White coat and masked hypertension

Authors:: Jordana Cohen, MD, MSCE; Raymond R Townsend, MD
Section Editors:: George L Bakris, MD; Bernard J Gersh, MB, ChB, DPhil, FRCP, MACC
Deputy Editors:: Karen Law, MD, FACP; John P Forman, MD, MSc

Literature review current through: Jan 2024.

This topic last updated: Jan 30, 2024.

INTRODUCTION — Discrepancies between office-based and out-of-office blood pressure readings may reveal "white coat" hypertension (if office-based pressures are elevated and out-of-office pressures are normal) or "masked" hypertension (if office-based pressure are normal and out-of-office pressures are elevated).

The diagnosis, management, and prognostic importance of white coat hypertension and masked hypertension are discussed in this topic.

Other relevant discussions pertaining to hypertension can be found separately:

●Out-of-office blood pressure measurement (ambulatory blood pressure monitoring [ABPM] and self-measured blood pressure [SMBP]) (see "Out-of-office blood pressure measurement: Ambulatory and self-measured blood pressure monitoring")

●Overview and diagnosis of hypertension (see "Overview of hypertension in adults")

●Evaluation of the hypertensive adult (see "Initial evaluation of adults with hypertension")

●Choice of drug therapy to treat hypertension (see "Choice of drug therapy in primary (essential) hypertension")

●Goal blood pressure in adults (see "Goal blood pressure in adults with hypertension")

●Evaluation and treatment of resistant hypertension (see "Definition, risk factors, and evaluation of resistant hypertension" and "Treatment of resistant hypertension")

DEFINITIONS — Blood pressure thresholds for determination of hypertension based upon office-based and out-of-office blood pressure readings are discussed elsewhere:

●(See "Overview of hypertension in adults", section on 'Hypertension'.)

●(See "Overview of hypertension in adults", section on 'Definitions based upon ambulatory and home readings'.)

●(See "Blood pressure measurement in the diagnosis and management of hypertension in adults", section on 'Interpretation of blood pressure measurements'.)

White coat hypertension — White coat hypertension, also known as untreated white coat hypertension or isolated office hypertension, is defined by the following in an untreated patient (ie, not on antihypertensive medication) (table 1):

●Mean blood pressure below the threshold for hypertension based upon out-of-office readings

●Mean blood pressures at or above the threshold for hypertension by office-based readings

White coat effect — White coat effect, also known as treated white coat hypertension, is defined by the following in a treated patient (ie, already being treated with antihypertensive medication) (table 1):

●Mean blood pressure at or below the patient's goal based upon out-of-office readings

●Mean blood pressures above the patient's goal by office-based readings

Masked hypertension — Masked hypertension, also known as untreated masked hypertension, is defined by the following in an untreated patient (ie, not on antihypertensive medication) (table 1):

●Mean blood pressure at or above the threshold for hypertension based upon out-of-office readings

●Mean blood pressures below the threshold for hypertension by office-based readings

Masked uncontrolled hypertension — Masked uncontrolled hypertension, also known as treated masked hypertension, is defined by the following in a treated patient (ie, already being treated with antihypertensive medication) (table 1):

●Mean blood pressure above the patient's goal based upon out-of-office readings

●Mean blood pressures at or below the patient's goal by office-based readings

EPIDEMIOLOGY — White coat hypertension (or white coat effect) and masked hypertension (or uncontrolled masked hypertension) are common, likely present in more than 10 percent of all patients who undergo office-based and out-of-office blood pressure measurement.

In cross-sectional studies, the prevalence of white coat hypertension ranges from 10 to 20 percent and appears to be highest in children, older adults, women, and those whose office-based blood pressure is closer to the diagnostic threshold [1-8]. White coat effect is most common in patients with treatment-resistant hypertension (ie, those who require a minimum of three antihypertensive medications at optimal dosing to achieve adequate blood pressure control).

Masked hypertension is present in approximately 10 to 30 percent of adults with normal office-based blood pressures [9,10]. Masked hypertension may be more common among men [1], African Americans [11], and patients with diabetes [12], chronic kidney disease [13,14], and obstructive sleep apnea [15].

WHO SHOULD BE EVALUATED WITH OUT-OF-OFFICE MEASUREMENTS

Who to evaluate for white coat hypertension or effect — We evaluate the following groups of patients for white coat hypertension or effect (table 2):

●All untreated patients (ie, not taking antihypertensive medications) who have elevated office-based blood pressure (ie, systolic pressure ≥130 mmHg or diastolic pressure ≥80 mmHg) after a three-month trial of lifestyle modification, unless one of the following scenarios is present (algorithm 1) [16,17]:

•Hypertensive emergency or severe asymptomatic hypertension (ie, office-based systolic pressure ≥180 mmHg or diastolic pressure ≥120 mmHg)

•Evidence for hypertension-related end-organ damage (eg, ischemic heart disease, heart failure, left ventricular hypertrophy, cerebrovascular disease, hypertensive retinopathy, chronic kidney disease plus an office-based systolic pressure ≥160 mmHg and/or diastolic pressure ≥100 mmHg)

●All patients with apparent treatment resistance, defined as office-based blood pressure above their goal (table 3), despite prescription of three or more antihypertensive drugs at optimal doses [16,18,19] (see "Definition, risk factors, and evaluation of resistant hypertension")

●All patients treated with antihypertensive therapy who have an office-based blood pressure above their goal and symptoms of hypotension (eg, lightheadedness, postural dizziness, falls) when outside of the office

Who to evaluate for masked or masked uncontrolled hypertension — We evaluate the following groups of patients for masked hypertension or masked uncontrolled hypertension (table 2):

●Untreated patients whose office-based blood pressure is 10 mmHg or less below their goal (table 3). As an example, if an untreated patient whose goal blood pressure is <130/<80 mmHg has an office-based systolic pressure of 120 to 129 mmHg or diastolic pressure 70 to 79 mmHg, then out-of-office readings should be obtained to evaluate for masked hypertension.

