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CHAPTER 62

WHITE COAT HYPERTENSION


AND WHITE COAT WORSE
HYPERTENSION
STEVEN G. CHRYSANT, MD, PhD

The introduction of ambulatory blood pressure (ABP) White Coat Hypertension


monitoring several years ago demonstrated that the clinic
blood pressure of a subject may not be the true blood DEFINITION
pressure. Many such subjects demonstrate an elevated
WCH has been defined as a “persistently elevated clinic or
blood pressure during the clinic visit and a normal blood
office blood pressure in the presence of normal daytime
pressure away from the clinic environment, either by
ambulatory blood pressure.”1–5 This has been ascribed to a
ABP monitoring (see Chapter 67, “Ambulatory Blood
defense or alarm reaction against the doctor or nurse
Pressure Monitoring: Its Use in Clinical Practice and
Implications for Therapy”) or by home blood pressure measuring the blood pressure by conventional means in the
monitoring (see Chapter 68, “The Role of Self-Measured clinic and is usually associated with an increase in heart rate
Home Blood Pressure”). The difference between the besides blood pressure.21 Elevated blood pressure in the
mean clinic blood pressure and the mean daytime ABP office or clinic has been defined by both the Seventh Joint
has been called white coat hypertension (WCH) by National Committee Report (JNC-7) and the 2003
several investigators. 1–5 This phenomenon is quite European Society of Hypertension and the European
common; it has been reported to occur between 20 and Society of Cardiology as blood pressure  139/89 mm
45%1,6–8 in persons with WCH and has a higher preva- Hg.22,23 The same societies have defined daytime ABP of
lence in women, the elderly, and mildly hypertensive 134/84 mm Hg as normal. The mean nighttime ABP has
subjects.9–12 WCH should not be confused with the white been defined as < 120/75 mm Hg.22 Despite these cutoff
coat effect (WCE), which represents an increase in blood levels for the normal ABP, some investigators have used
pressure during the clinic visit compared with the mean higher blood pressure levels (< 140/90 mm Hg), whereas
daytime ABP and occurs in patients with sustained others have used lower (< 130/80 mm Hg) ABP
hypertension, treated or untreated.4,8,10,13–15 Another levels.7,24–26 Other investigators have proposed the follow-
phenomenon that was recently observed is a normal ing cutoff levels for a normal ABP: 130/80 mm Hg for
clinic blood pressure and an elevated ABP, the opposite the 24-hour mean, 135/85 mm Hg for the daytime
of WCH. This phenomenon, which is also quite mean, and 120/70 mm Hg for the nighttime mean.3,27 In
common, has been called by different names, such as addition, Verdecchia and colleagues suggested using sepa-
“inverse white coat hypertension,”16 “reverse white coat rate ABP levels for normal blood pressure of 131/86 mm
hypertension,”17,18 and “white coat normotension.”19,20 Hg for women and 136/87 mm Hg for men.28 However,
Because these terms are confusing, in this chapter, I use this distinction is not warranted because treatment deci-
the term white coat worse hypertension (WCWH), which sions are the same for both sexes. On the contrary, the
is more descriptive of the situation. The significance, suggestion by Bindlingmeyer and colleagues to use differ-
prognostic implications, and management of WCH, ent cutoff levels for normal ABP in younger and older
WCE, and WCWH are discussed in this chapter. patients, such as < 134/90 mm Hg for persons younger
537
538 / Advanced Therapy in Hypertension and Vascular Disease

