office BP levels are increased, the probability of white coat hypertension is reduced.<ref name="pmid24107724">{{cite journal| author=Mancia G, Fagard R, Narkiewicz K, Redán J, Zanchetti A, Böhm M et al.| title=2013 Practice guidelines for the management of arterial hypertension of the European Society of Hypertension (ESH) and the European Society of Cardiology (ESC): ESH/ESC Task Force for the Management of Arterial Hypertension. | journal=J Hypertens | year= 2013 | volume= 31 | issue= 10 | pages= 1925-38 | pmid=24107724 | doi=10.1097/HJH.0b013e328364ca4c | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24107724 }} </ref> Ambulatory blood pressure monitoring and patient self-measurement using a home blood pressure monitoring device are being increasingly used to differentiate those with white coat hypertension or experiencing the white coat effect from those with true hypertension. Ambulatory monitoring has been found to be a 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.<ref name="pmid16647616">{{cite journal |author=Niiranen TJ, Kantola IM, Vesalainen R, Johansson J, Ruuska MJ |title=A comparison of home measurement and ambulatory monitoring of blood pressure in the adjustment of antihypertensive treatment |journal=Am. J. Hypertens. |volume=19|issue=5 |pages=468–74 |year=2006 |month=May |pmid=16647616 |doi=10.1016/j.amjhyper.2005.10.017}}</ref> According to ESC/ESH recommendations in 2013, white coat hypertension must be confirmed within 3-6 months of diagnosis and close follow-up, evaluation, and periodical out-of-office BP measurements are also required.<ref name="pmid24107724">{{cite journal| author=Mancia G, Fagard R, Narkiewicz K, Redán J, Zanchetti A, Böhm M et al.| title=2013 Practice guidelines for the management of arterial hypertension of the European Society of Hypertension (ESH) and the European Society of Cardiology (ESC): ESH/ESC Task Force for the Management of Arterial Hypertension. | journal=J Hypertens | year= 2013 | volume= 31 | issue= 10 | pages= 1925-38 | pmid=24107724 | doi=10.1097/HJH.0b013e328364ca4c | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24107724 }} </ref> Finally, target organ damage and prognosis of patients with white coat hypertension is still unknown. Although it was considered an intermediate between normal blood pressure and hypertension(105), larger meta-analyses failed to show any significant difference between patients with white coat hypertension and those with normal blood pressure levels.<ref name="pmid17921809">{{cite journal| author=Fagard RH, Cornelissen VA| title=Incidence of cardiovascular events in white-coat, masked and sustained hypertension versus true normotension: a meta-analysis. | journal=J Hypertens | year= 2007 | volume= 25 | issue= 11 | pages= 2193-8 | pmid=17921809 | doi=10.1097/HJH.0b013e3282ef6185 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17921809 }} </ref><ref name="pmid20847724">{{cite journal| author=Pierdomenico SD, Cuccurullo F| title=Prognostic value of white-coat and masked hypertension diagnosed by ambulatory monitoring in initially untreated subjects: an updated meta analysis. | journal=Am J Hypertens | year= 2011 | volume= 24 | issue= 1 | pages= 52-8 | pmid=20847724 | doi=10.1038/ajh.2010.203 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20847724 }} </ref><ref name="pmid22252396">{{cite journal| author=Franklin SS, Thijs L, Hansen TW, Li Y, Boggia J, Kikuya M et al.| title=Significance of white-coat hypertension in older persons with isolated systolic hypertension: a meta-analysis using the International Database on Ambulatory Blood Pressure Monitoring in Relation to Cardiovascular Outcomes population. | journal=Hypertension | year= 2012 | volume= 59 | issue= 3 | pages= 564-71 | pmid=22252396 | doi=10.1161/HYPERTENSIONAHA.111.180653 | pmc=PMC3607330 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22252396 }} </ref>
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.<ref name="urlHypertension: Overview - eMedicine">{{cite web |url=http://emedicine.medscape.com/article/889877-overview |title=Hypertension: Overview - eMedicine }}</ref> It is believed that this is due to the [[anxiety]] some people experience during a clinic visit.<ref name="healthminutes01">{{cite video |people=Swan, Norman |date=20 June 2010 |title=Health Minutes - Hypertension |url=http://www.youtube.com/watch?v=YQC9PYgZ_Zw |accessdate=27 August 2010}}</ref> 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.<ref name="pmid18320786">{{cite journal |author=Ruxer J, Mozdzan M, Baranski M, Wozniak-Sosnowska U, Markuszewski L |title="White coat hypertension" in type 2 diabetic patients |journal=Pol. Arch. Med. Wewn. |volume=117 |issue=10 |pages=452–6 |year=2007 |month=October |pmid=18320786 |doi= |url=http://tip.org.pl/pamw/issue/search.html?lang=en&search=18320786}}</ref>