●Patients treated with antihypertensive therapy who have an office-based blood pressure below their goal (table 3) but who have one or more of the following:

•Elevated atherosclerotic cardiovascular disease risk (eg, a calculated 10-year risk of having an atherosclerotic cardiovascular event >10 percent)

•Chronic kidney disease

•Diabetes mellitus

•Evidence of hypertensive end-organ damage (eg, prior atherosclerotic cardiovascular event, heart failure, left ventricular hypertrophy, hypertensive retinopathy)

The consequence of this recommendation is that these patients at high cardiovascular risk should have their blood pressure monitored and managed using out-of-office measurements, rather than office-based readings.

Our approach is consistent with major guidelines [16,18,19] and reflects the high prevalence of masked and masked uncontrolled hypertension. (See 'Epidemiology' above.)

In the United States, over 30 percent of adults who are not on antihypertensive medication and over 50 percent of adults who are on antihypertensive medication meet criteria to undergo evaluation for masked hypertension with out-of-office measurements [20].

Patients with labile office-based blood pressures — Patients with substantial variability (ie, lability) in their office-based blood pressure (from visit to visit or during a single office visit) should be evaluated using out-of-office measurements. Such patients may have white coat hypertension or effect, masked hypertension, or masked uncontrolled hypertension, depending upon their office-based and out-of-office blood pressure measurements, and whether they are treated with medication. Out-of-office readings provide additional data and more accurately depict the patient's average usual blood pressure.

DIAGNOSIS — To diagnose white coat hypertension, white coat effect, masked hypertension, and masked uncontrolled hypertension, blood pressures need to be measured using appropriate technique [21-23] and validated blood pressure monitors [24,25] both in a clinician's office and out of the office (using ambulatory blood pressure monitoring [ABPM] or self-measured blood pressure [SMBP]). The approach to ABPM and SMBP is discussed elsewhere. (See "Out-of-office blood pressure measurement: Ambulatory and self-measured blood pressure monitoring".)

How to evaluate for white coat hypertension or effect — Out-of-office blood pressure can be assessed using either 24-hour ABPM or SMBP at home or at work. Appropriate techniques for performing ABPM and SMBP are presented elsewhere. (See "Out-of-office blood pressure measurement: Ambulatory and self-measured blood pressure monitoring".)

●Untreated patients – In an untreated patient with office-based blood pressure readings ≥130 mmHg systolic or ≥80 mmHg diastolic, we ask the patient to obtain SMBP while at home or at work for one week:

•If the mean of SMBPs over that week are ≥130 mmHg systolic or ≥80 mmHg diastolic, then the diagnosis of hypertension is confirmed.

•If the mean of SMBPs over that week are <130/<80 mmHg, then we obtain 24-hour ABPM (if feasible); if the mean 24-hour ambulatory blood pressure is <125/<75 mmHg and the mean daytime (awake) blood pressure is <130/<80 mmHg, then a diagnosis of white coat hypertension is confirmed (algorithm 1).

•If the mean of SMBPs over that week are <130/<80 mmHg and obtaining ABPM is not feasible (eg, cost, lack of availability), then we obtain a second week of SMBPs to either establish a diagnosis of hypertension or confirm the presence of white coat hypertension.

If SMBP cannot be obtained (eg, measurement device is not covered by the patient's insurance and the patient cannot afford to purchase a device), then we obtain an ABPM, if feasible, to establish a diagnosis of hypertension or confirm the presence of white coat hypertension. If neither SMBP nor ABPM can be obtained, then white coat hypertension can be evaluated by performing office-based automated office blood pressure measurement (using a device that can average multiple readings while the patient sits alone in a room) [26]. (See "Blood pressure measurement in the diagnosis and management of hypertension in adults", section on 'Automated office blood pressure measurement'.)

●Treated patients – In a patient with apparent resistant hypertension, white coat effect is diagnosed in the same manner as white coat hypertension in untreated patients (ie, by obtaining SMBPs and, if at or below the patient's goal, confirmation with ABPM).

ABPM is the gold standard for diagnosing hypertension, the strongest predictor of cardiovascular risk [5], and the ideal method for confirming white coat hypertension that is suspected based upon normal SMBPs [16,18,19]. ABPM and SMBPs can yield discordant data for several reasons, including [27-30]:

●ABPM measures blood pressures both during the day and at night, across various levels of activity, and at rest, whereas SMBP yields resting daytime readings only.

●Patients may report their SMBPs incorrectly, whether intentionally or unintentionally.