than 65 years of age and < 142/90 mm Hg for persons older clinic and first ABP to 13.6% after the fifth visit.33 In
than 65 years of age, does not seem appropriate under the addition, the incidence of WCH increases if the doctor,
current thinking because initiation of treatment for high instead of the nurse, takes the patient’s blood pressure,
blood pressure does not take into account the age of the and it has been proposed that physicians should not be
patient.29 All of these suggestions, although they may be measuring blood pressures.34
useful, create confusion with respect to decision making
regarding treatment of hypertension, and the physician TARGET ORGAN DAMAGE
should adhere to the guidelines of JNC-7 and the European The currently held view by most investigators is that
Society of Hypertension and the European Society of WCH is a fairly benign condition and is not associated
Cardiology.22,23 with target organ damage. This view is strengthened by
the fact that there is no difference in the left ventricular
PREVALENCE mass index (LVMI) between normotensive individuals
WCH is common, but its actual prevalence depends on and those with WCH.7,12,13,30,33,35,36 In contrast, others
the definition of normal office blood pressure and ABP. have found that the LVMI was higher in subjects with
According to cutoffs of 139/89 mm Hg for normal office WCH compared with normotensive persons,25,26,37–41
blood pressure and 134/84 mm Hg for normal daytime although the LVMI values were within normal ranges for
ABP, the prevalence of WCH varies between 20 and both groups (Table 62-1). The effect of blood pressure or
45%,1,6–8 and it is more prevalent in women, the elderly, left ventricular thickness is quantitative, and as blood
and mildly hypertensive patients. 9–12 Verdecchia and pressure increases, so does the left ventricular thickness
colleagues reported an overall prevalence of 19% in a (Figure 62-1). This figure also shows that ABP is better
population of 1,333 hypertensive patients, with the preva- correlated with left ventricular thickness than with clinic
lence being even higher among subjects with the mildest blood pressure.
form of hypertension.13 A similar incidence (19.2%) was Another measure of target organ damage is carotid inti-
reported among 1,187 adult subjects in the PIUMA mal medial thickness measured by ultrasonography. In a
(Progetto Ipertensione Umbria Monitoraggio study of subjects with normal blood pressures, WCH, and
Ambulatoriale) study.30 Martinez and colleagues reported sustained hypertension, the carotid intimal medial thickness
a prevalence of WCH of 39% among 345 subjects using a was 0.76 mm for those with normal blood pressure and
cutoff level of ABP 135/85 mm Hg.31 In a meta-analysis of 0.84 mm for those with WCH but was significantly higher,
large ABP data, Staessen and colleagues reported that 0.98 mm, for those with sustained hypertension.35 In a simi-
among 7,069 patients, the overall incidence of WCH was lar study of normotensive, WCH, and sustained hyperten-
24%.32 They also found that female sex, old age, mild sive persons matched for age and sex, the left ventricular
hypertension, and infrequent visits accounted for a higher mass, carotid intimal medial thickness, forearm vascular
incidence of WCH. The importance of the frequency of resistance, and urinary albumin excretion were similar for
screening visits on the prevalence of WCH has been the normotensive and WCH subjects and much higher for
emphasized by other investigators who found that the those with sustained hypertension.42 Similar findings were
prevalence of WCH decreased from 25.8% from the first also reported by Hoegholm and colleagues in 420 subjects

Table 62-1 Ambulatory Daytime Blood Pressure and Left Ventricular Mass Index in Normotensive Persons and Patients with
White Coat Hypertension
Blood Pressure, mm Hg LVMI, g/m2
Study Normotensive Group WCH Group Normotensive Group WCH Group
Cavallini et al35 126/77 130/79 78 82
Palatini et al36 120/74 121/74 82 88
Pierdomenico et al42 126/78 128/78 94 98
Verdecchia et al13 125/81 124/79 87 93
White et al37 120/78 126/79 91 97
Cerasola et al38 119/76 130/82* 81 93*
Cardillo et al40 113/78 126/88* 82 103*
Kuwajima et al41 129/69 138/78* 91 119*
Pose-Reino et al39 114/69 125/75* 106 132*
Grandi et al25 125/74 126/74 85 103*

LVMI = left ventricular mass index; WCH = white coat hypertension.


*Values significantly higher than those in normotensive persons.
White Coat Hypertension and White Coat Worse Hypertension / 539

150 150
r = 0.64 r = 0.74
140 p < 0.003 140 p < 0.0002
n = 20 n = 20
130 130

LVMI, g/m2
120 120

LVMI, g/m2
110 110

100 100

90 90

80 80

70 70

100 110 120 130 140 150 160 170 110 120 130 140 150 160

A Clinic systolic BP, mm Hg B Daytime systolic BP, mm Hg

Figure 62-1 The figure depicts data from six published studies relating clinic systolic blood pressure (SBP) to left ventricular mass index (LVMI).
A, Clinic SBP. B, Daytime mean ambulatory SBP. Each point represents the average value for one group of subjects (subjects with white coat
hypertension or patients with sustained hypertension). The blood pressure effect is continuous and is more closely correlated with the daytime
ambulatory than clinic blood pressure. Adapted from Chrysant SG.8