====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.<ref name="pmid16778338">{{cite journal |author=Helvaci MR, Seyhanli M |title=What a high prevalence of white coat hypertension in society! |journal=Intern. Med. |volume=45 |issue=10 |pages=671–4 |year=2006 |pmid=16778338 |doi= 10.2169/internalmedicine.45.1650|url=http://joi.jlc.jst.go.jp/JST.JSTAGE/internalmedicine/45.1650?from=PubMed |format= &ndash; <sup>[http://scholar.google.co.uk/scholar?hl=en&lr=&q=intitle%3AWhat+a+high+prevalence+of+white+coat+hypertension+in+society%21&as_publication=Intern.+Med.&as_ylo=2006&as_yhi=2006&btnG=Search Scholar search]</sup>}} {{dead link|date=April 2009}}</ref>


====Risk Factors====
===Masked Hypertension===
Patients with white coat hypertension do not exhibit the signs indicative of trepidation and their increased blood pressure is often not accompanied by [[tachycardia]].<ref name="Pickering1988">{{cite journal | author=Pickering T, James G, Boddie C, Harshfield G, Blank S, Laragh J | title=How common is white coat hypertension? | journal=JAMA | volume=259 | issue=2 | pages=225–8 | year=1988 | pmid=3336140 | doi=10.1001/jama.259.2.225}}</ref> This is supported by studies that repeatedly indicate that 15%&ndash;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.<ref>{{cite journal | author=McGrath B | title=Is white-coat hypertension innocent? | journal=Lancet | volume=348 | issue=9028 | pages=630 | year=1996 | pmid=8782749 | doi=10.1016/S0140-6736(05)65069-6}} - commenatry on:<br>{{cite journal | author=Glen S, Elliott H, Curzio J, Lees K, Reid J | title=White-coat hypertension as a cause of cardiovascular dysfunction | journal=Lancet | volume=348 | issue=9028 | pages=654–7 | year=1996 | pmid=8782756 | doi=10.1016/S0140-6736(96)02303-3}}</ref>
The term "masked hypertension" can be used to describe a contrasting phenomenon from that of white coat hypertension, where blood pressure is elevated during daily living, but not in an office setting.<ref name="pmid17664850">{{cite journal |author=Pickering TG, Eguchi K, Kario K |title=Masked hypertension: a review |journal=Hypertens. Res. |volume=30 |issue=6 |pages=479–88 |year=2007 |month=June |pmid=17664850 |doi= 10.1291/hypres.30.479|url=http://joi.jlc.jst.go.jp/JST.JSTAGE/hypres/30.479?from=PubMed |format= &ndash; <sup>[http://scholar.google.co.uk/scholar?hl=en&lr=&q=intitle%3AMasked+hypertension%3A+a+review&as_publication=Hypertens.+Res.&as_ylo=2007&as_yhi=2007&btnG=Search Scholar search]</sup>}} {{dead link|date=April 2009}}</ref> Similarly, the prevalence of masked hypertension is also thought to be approximately 13% and tends to increase when office BP values are high-normal.<ref name="pmid9576133">{{cite journal| author=Parati G, Ulian L, Santucciu C, Omboni S, Mancia G| title=Difference between clinic and daytime blood pressure is not a measure of the white coat effect. | journal=Hypertension | year= 1998 | volume= 31 | issue= 5 | pages= 1185-9 | pmid=9576133 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9576133 }} </ref><ref name="pmid18698202">{{cite journal| author=Bobrie G, Clerson P, Ménard J, Postel-Vinay N, Chatellier G, Plouin PF| title=Masked hypertension: a systematic review. | journal=J Hypertens | year= 2008 | volume= 26 | issue= 9 | pages= 1715-25 | pmid=18698202 | doi=10.1097/HJH.0b013e3282fbcedf | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18698202 }} </ref> Risk factors for masked hypertension include young age, male gender, smoking, alcohol, physical exercise, anxiety and stress, obesity, diabetes, chronic renal insufficiency, and family history of hypertension. In contrast to white coat hypertension, patients with masked hypertension are at a two-fold increased risk of cardiovascular events and target organ damage, especially when BP levels are elevated at night.<ref name="pmid12226150">{{cite journal| author=Lurbe E, Redon J, Kesani A, Pascual JM, Tacons J, Alvarez V et al.| title=Increase in nocturnal blood pressure and progression to microalbuminuria in type 1 diabetes. | journal=N Engl J Med | year= 2002 | volume= 347 | issue= 11 | pages= 797-805 | pmid=12226150 | doi=10.1056/NEJMoa013410 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12226150 }} </ref><ref name="pmid19396423">{{cite journal| author=Wijkman M, Länne T, Engvall J, Lindström T, Ostgren CJ, Nystrom FH| title=Masked nocturnal hypertension--a novel marker of risk in type 2 diabetes. | journal=Diabetologia | year= 2009 | volume= 52 | issue= 7 | pages= 1258-64 | pmid=19396423 | doi=10.1007/s00125-009-1369-9 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19396423 }} </ref>
 