As an example, in a study of 1774 patients who underwent both measurement techniques, the prevalence of white coat hypertension was substantially higher according to SMBP as compared with ABPM; SMBP thereby overestimated the prevalence of white coat hypertension and underestimated the prevalence of hypertension (20 versus 13 percent) [27]. Among treated patients, the prevalence of white coat effect was similar according to SMBP and ABPM (19 percent). Using ABPM as the gold standard, the positive and negative predictive values of SMBP were, respectively, 41 and 94 percent for identifying white coat hypertension. The positive and negative predictive values were, respectively, 53 and 88 percent for identifying white coat effect. These and other data support the use of SMBP as a first strategy for either confirming the diagnosis of hypertension or suggesting the possible presence of white coat hypertension or effect [27-29]. If SMBP suggests white coat hypertension or effect, ABPM is used for confirmation.

How to evaluate for masked or masked uncontrolled hypertension — Out-of-office blood pressure can be assessed using either 24-hour ABPM or SMBP at home or at work. Appropriate techniques for performing ABPM and SMBP are presented elsewhere. (See "Out-of-office blood pressure measurement: Ambulatory and self-measured blood pressure monitoring".)

●Untreated patients – In an untreated patient with office-based blood pressure readings at, or less than 10 mmHg below, the patient's goal (table 3), we ask the patient to obtain SMBPs while at home or at work for one week. As an example, in a patient whose goal office-based blood pressure is <130/<80 mmHg, SMBPs should be obtained if the office-based blood pressure is 125/75 mmHg but are not needed if the office-based blood pressure is 115/65 mmHg (unless the patient has unexplained evidence of end-organ damage).

•If the mean of SMBPs over that week are at or below the patient's goal, then the diagnosis of masked hypertension is excluded.

•However, if the mean of SMBPs over that week are above the patient's goal, then we obtain 24-hour ABPM (if feasible); if the mean 24-hour ambulatory blood pressure or the mean daytime (awake) blood pressure is above the patient's goal, then a diagnosis of masked hypertension is confirmed (algorithm 1).

If, in such cases, obtaining ABPM is not feasible (eg, cost, lack of availability), then we obtain a second week of SMBPs approximately one month later to evaluate for the presence of masked hypertension.

If SMBP cannot be obtained (eg, measurement device is not covered by the patient's insurance and the patient cannot afford to purchase a device), then we obtain an ABPM, if feasible, to evaluate for masked hypertension. If neither SMBP nor ABPM can be obtained, then masked hypertension cannot be appropriately evaluated. In such cases, efforts should be made to identify and remove barriers to out-of-office blood pressure measurement [26]. (See "Blood pressure measurement in the diagnosis and management of hypertension in adults", section on 'Automated office blood pressure measurement'.)

●Treated patients – In patients receiving antihypertensive therapy whose office-based blood pressure is at or below goal (table 3), we monitor out-of-office blood pressures (ie, with SMBP) to confirm control if the patient has one or more of the following features:

•Evidence of prior atherosclerotic cardiovascular disease, such as prior acute coronary syndrome, transient ischemic attack, or stroke

•Elevated atherosclerotic cardiovascular risk (ie, calculated 10-year risk ≥10 percent)

•Heart failure

•Chronic kidney disease

•Diabetes mellitus

•Other hypertension-related end-organ damage, such as left ventricular hypertrophy or hypertensive retinopathy

Longitudinal monitoring of out-of-office blood pressures with SMBP is more practical, less costly, and more widely accepted by patients than longitudinal monitoring using serial ABPM.

The evidence comparing ABPM with SMBP for the diagnosis of masked and masked uncontrolled hypertension is conflicting [28,29,31]. However, our approach outlined above is generally consistent with contemporary guidelines [16,18,19]. ABPM may be superior for the initial evaluation and confirmation of these conditions due to its greater sensitivity and prognostic value [21,32-35], but SMBP may be a better option for long-term monitoring and medication titration due to its greater reproducibility, tolerability, and feasibility [21,35-37]. (See 'Prognosis of masked and masked uncontrolled hypertension' below and "Out-of-office blood pressure measurement: Ambulatory and self-measured blood pressure monitoring".)

Similar to white coat hypertension and white coat effect (discussed above), there can be diagnostic disagreement between SMBP and ABPM in determining masked and masked uncontrolled hypertension [27-30,38,39]. (See 'How to evaluate for white coat hypertension or effect' above.)

Examples of this discordance include:

●In the study mentioned above of 1774 patients who underwent both measurement techniques, the prevalence of masked hypertension was higher when using ABPM than when using SMBP; SMBP therefore underestimated the prevalence of masked hypertension (18 versus 13 percent) [27]. Among treated patients, the prevalence of masked uncontrolled hypertension was also higher with ABPM (19 versus 14 percent). Using ABPM as the gold standard, the positive and negative predictive values of SMBP were, respectively, 64 and 89 percent for identifying masked hypertension. The positive and negative predictive values were, respectively, 61 and 88 percent for identifying masked uncontrolled hypertension.

●In a prospective study of 333 community-based adults in New York City who underwent successive ambulatory and home monitoring, masked hypertension was present in 26 percent of participants based upon ABPM and 11 percent based upon SMBP [39]. Using ABPM as the gold standard, SMBP did not reliably detect masked hypertension (sensitivity was only 32 percent) but reliably excluded it (specificity was 96 percent).

Some of the discrepancy comparing home versus ambulatory pressures results from the incorporation of nocturnal measurements with ambulatory, but not home, blood pressures. Incorporating nocturnal measurements increases the prevalence of masked and masked uncontrolled hypertension by identifying patients with nocturnal hypertension. As an example, in a study of 738 African-American individuals who underwent ABPM, the prevalence of masked hypertension was 28 percent if considering only daytime blood pressures and 48 percent using only nighttime blood pressures [11].