with normotension, WCH, and established hypertension.33 sure.8,10,13–15 The WCE should not be confused with WCH
With respect to cardiovascular event rate (fatal, nonfatal because it occurs in subjects with sustained hypertension,
cardiovascular events), Verdecchia and colleagues reported treated or untreated, in whom the ABP is lower than the
an incidence of 0.47 in 100 patient-years for normotensive office blood pressure. The WCE is conceived as the increase
subjects, 0.49 in 100 patient-years for subjects with WCH, in blood pressure that occurs at the time of the clinic visit
and 1.79 in 100 patient-years for patients with sustained and dissipates soon thereafter. Therefore, the WCE is a
hypertension among 1,187 patients from the PIUMA measure of blood pressure change, whereas WCH is a
study.30 The cardiovascular event rate was even higher: 4.9 measure of blood pressure level. The difference in blood
in 100 patient-years for nondippers compared with 1.79 in pressure between the clinic and the outside setting is quite
100 patient-years for dippers. Complementary to these find- variable and depends on whether low-normal or high-
ings are those reported by Kario and colleagues regarding normal clinic blood pressure levels are used (eg, 140/90 mm
the incidence of silent and clinically overt strokes in older Hg or less) and the activity of the patient while wearing the
Japanese subjects with normal blood pressure, WCH, and ABP monitor. Inactivity tends to increase the difference,
sustained hypertension.24 After a follow-up period of 42 whereas activity, cigarette smoking, or alcohol drinking will
months, they found no difference in the incidence of strokes tend to decrease the difference by increasing the ABP. The
between the normotensive and WCH subjects in contrast to mechanisms underlying the WCE are not well defined but
sustained hypertensive subjects who had a significant inci-
may include anxiety or a hyperalerting response to the clinic
dence of strokes. In most cases, the differences in outcomes
setting and can vary from 14/9 to 27/14 mm Hg for systolic
are due to different cutoff levels for normal ABP used by the
and diastolic blood pressure, respectively,13,15 especially
different investigators. Those using higher cutoff levels (ABP
during the first few minutes of the visit. Stergiou and
> 135/80 mm Hg) had higher target organ damage than
colleagues reported that treatment of hypertension
those using lower levels (ABP 135/80 mm Hg). It is
decreases the WCE but does not abolish it.14 Also, the differ-
hoped that future studies using the standardized normal
levels for ABP from the JNC-722 and the European Society ence in WCE is smaller between self-measurement and
of Hypertension and the European Society of Cardiology23 clinic blood pressure than between ABP and clinic pressure.
will define whether WCH is a benign condition.
PREVALENCE
The prevalence of WCE varies from study to study.
White Coat Effect Pickering and colleagues stated that WCE is a universal
phenomenon and is seen to a greater or lesser extent in
DEFINITION most, if not all, hypertensive patients. 15 In contrast,
WCE is defined as the difference between the average clinic Stergiou and colleagues found it in 27% of untreated
blood pressure and daytime ABP or home blood pres- versus 20% of treated hypertensive patients.14 The WCE
540 / Advanced Therapy in Hypertension and Vascular Disease

is more common in women, the elderly, patients with studies found that WCWH is more common in males,
severe hypertension, and obese subjects.4,10,13 the elderly, cigarette smokers, and alcohol drinkers.
However, it should be stressed that the true incidence of
TARGET ORGAN DAMAGE WCWH is difficult to identify because most, if not all,
Most investigators believe that the WCE is a fairly benign hypertensive patients are diagnosed with clinic blood
phenomenon and does not exert any additional harmful pressure measurements and it is difficult to justify ABP
effects over and above the blood pressure outside the measurements in such individuals. Easier to identify are
clinic.43,44 However, other investigators have found a treated hypertensive individuals, who present to the
significant correlation with WCE and target organ clinic with uncontrolled hypertension. However, if
damage, especially in those patients who demonstrate patients with normal clinic blood pressure show target
higher values for this effect.45 Besides these different organ damage, WCWH should be suspected.
reports, the consensus of opinion is that this is a very
temporary phenomenon occurring during the clinic visit TARGET ORGAN DAMAGE
and should not have any adverse clinical conse- WCWH is more serious with respect to target organ
quences.13,15 Future studies might clarify this issue. damage than isolated clinic hypertension. Many studies
have shown that target organ damage is correlated more
with ABP than clinic blood pressure.30,46 Recent studies
White Coat Worse Hypertension have shown that the LVMI and the carotid intimal medial
thickness are higher in subjects with WCWH than in
DEFINITION those with WCH or sustained normotension.16,20 The
WCWH has recently been described with different defin- true prevalence and significance of WCWH are not
itions, such as “inverse white coat hypertension,” 16 known at present. Most investigators believe that it is not
“reverse white coat hypertension,”17,18 or “white coat a true pathologic condition but is mostly due to different
normotension.” 19,20 In this chapter, I use the term stimuli, such as cigarette smoking, alcohol drinking, and
WCWH, which is more descriptive of the condition and physical activity. However, the true physical prognostic
causes less confusion. This phenomenon refers to higher significance of WCWH must be defined in prospective
mean daily ABP than office blood pressure and is the observational studies and randomized clinical trials that
opposite of WCH. Numerically, WCWH is defined as use actual morbid event rates.
office blood pressure < 140/90 mm Hg and home or
daytime ABP > 135/85 mm Hg.
Management
PREVALENCE
The prevalence of WCWH has been estimated to be WHITE COAT HYPERTENSION
between 14 and 24%16,18 and up to 45% of patients with The diagnosis of WCH must be established before any
high daytime ambulatory systolic or diastolic blood pres- treatment is initiated. The diagnosis should be based on
sure.19,20 This depends on the definition of normal clinic the criteria discussed earlier, and after the patient has had
blood pressure. Hernandez Del-Rey and colleagues three visits to the doctor’s office and has a normal ABP,
reported an incidence of WCWH of 14% among 211 then the course of treatment should be decided. The use
patients with grade 1 to 2 clinic hypertension,16 whereas of antihypertensive drugs in subjects with WCH is
Liu and colleagues found an incidence of WCWH of 20% controversial because several large studies have shown
among 295 clinically normotensive subjects.20 Similar that this condition is fairly benign and that antihyperten-
results were reported by Selenta and colleagues, who sive drugs seem to have a negligible effect on ABP in these
found an incidence of 23% and 24% for WCWH for subjects.47,48 In the Hypertension And Lipid Trial (HALT)
systolic and diastolic blood pressure, respectively, among study, Pickering and colleagues reported that the adminis-
319 subjects.19 On the other hand, Wing and colleagues tration of doxazosin, an 1 receptor blocker, decreased the
found an incidence of WCWH of 21% when the systolic ABP in patients with sustained hypertension but not in
blood pressure was considered and 45% when the dias- those with WCH, although it was equally effective in
tolic blood pressure was taken into account.18 These data reducing the clinic blood pressure in both groups.48 Other
were extracted from a sample of 713 elderly hypertensive investigators have also shown that the ABP is not affected
patients whose ABP was measured, of a total cohort of by antihypertensive treatment in contrast to clinic blood
6,085 patients, who participated in the Second Australian pressure, when the decision to treat is based on clinic
National Blood Pressure Study (ANBP2). All of these blood pressures.49,50 These studies suggest that the inef-
White Coat Hypertension and White Coat Worse Hypertension / 541