====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.<ref name="pmid17435652">{{cite journal |author=Khan TV, Khan SS, Akhondi A, Khan TW |title=White coat hypertension: relevance to clinical and emergency medical services personnel |journal=MedGenMed |volume=9 |issue=1 |pages=52 |year=2007 |pmid=17435652 |pmc=1924974 |doi= |url=http://www.medscape.com/viewarticle/552593}}</ref> 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".<ref name="Pickering1994"/>
 
====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 (medicine)|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 [[medical diagnosis|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,<ref>{{cite journal|url=http://www.bpmonitoring.com/pt/re/bpm/abstract.00126097-200512000-00006.htm;jsessionid=LpvGzJN7PDC1yqJtnQj3ZWfmzgdnhWycyzsKybSHsr2FLx3hR1vh!1805002056!181195629!8091!-1 |author=Jhalani, Juhee a; Goyal, Tanya a; Clemow, Lynn a; Schwartz, Joseph E. b; Pickering, Thomas G. a; Gerin, William a|title=Anxiety and outcome expectations predict the white-coat effect. |volume=10 | issue = 6 |month= December | year=2005 |publisher= Lippincott Williams & Wilkins, Inc. |pages=pp317–319}}</ref> 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,"<ref name="Pickering1994">{{cite journal | author=Pickering T | title=Blood pressure measurement and detection of hypertension | journal=Lancet | volume=344 | issue=8914 | pages=31–5 | year=1994 | pmid=7912303 | doi=10.1016/S0140-6736(94)91053-7}}</ref> 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.<ref name='Pickering2005p146'>{{cite journal|title=Recommendations for blood pressure measurement in humans and experimental animals: Part 1: blood pressure measurement in humans: a statement for professionals from the Subcommittee of Professional and Public Education of the American Heart Association Council on High Blood Pressure Research |journal=Hypertension |year=2005|first1=TG |last1=Pickering |first2=JE |last2=Hall |first3=LJ |last3=Appel |first4=BE |last4=Falkner |first5=J |last5=Graves |first6=MN |last6=Hill |first7=DW |last7=Jones |first8=T |last8=Kurtz |author9=Sheps, SG; Roccella, EJ |display-authors=3|volume=45|issue=5|pages=142–61|pmid=15611362 |doi=10.1161/01.HYP.0000150859.47929.8e |url=http://hyper.ahajournals.org/cgi/content/full/45/1/142|format=|accessdate=2009-10-01| ref=harv}} See p. 146, ''Masked Hypertension or Isolated Ambulatory Hypertension''.</ref>
 
[[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.<ref name="pmid16647616">{{cite journal |author=Niiranen TJ, Kantola IM, Vesalainen R, Johansson J, Ruuska MJ |title=A comparison of home measurement and ambulatory monitoring of blood pressure in the adjustment of antihypertensive treatment |journal=Am. J. Hypertens. |volume=19 |issue=5 |pages=468–74 |year=2006 |month=May |pmid=16647616 |doi=10.1016/j.amjhyper.2005.10.017}}</ref> 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."
===Pseudohypertension===
 