TREATMENT

Treatment of white coat hypertension and white coat effect — Patients with white coat hypertension or white coat effect who have out-of-office blood pressure readings that are consistently at or below goal should not have therapy initiated or intensified, respectively, due to the risk of adverse effects from potentially inappropriate antihypertensive treatment [40,41]. Instead, intensive lifestyle modifications and cardiovascular risk reduction should be continued, including monitoring and managing concomitant dyslipidemia and diabetes, if present.

Treatment of masked and masked uncontrolled hypertension — There are no high-quality data to guide therapy of masked hypertension or masked uncontrolled hypertension [42]. However, we agree with the American College of Cardiology/American Heart Association (ACC/AHA) guidelines that patients with masked or masked uncontrolled hypertension should have initiation or intensification, respectively, of antihypertensive treatment and that treatment should be guided by out-of-office blood pressure measurements [16]. This recommendation is based on the increased risk of adverse cardiovascular outcomes associated with masked and masked uncontrolled hypertension [43]. (See 'Prognosis of masked and masked uncontrolled hypertension' below.)

The specific management of patients with acute, episodic elevations in blood pressure due to labile hypertension or paroxysmal hypertension (pseudopheochromocytoma) is discussed elsewhere:

●(See "Labile hypertension", section on 'Acute therapy of episodic blood pressure elevation'.)

●(See "Paroxysmal hypertension (pseudopheochromocytoma)", section on 'Acute management of paroxysms'.)

PROGNOSIS

Prognosis of white coat hypertension and white coat effect — The data regarding the cardiovascular risk of white coat hypertension are conflicting, possibly related to differences in antihypertensive treatment status in different studies [5]. Untreated white coat hypertension seems to be associated with a higher risk of adverse cardiovascular outcomes compared with normotension [4,5,44-46], although this risk is lower in magnitude than the risk of masked or sustained hypertension [47]. By contrast, white coat effect is not associated with elevated cardiovascular risk compared with sustained normotension [5,45,48,49], although one study reported an association of white coat effect with the development of end-stage kidney disease [50].

An example of the association of white coat hypertension or effect with cardiovascular disease comes from a meta-analysis of 26 studies, in which patients with either untreated white coat hypertension or treated white coat effect (patients treated for hypertension with a white coat effect by office blood pressure) were followed for 3 to 19 years [5]. Compared with normotensive individuals, untreated white coat hypertension was associated with a nonsignificantly higher risk of cardiovascular events (hazard ratio [HR] 1.26, 95% CI 1.00-1.54) and an increased risk of all-cause mortality (HR 1.20, 95% CI 1.02-1.41). There was no association between treated white coat effect and these cardiovascular outcomes.

In addition to a higher cardiovascular risk, patients who are diagnosed with white coat hypertension have a three- to fourfold increased risk of developing sustained hypertension at 7 to 10 years compared with normotensive patients [4,51]. Consequently, all patients with white coat hypertension should undergo out-of-office blood pressure monitoring (using self-monitoring of blood pressure or 24-hour ambulatory blood pressure monitoring [ABPM]) at least annually, and among those at elevated cardiovascular risk, self-monitoring of blood pressure should be performed more frequently (eg, monthly).

Prognosis of masked and masked uncontrolled hypertension — Masked and masked uncontrolled hypertension are consistently associated with increased risk of major adverse cardiovascular events and all-cause mortality, similar to that of sustained hypertension. As an example, in a meta-analysis of 11 studies including 30,352 participants who underwent home or ambulatory blood pressure monitoring, masked uncontrolled hypertension was associated with an increased risk of major adverse cardiovascular events (HR 1.70, 95% CI 1.27-2.27) and all-cause mortality (HR 1.85, 95% CI 1.36-2.51) [43].

In addition, several studies have demonstrated an association of masked hypertension with the development of end-stage kidney disease among individuals with chronic kidney disease [50,52-54].

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Hypertension in adults".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topics (see "Patient education: Checking your blood pressure at home (The Basics)" and "Patient education: High blood pressure in adults (The Basics)")

●Beyond the Basics topics (see "Patient education: High blood pressure in adults (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

●White coat hypertension, white coat effect, masked hypertension, and masked uncontrolled hypertension are defined, among patients whose office-based and out-of-office blood pressures are discordant, according to the pattern of the discordance (ie, office-based readings elevated with normal out-of-office readings versus normal office-based readings with elevated out-of-office readings) and whether the patient is taking antihypertensive medication (table 1). (See 'Definitions' above.)

●We evaluate the following groups of patients for white coat hypertension or effect (table 2) (see 'Who to evaluate for white coat hypertension or effect' above):

•All untreated patients (ie, not taking antihypertensive medications) who have elevated office-based blood pressure (ie, systolic pressure ≥130 mmHg or diastolic pressure ≥80 mmHg) after a three-month trial of lifestyle modification, unless one of the following scenarios is present (algorithm 1):

-Hypertensive emergency or severe asymptomatic hypertension (ie, office-based systolic pressure ≥180 mmHg or diastolic pressure ≥120 mmHg)

-Evidence for hypertension-related end-organ damage plus an office-based systolic pressure ≥160 mmHg and/or diastolic pressure ≥100 mmHg

•All patients with apparent treatment resistance, defined as office-based blood pressure above their goal (table 3), despite taking three or more antihypertensive drugs at optimal doses.

•All patients treated with antihypertensive therapy who have an office-based blood pressure above their goal and symptoms of hypotension (eg, lightheadedness, postural dizziness, falls) when outside of the office.