fectiveness of antihypertensive treatment in WCH is ronment, despite the current view that blood pressure
mostly due to the level of ABP because patients with low- management should be based on clinic blood pressures.
normal ABP were most resistant to treatment. Fagard and The WCE can be significantly ameliorated, besides good
colleagues also showed that a daytime ABP of 128/88 mm blood pressure control, by weight loss and having nurses
Hg was resistant to treatment with isradipine and lisino- check the blood pressure at the clinic instead of doctors.34
pril.47 Given the evidence today regarding the ineffective-
ness of antihypertensive treatment in subjects with WCH WHITE COAT WORSE HYPERTENSION
and the results of the Hypertension Optimal Treatment WCWH can be very elusive in its detection and treat-
(HOT) study, that there was no cardiovascular benefit ment because in the great majority of cases, the diagnosis
with reducing the blood pressure to less than of hypertension is based on clinic blood pressures. In
138.5/86.5 mm Hg, except in diabetic patients,51 pharma- addition, treatment decisions regarding hypertension are
cologic treatment of WCH is not advisable. Instead, a still based on clinic blood pressure measurements; there-
nonpharmacologic approach to management of WCH fore, justification to treat these patients with office
should be instituted. Nonpharmacologic management normal blood pressure levels is difficult. The presence of
should include modification of the subject’s lifestyle, WCWH should be suspected in patients with high
moderate salt restriction, weight loss if the subject is normal clinic blood pressure (140/90 mm Hg), the
obese, regular aerobic exercise, cessation of cigarette elderly, smokers, and drinkers. The actual daytime ABP
smoking, moderation of alcohol consumption, correction should be verified by instructing patients to avoid exces-
of blood glucose and lipid abnormalities, and regular sive physical activity, cigarette smoking, and alcohol
follow-ups by ABP monitoring every 6 to 12 months. This drinking while wearing the ABP monitor. Also, when
will result in early detection of those subjects who will they return to the clinic, they should not be allowed to
develop sustained hypertension because WCH has been rest but should have their blood pressure checked manu-
considered by some as a prehypertensive condition. It has ally while wearing the monitor. This provides a clearer
been estimated that approximately 37% of those subjects picture regarding the influence of the clinic environment
with WCH will eventually develop sustained hypertension on blood pressure. Those patients who consistently
after 2 to 3 years.52 The cost-effectiveness of ABP moni- present with higher ABP readings than clinic readings
toring as an adjunct to conventional clinic blood pressure should be treated accordingly because ABP is better
measurement is a matter of debate, although ABP moni- correlated with target organ damage and cardiovascular
toring is now funded by Medicare with a meager compen- morbidity and mortality than isolated clinic blood pres-
sation and great restrictions to its use.5 However, ABP sure.46,53 However, more studies are needed to under-
monitoring has certain advantages over office blood pres- stand the prognostic significance of WCWH.
sure monitoring because it provides better information
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