Pseudohypertension is defined as marked arterial stiffness associated with calcification of brachial arteries that require much higher cuff-inflating pressures to occlude. Measurements of blood pressure values in the clinic might thus be falsely high.<ref name="pmid24107724">{{cite journal| author=Mancia G, Fagard R, Narkiewicz K, Redán J, Zanchetti A, Böhm M et al.| title=2013 Practice guidelines for the management of arterial hypertension of the European Society of Hypertension (ESH) and the European Society of Cardiology (ESC): ESH/ESC Task Force for the Management of Arterial Hypertension. | journal=J Hypertens | year= 2013 | volume= 31 | issue= 10 | pages= 1925-38 | pmid=24107724 |doi=10.1097/HJH.0b013e328364ca4c | pmc= |url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24107724 }} </ref> Pseudohypertension is more common among elderly patients.<ref name="pmid24107724">{{cite journal| author=Mancia G, Fagard R, Narkiewicz K, Redán J, Zanchetti A, Böhm M et al.| title=2013 Practice guidelines for the management of arterial hypertension of the European Society of Hypertension (ESH) and the European Society of Cardiology (ESC): ESH/ESC Task Force for the Management of Arterial Hypertension. | journal=J Hypertens | year= 2013 | volume= 31 | issue= 10 | pages= 1925-38 | pmid=24107724 |doi=10.1097/HJH.0b013e328364ca4c | pmc= |url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24107724 }} </ref>
Use of breathing patterns has been proposed as a technique for identifying white coat hypertension.<ref name="pmid19009177">{{cite journal |author=Thalenberg JM, Póvoa RM, Bombig MT, de Sá GA, Atallah AN, Luna Filho B |title=Slow breathing test increases the suspicion of white-coat hypertension in the office |journal=Arq. Bras. Cardiol. |volume=91 |issue=4 |pages=243–9, 267–73 |year=2008 |month=October |pmid=19009177 |doi= |url=http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0066-782X2008001600010&lng=en&nrm=iso&tlng=en}}</ref>
 
====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.<ref name="pmid17664850">{{cite journal |author=Pickering TG, Eguchi K, Kario K |title=Masked hypertension: a review |journal=Hypertens. Res. |volume=30 |issue=6 |pages=479–88 |year=2007 |month=June |pmid=17664850 |doi= 10.1291/hypres.30.479|url=http://joi.jlc.jst.go.jp/JST.JSTAGE/hypres/30.479?from=PubMed |format= &ndash; <sup>[http://scholar.google.co.uk/scholar?hl=en&lr=&q=intitle%3AMasked+hypertension%3A+a+review&as_publication=Hypertens.+Res.&as_ylo=2007&as_yhi=2007&btnG=Search Scholar search]</sup>}} {{dead link|date=April 2009}}</ref>


==References==
==References==

Revision as of 07:25, 6 November 2013

Hypertension Main page

Overview

Causes

Classification

Primary Hypertension
Secondary Hypertension
Hypertensive Emergency
Hypertensive Urgency

Screening

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

Before the diagnosis of primary (essential) hypertension is made, ruling out secondary causes of hypertension is important. Additionally, other conditions that might reveal high blood pressure levels in the clinic or outside must be considered in the differential diagnosis of hypertension.

White Coat Hypertension

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.[1] The prevalence of white coat hypertension is approximately 13%.[2] Risk factors based on observational studies include age, female sex, and non-smoking. Nonetheless, as office BP levels are increased, the probability of white coat hypertension is reduced.[1] Ambulatory blood pressure monitoring and patient self-measurement using a home blood pressure monitoring device are being increasingly used to differentiate those with white coat hypertension or experiencing the white coat effect from those with true hypertension. Ambulatory monitoring has been found to be a 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.[3] According to ESC/ESH recommendations in 2013, white coat hypertension must be confirmed within 3-6 months of diagnosis and close follow-up, evaluation, and periodical out-of-office BP measurements are also required.[1] Finally, target organ damage and prognosis of patients with white coat hypertension is still unknown. Although it was considered an intermediate between normal blood pressure and hypertension(105), larger meta-analyses failed to show any significant difference between patients with white coat hypertension and those with normal blood pressure levels.[2][4][5]