●We evaluate the following groups of patients for masked hypertension or masked uncontrolled hypertension (table 2) (see 'Who to evaluate for masked or masked uncontrolled hypertension' above):

•Untreated patients whose office-based blood pressure is 10 mmHg or less below their goal (table 3). As an example, if an untreated patient whose goal blood pressure is <130/<80 mmHg has an office-based systolic pressure of 120 to 129 mmHg or diastolic pressure 70 to 79 mmHg, then out-of-office readings should be obtained to evaluate for masked hypertension.

•Patients treated with antihypertensive therapy who have an office-based blood pressure below their goal (table 3) but who have one or more of the following: elevated atherosclerotic cardiovascular disease risk, chronic kidney disease, diabetes mellitus, evidence of hypertensive end-organ damage.

●Patients with substantial variability (ie, lability) in their office-based blood pressure (from visit to visit or during a single office visit) should be evaluated using out-of-office measurements. (See 'Patients with labile office-based blood pressures' above.)

●Evaluation for white coat hypertension – To evaluate for white coat hypertension in an untreated individual, we ask the patient to obtain self-measured blood pressures (SMBPs) while at home or at work for one week (see 'How to evaluate for white coat hypertension or effect' above):

•If the mean of SMBPs over that week are ≥130 mmHg systolic or ≥80 mmHg diastolic, then the diagnosis of hypertension is confirmed.

•If the mean of SMBPs over that week are <130/<80 mmHg, then we obtain 24-hour ambulatory blood pressure monitoring (ABPM; if feasible); if the mean 24-hour ambulatory blood pressure is <125/<75 mmHg and the mean daytime (awake) blood pressure is <130/<80 mmHg, then a diagnosis of white coat hypertension is confirmed (algorithm 1).

•If the mean of SMBPs over that week are <130/<80 mmHg and obtaining ABPM is not feasible (eg, high cost, lack of availability), then we obtain a second week of SMBPs to either establish a diagnosis of hypertension or confirm the presence of white coat hypertension.

●Evaluation for white coat effect – In a patient with apparent resistant hypertension, white coat effect is diagnosed in the same manner as white coat hypertension in untreated patients (ie, by obtaining SMBPs and, if at or below the patient’s goal, confirmation with ABPM). (See 'How to evaluate for white coat hypertension or effect' above.)

●Evaluation for masked hypertension – To evaluate for masked hypertension in an untreated individual, we ask the patient to obtain SMBPs while at home or at work for one week (see 'How to evaluate for masked or masked uncontrolled hypertension' above):

•If the mean of SMBPs over that week are at or below the patient's goal, then the diagnosis of masked hypertension is excluded.

•If, in such cases, obtaining ABPM is not feasible (eg, cost, lack of availability), then we obtain a second week of SMBPs approximately one month later to evaluate for the presence of masked hypertension.

●Evaluation for masked uncontrolled hypertension – To evaluate for masked uncontrolled hypertension in a treated individual, we monitor out-of-office blood pressures longitudinally (ie, with SMBP) to confirm control if the patient has one or more of the following features: evidence of prior atherosclerotic cardiovascular disease, elevated atherosclerotic cardiovascular risk, heart failure, chronic kidney disease, diabetes mellitus, other hypertension-related end-organ damage. (See 'How to evaluate for masked or masked uncontrolled hypertension' above.)

●Patients with white coat hypertension or white coat effect who have out-of-office blood pressure readings that are consistently at or below goal should not have therapy initiated or intensified. Instead, intensive lifestyle modifications and cardiovascular risk reduction should be continued. (See 'Treatment of white coat hypertension and white coat effect' above.)

●Patients with masked or masked uncontrolled hypertension should have initiation or intensification, respectively, of antihypertensive treatment, and that treatment should be guided by out-of-office blood pressure measurements. (See 'Treatment of masked and masked uncontrolled hypertension' above.)

Sheppard JP, Fletcher B, Gill P, et al. Predictors of the Home-Clinic Blood Pressure Difference: A Systematic Review and Meta-Analysis. Am J Hypertens 2016; 29:614.
Pierdomenico SD, Cuccurullo F. Prognostic value of white-coat and masked hypertension diagnosed by ambulatory monitoring in initially untreated subjects: an updated meta analysis. Am J Hypertens 2011; 24:52.
Niiranen TJ, Jula AM, Kantola IM, Reunanen A. Prevalence and determinants of isolated clinic hypertension in the Finnish population: the Finn-HOME study. J Hypertens 2006; 24:463.
Mancia G, Bombelli M, Brambilla G, et al. Long-term prognostic value of white coat hypertension: an insight from diagnostic use of both ambulatory and home blood pressure measurements. Hypertension 2013; 62:168.
Cohen JB, Lotito MJ, Trivedi UK, et al. Cardiovascular Events and Mortality in White Coat Hypertension: A Systematic Review and Meta-analysis. Ann Intern Med 2019; 170:853.
Muxfeldt ES, Bloch KV, Nogueira Ada R, Salles GF. True resistant hypertension: is it possible to be recognized in the office? Am J Hypertens 2005; 18:1534.
Carey RM, Calhoun DA, Bakris GL, et al. Resistant Hypertension: Detection, Evaluation, and Management: A Scientific Statement From the American Heart Association. Hypertension 2018; 72:e53.
Verdecchia P, Palatini P, Schillaci G, et al. Independent predictors of isolated clinic ('white-coat') hypertension. J Hypertens 2001; 19:1015.
Wang YC, Shimbo D, Muntner P, et al. Prevalence of Masked Hypertension Among US Adults With Nonelevated Clinic Blood Pressure. Am J Epidemiol 2017; 185:194.
Peacock J, Diaz KM, Viera AJ, et al. Unmasking masked hypertension: prevalence, clinical implications, diagnosis, correlates and future directions. J Hum Hypertens 2014; 28:521.
Booth JN 3rd, Diaz KM, Seals SR, et al. Masked Hypertension and Cardiovascular Disease Events in a Prospective Cohort of Blacks: The Jackson Heart Study. Hypertension 2016; 68:501.
Franklin SS, Thijs L, Li Y, et al. Masked hypertension in diabetes mellitus: treatment implications for clinical practice. Hypertension 2013; 61:964.
Drawz PE, Alper AB, Anderson AH, et al. Masked Hypertension and Elevated Nighttime Blood Pressure in CKD: Prevalence and Association with Target Organ Damage. Clin J Am Soc Nephrol 2016; 11:642.
Mwasongwe SE, Tanner RM, Poudel B, et al. Ambulatory Blood Pressure Phenotypes in Adults Taking Antihypertensive Medication with and without CKD. Clin J Am Soc Nephrol 2020; 15:501.
Baguet JP, Lévy P, Barone-Rochette G, et al. Masked hypertension in obstructive sleep apnea syndrome. J Hypertens 2008; 26:885.
Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension 2018; 71:e13.
US Preventive Services Task Force, Krist AH, Davidson KW, et al. Screening for Hypertension in Adults: US Preventive Services Task Force Reaffirmation Recommendation Statement. JAMA 2021; 325:1650.
Mancia G, Kreutz R, Brunström M, et al. 2023 ESH Guidelines for the management of arterial hypertension The Task Force for the management of arterial hypertension of the European Society of Hypertension: Endorsed by the International Society of Hypertension (ISH) and the European Renal Association (ERA). J Hypertens 2023; 41:1874.
Nerenberg KA, Zarnke KB, Leung AA, et al. Hypertension Canada's 2018 Guidelines for Diagnosis, Risk Assessment, Prevention, and Treatment of Hypertension in Adults and Children. Can J Cardiol 2018; 34:506.
Booth JN 3rd, Hubbard D, Sakhuja S, et al. Proportion of US Adults Recommended Out-of-Clinic Blood Pressure Monitoring According to the 2017 Hypertension Clinical Practice Guidelines. Hypertension 2019; 74:399.
Muntner P, Shimbo D, Carey RM, et al. Measurement of Blood Pressure in Humans: A Scientific Statement From the American Heart Association. Hypertension 2019; 73:e35.
American Heart Association and American Medical Association, Target:BP (Tools & Downloads) https://targetbp.org/tools-downloads/?sort=topic&topics=Patient-Measured%20BP& (Accessed on July 25, 2019).
Self-Measured Blood Pressure Monitoring: Actions Steps for Clinicians https://millionhearts.hhs.gov/files/MH_SMBP_Clinicians.pdf (Accessed on December 05, 2019).
Cohen JB, Padwal RS, Gutkin M, et al. History and Justification of a National Blood Pressure Measurement Validated Device Listing. Hypertension 2019; 73:258.
Sharman JE, O'Brien E, Alpert B, et al. Lancet Commission on Hypertension group position statement on the global improvement of accuracy standards for devices that measure blood pressure. J Hypertens 2020; 38:21.
Roerecke M, Kaczorowski J, Myers MG. Comparing Automated Office Blood Pressure Readings With Other Methods of Blood Pressure Measurement for Identifying Patients With Possible Hypertension: A Systematic Review and Meta-analysis. JAMA Intern Med 2019; 179:351.
Kang YY, Li Y, Huang QF, et al. Accuracy of home versus ambulatory blood pressure monitoring in the diagnosis of white-coat and masked hypertension. J Hypertens 2015; 33:1580.
Niiranen TJ, Mäki J, Puukka P, et al. Office, home, and ambulatory blood pressures as predictors of cardiovascular risk. Hypertension 2014; 64:281.