Masked Hypertension

The term "masked hypertension" can be used to describe a contrasting phenomenon from that of white coat hypertension, where blood pressure is elevated during daily living, but not in an office setting.[6] Similarly, the prevalence of masked hypertension is also thought to be approximately 13% and tends to increase when office BP values are high-normal.[7][8] Risk factors for masked hypertension include young age, male gender, smoking, alcohol, physical exercise, anxiety and stress, obesity, diabetes, chronic renal insufficiency, and family history of hypertension. In contrast to white coat hypertension, patients with masked hypertension are at a two-fold increased risk of cardiovascular events and target organ damage, especially when BP levels are elevated at night.[9][10]

Pseudohypertension

Pseudohypertension is defined as marked arterial stiffness associated with calcification of brachial arteries that require much higher cuff-inflating pressures to occlude. Measurements of blood pressure values in the clinic might thus be falsely high.[1] Pseudohypertension is more common among elderly patients.[1]

References

  1. ↑ 1.0 1.1 1.2 1.3 1.4 Mancia G, Fagard R, Narkiewicz K, Redán J, Zanchetti A, Böhm M; et al. (2013). "2013 Practice guidelines for the management of arterial hypertension of the European Society of Hypertension (ESH) and the European Society of Cardiology (ESC): ESH/ESC Task Force for the Management of Arterial Hypertension". J Hypertens. 31 (10): 1925–38. doi:10.1097/HJH.0b013e328364ca4c. PMID 24107724.
  2. ↑ 2.0 2.1 Fagard RH, Cornelissen VA (2007). "Incidence of cardiovascular events in white-coat, masked and sustained hypertension versus true normotension: a meta-analysis". J Hypertens. 25 (11): 2193–8. doi:10.1097/HJH.0b013e3282ef6185. PMID 17921809.
  3. ↑ Niiranen TJ, Kantola IM, Vesalainen R, Johansson J, Ruuska MJ (2006). "A comparison of home measurement and ambulatory monitoring of blood pressure in the adjustment of antihypertensive treatment". Am. J. Hypertens. 19 (5): 468–74. doi:10.1016/j.amjhyper.2005.10.017. PMID 16647616. Unknown parameter |month= ignored (help)
  4. ↑ Pierdomenico SD, Cuccurullo F (2011). "Prognostic value of white-coat and masked hypertension diagnosed by ambulatory monitoring in initially untreated subjects: an updated meta analysis". Am J Hypertens. 24 (1): 52–8. doi:10.1038/ajh.2010.203. PMID 20847724.
  5. ↑ Franklin SS, Thijs L, Hansen TW, Li Y, Boggia J, Kikuya M; et al. (2012). "Significance of white-coat hypertension in older persons with isolated systolic hypertension: a meta-analysis using the International Database on Ambulatory Blood Pressure Monitoring in Relation to Cardiovascular Outcomes population". Hypertension. 59 (3): 564–71. doi:10.1161/HYPERTENSIONAHA.111.180653. PMC 3607330. PMID 22252396.
  6. ↑ Pickering TG, Eguchi K, Kario K (2007). "Masked hypertension: a review" (– Scholar search). Hypertens. Res. 30 (6): 479–88. doi:10.1291/hypres.30.479. PMID 17664850. Unknown parameter |month= ignored (help)[dead link]
  7. ↑ Parati G, Ulian L, Santucciu C, Omboni S, Mancia G (1998). "Difference between clinic and daytime blood pressure is not a measure of the white coat effect". Hypertension. 31 (5): 1185–9. PMID 9576133.
  8. ↑ Bobrie G, Clerson P, Ménard J, Postel-Vinay N, Chatellier G, Plouin PF (2008). "Masked hypertension: a systematic review". J Hypertens. 26 (9): 1715–25. doi:10.1097/HJH.0b013e3282fbcedf. PMID 18698202.
  9. ↑ Lurbe E, Redon J, Kesani A, Pascual JM, Tacons J, Alvarez V; et al. (2002). "Increase in nocturnal blood pressure and progression to microalbuminuria in type 1 diabetes". N Engl J Med. 347 (11): 797–805. doi:10.1056/NEJMoa013410. PMID 12226150.
  10. ↑ Wijkman M, Länne T, Engvall J, Lindström T, Ostgren CJ, Nystrom FH (2009). "Masked nocturnal hypertension--a novel marker of risk in type 2 diabetes". Diabetologia. 52 (7): 1258–64. doi:10.1007/s00125-009-1369-9. PMID 19396423.

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