Fagard RH, Van Den Broeke C, De Cort P. Prognostic significance of blood pressure measured in the office, at home and during ambulatory monitoring in older patients in general practice. J Hum Hypertens 2005; 19:801.
Sega R, Facchetti R, Bombelli M, et al. Prognostic value of ambulatory and home blood pressures compared with office blood pressure in the general population: follow-up results from the Pressioni Arteriose Monitorate e Loro Associazioni (PAMELA) study. Circulation 2005; 111:1777.
Shimbo D, Abdalla M, Falzon L, et al. Studies comparing ambulatory blood pressure and home blood pressure on cardiovascular disease and mortality outcomes: a systematic review. J Am Soc Hypertens 2016; 10:224.
Ohkubo T, Kikuya M, Metoki H, et al. Prognosis of "masked" hypertension and "white-coat" hypertension detected by 24-h ambulatory blood pressure monitoring 10-year follow-up from the Ohasama study. J Am Coll Cardiol 2005; 46:508.
Dolan E, Stanton A, Thijs L, et al. Superiority of ambulatory over clinic blood pressure measurement in predicting mortality: the Dublin outcome study. Hypertension 2005; 46:156.
Li Y, Thijs L, Hansen TW, et al. Prognostic value of the morning blood pressure surge in 5645 subjects from 8 populations. Hypertension 2010; 55:1040.
Muntner P, Einhorn PT, Cushman WC, et al. Blood Pressure Assessment in Adults in Clinical Practice and Clinic-Based Research: JACC Scientific Expert Panel. J Am Coll Cardiol 2019; 73:317.
Guo QH, Cheng YB, Zhang DY, et al. Comparison Between Home and Ambulatory Morning Blood Pressure and Morning Hypertension in Their Reproducibility and Associations With Vascular Injury. Hypertension 2019; 74:137.
Kronish IM, Kent S, Moise N, et al. Barriers to conducting ambulatory and home blood pressure monitoring during hypertension screening in the United States. J Am Soc Hypertens 2017; 11:573.
Stergiou GS, Kyriakoulis KG, McManus RJ, et al. Phenotypes of masked hypertension: Isolated ambulatory, isolated home and dual masked hypertension. J Hypertens 2020; 38:218.
Anstey DE, Muntner P, Bello NA, et al. Diagnosing Masked Hypertension Using Ambulatory Blood Pressure Monitoring, Home Blood Pressure Monitoring, or Both? Hypertension 2018; 72:1200.
Bromfield SG, Ngameni CA, Colantonio LD, et al. Blood Pressure, Antihypertensive Polypharmacy, Frailty, and Risk for Serious Fall Injuries Among Older Treated Adults With Hypertension. Hypertension 2017; 70:259.
Shimbo D, Barrett Bowling C, Levitan EB, et al. Short-Term Risk of Serious Fall Injuries in Older Adults Initiating and Intensifying Treatment With Antihypertensive Medication. Circ Cardiovasc Qual Outcomes 2016; 9:222.
Parati G, Agabiti-Rosei E, Bakris GL, et al. MASked-unconTrolled hypERtension management based on office BP or on ambulatory blood pressure measurement (MASTER) Study: a randomised controlled trial protocol. BMJ Open 2018; 8:e021038.
Pierdomenico SD, Pierdomenico AM, Coccina F, et al. Prognostic Value of Masked Uncontrolled Hypertension. Hypertension 2018; 72:862.
Mancia G, Facchetti R, Vanoli J, et al. White-Coat Hypertension Without Organ Damage: Impact on Long-Term Mortality, New Hypertension, and New Organ Damage. Hypertension 2022; 79:1057.
Stergiou GS, Asayama K, Thijs L, et al. Prognosis of white-coat and masked hypertension: International Database of HOme blood pressure in relation to Cardiovascular Outcome. Hypertension 2014; 63:675.
Asayama K, Thijs L, Li Y, et al. Setting thresholds to varying blood pressure monitoring intervals differentially affects risk estimates associated with white-coat and masked hypertension in the population. Hypertension 2014; 64:935.
Shimbo D, Muntner P. Should Out-of-Office Monitoring Be Performed for Detecting White Coat Hypertension? Ann Intern Med 2019; 170:890.
Pierdomenico SD, Pierdomenico AM, Coccina F, Porreca E. Prognosis of Masked and White Coat Uncontrolled Hypertension Detected by Ambulatory Blood Pressure Monitoring in Elderly Treated Hypertensive Patients. Am J Hypertens 2017; 30:1106.
Franklin SS, Thijs L, Hansen TW, et al. 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 2012; 59:564.
Ku E, Hsu RK, Tuot DS, et al. Magnitude of the Difference Between Clinic and Ambulatory Blood Pressures and Risk of Adverse Outcomes in Patients With Chronic Kidney Disease. J Am Heart Assoc 2019; 8:e011013.
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; 66:2159.
Rahman M, Wang X, Bundy JD, et al. Prognostic Significance of Ambulatory BP Monitoring in CKD: A Report from the Chronic Renal Insufficiency Cohort (CRIC) Study. J Am Soc Nephrol 2020; 31:2609.
Agarwal R, Andersen MJ. Prognostic importance of ambulatory blood pressure recordings in patients with chronic kidney disease. Kidney Int 2006; 69:1175.
Suzuki H, Nakamoto H, Okada H, et al. Self-measured systolic blood pressure in the morning is a strong indicator of decline of renal function in hypertensive patients with non-diabetic chronic renal insufficiency. Clin Exp Hypertens 2002; 24:249.

Topic 123119 Version 13.0

References

1 : Predictors of the Home-Clinic Blood Pressure Difference: A Systematic Review and Meta-Analysis.

2 : Prognostic value of white-coat and masked hypertension diagnosed by ambulatory monitoring in initially untreated subjects: an updated meta analysis.

3 : Prevalence and determinants of isolated clinic hypertension in the Finnish population: the Finn-HOME study.

4 : Long-term prognostic value of white coat hypertension: an insight from diagnostic use of both ambulatory and home blood pressure measurements.

5 : Cardiovascular Events and Mortality in White Coat Hypertension: A Systematic Review and Meta-analysis.

6 : True resistant hypertension: is it possible to be recognized in the office?

7 : Resistant Hypertension: Detection, Evaluation, and Management: A Scientific Statement From the American Heart Association.

8 : Independent predictors of isolated clinic ('white-coat') hypertension.

9 : Prevalence of Masked Hypertension Among US Adults With Nonelevated Clinic Blood Pressure.

10 : Unmasking masked hypertension: prevalence, clinical implications, diagnosis, correlates and future directions.

11 : Masked Hypertension and Cardiovascular Disease Events in a Prospective Cohort of Blacks: The Jackson Heart Study.

12 : Masked hypertension in diabetes mellitus: treatment implications for clinical practice.

13 : Masked Hypertension and Elevated Nighttime Blood Pressure in CKD: Prevalence and Association with Target Organ Damage.

14 : Ambulatory Blood Pressure Phenotypes in Adults Taking Antihypertensive Medication with and without CKD.

15 : Masked hypertension in obstructive sleep apnea syndrome.

16 : 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.

17 : Screening for Hypertension in Adults: US Preventive Services Task Force Reaffirmation Recommendation Statement.

18 : 2023 ESH Guidelines for the management of arterial hypertension The Task Force for the management of arterial hypertension of the European Society of Hypertension: Endorsed by the International Society of Hypertension (ISH) and the European Renal Association (ERA).

19 : Hypertension Canada's 2018 Guidelines for Diagnosis, Risk Assessment, Prevention, and Treatment of Hypertension in Adults and Children.

20 : Proportion of US Adults Recommended Out-of-Clinic Blood Pressure Monitoring According to the 2017 Hypertension Clinical Practice Guidelines.

21 : Measurement of Blood Pressure in Humans: A Scientific Statement From the American Heart Association.

22 : Measurement of Blood Pressure in Humans: A Scientific Statement From the American Heart Association.

23 : Measurement of Blood Pressure in Humans: A Scientific Statement From the American Heart Association.

24 : History and Justification of a National Blood Pressure Measurement Validated Device Listing.

25 : Lancet Commission on Hypertension group position statement on the global improvement of accuracy standards for devices that measure blood pressure.

26 : Comparing Automated Office Blood Pressure Readings With Other Methods of Blood Pressure Measurement for Identifying Patients With Possible Hypertension: A Systematic Review and Meta-analysis.

27 : Accuracy of home versus ambulatory blood pressure monitoring in the diagnosis of white-coat and masked hypertension.

28 : Office, home, and ambulatory blood pressures as predictors of cardiovascular risk.

29 : Prognostic significance of blood pressure measured in the office, at home and during ambulatory monitoring in older patients in general practice.

30 : Prognostic value of ambulatory and home blood pressures compared with office blood pressure in the general population: follow-up results from the Pressioni Arteriose Monitorate e Loro Associazioni (PAMELA) study.

31 : Studies comparing ambulatory blood pressure and home blood pressure on cardiovascular disease and mortality outcomes: a systematic review.

32 : Prognosis of "masked" hypertension and "white-coat" hypertension detected by 24-h ambulatory blood pressure monitoring 10-year follow-up from the Ohasama study.

33 : Superiority of ambulatory over clinic blood pressure measurement in predicting mortality: the Dublin outcome study.

34 : Prognostic value of the morning blood pressure surge in 5645 subjects from 8 populations.

35 : Blood Pressure Assessment in Adults in Clinical Practice and Clinic-Based Research: JACC Scientific Expert Panel.

36 : Comparison Between Home and Ambulatory Morning Blood Pressure and Morning Hypertension in Their Reproducibility and Associations With Vascular Injury.

37 : Barriers to conducting ambulatory and home blood pressure monitoring during hypertension screening in the United States.

38 : Phenotypes of masked hypertension: Isolated ambulatory, isolated home and dual masked hypertension.

39 : Diagnosing Masked Hypertension Using Ambulatory Blood Pressure Monitoring, Home Blood Pressure Monitoring, or Both?

40 : Blood Pressure, Antihypertensive Polypharmacy, Frailty, and Risk for Serious Fall Injuries Among Older Treated Adults With Hypertension.

41 : Short-Term Risk of Serious Fall Injuries in Older Adults Initiating and Intensifying Treatment With Antihypertensive Medication.

42 : MASked-unconTrolled hypERtension management based on office BP or on ambulatory blood pressure measurement (MASTER) Study: a randomised controlled trial protocol.

43 : Prognostic Value of Masked Uncontrolled Hypertension.

44 : White-Coat Hypertension Without Organ Damage: Impact on Long-Term Mortality, New Hypertension, and New Organ Damage.

45 : Prognosis of white-coat and masked hypertension: International Database of HOme blood pressure in relation to Cardiovascular Outcome.

46 : Setting thresholds to varying blood pressure monitoring intervals differentially affects risk estimates associated with white-coat and masked hypertension in the population.

47 : Should Out-of-Office Monitoring Be Performed for Detecting White Coat Hypertension?

48 : Prognosis of Masked and White Coat Uncontrolled Hypertension Detected by Ambulatory Blood Pressure Monitoring in Elderly Treated Hypertensive Patients.

49 : 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.

50 : Magnitude of the Difference Between Clinic and Ambulatory Blood Pressures and Risk of Adverse Outcomes in Patients With Chronic Kidney Disease.

51 : Target Organ Complications and Cardiovascular Events Associated With Masked Hypertension and White-Coat Hypertension: Analysis From the Dallas Heart Study.

52 : Prognostic Significance of Ambulatory BP Monitoring in CKD: A Report from the Chronic Renal Insufficiency Cohort (CRIC) Study.

53 : Prognostic importance of ambulatory blood pressure recordings in patients with chronic kidney disease.

54 : Self-measured systolic blood pressure in the morning is a strong indicator of decline of renal function in hypertensive patients with non-diabetic chronic renal insufficiency.

خرید پکیج

White coat and masked hypertension

References