White-Coat and Reverse White-Coat Effects Correlate with 24-h Pulse Pressure and Systolic Blood Pressure Variability in Children and Young Adults

Main Factors Related with the White Coat Effect Level in Patients with Arterial Hypertension and Bronchial Asthma

Aim. To study the main relationships of the white coat effect (WCE) levels in patients with arterial hypertension (AH) with bronchial asthma (BA) who treated with AH and BA drugs in routine clinical practice.

Material and Methods. We analyzed the prospective cohort study data of AH patients, some of them had BA without exacerbation. We have formed two groups of patients:1 - control group, patients with AH without BA, the second - with AH + BA. The study consisted of three visits (first visit, 6 months and 12 months visits) and data collection period (30.1±7.6 months of follow-up). The following procedures were performed at the first and 12 month visits: clinical blood pressure (BP) measurements (sitting and standing), 24-hour monitoring ambulatory (ABPM), spirometry, clinical and biochemical blood tests, BA control questionnaires (ACQ) and quality of life (QL) questionnaire (GWBQ), at the second visit clinical BP measurement was performed and, if necessary, the drug dose was corrected.

Results. The study included 125 patients, 28 men, 97 women. The first group of AH patients without BA included 85 people, the second (AH + BA) - 40. In AH patients without BA with ischemic heart disease, arterial revascularization, regular alcohol intake and smoking we identified the association with the lower WCE levels. In AH+BA patients with diabetes mellitus, gastrointestinal diseases, higher education was identified WCE decrease. In AH patients without asthma we found inverse relationships WCE levels with respiratory function parameters, the nighttime BP decrease, heart rate and the difference between standing and sitting BP levels, and correlations with the EchoCG variables (the left ventricular hypertrophy (LVH) indices), with age, AH duration and body mass index (BMI). In patients with AH + BA we found inverse correlations between WCE levels and some EchoCG variables, the difference between standing and sitting BP levels, and correlations with body weight, BMI.

Conclusion. Thereby, in AH patients without BA with ischemic heart disease, revascularization, regular alcohol intake, smoking we identified the association with the lower WCE levels. This patients WCE indices had inverse correlations with height, respiratory function parameters, the BP nighttime decrease, the difference between standing and sitting BP levels and direct relationships with EchoCG variables of LVH, age, AH duration and BMI. In AH + BA patients with diabetes, gastrointestinal diseases, higher education we found relationships with lesser WCE manifestation. WCE levels in this group had inverse correlations with some EchoCG indicators, the standing and sitting BP difference and direct relations with weight and BMI.

Short-Term but not Long-Term Blood Pressure Variability Is a Predictor of Adverse Cardiovascular Outcomes in Young Untreated Hypertensives

BACKGROUND

Whether blood pressure variability (BPV) measured with ambulatory monitoring (short-term BPV) or computed from office visits (long-term BPV) are related to each other and carry similar prognostic information is not well known. We investigated the independent determinants of short-term and long-term BPVs and their predictive capacity for the development of major adverse cardiovascular and renal events (MACEs) in a cohort of young hypertensive participants.

METHODS

Long-term BPV was calculated as visit-to-visit SD and average real variability from office blood pressure (BP) measured during 7 visits, within 1 year. Short-term BPV was calculated as weighted 24-hour SD and coefficient of variation. Hazard ratios (HRs) for risk of MACE were computed from multivariable Cox regressions.

RESULTS

1,167 participants were examined; mean age was 33.1 ± 8.5 years. Variables independently associated with 24-hour systolic SD were 24-hour systolic BP, low physical activity, smoking, baseline office pulse pressure, systolic BP dipping, and diastolic white coat effect, while those associated with long-term BPV were mean systolic BP, age, female gender, and baseline office heart rate. During a median follow-up of 17.4 years 75 MACEs occurred. In Cox analysis only short-term BPV resulted a significant predictor of MACE (HR, 1.31 (1.07-1.59); P = 0.0086), while no index of long-term BPV was independently associated with outcome.

CONCLUSIONS

In young hypertensive subjects only short-term BPV resulted a significant predictor of MACE on top of traditional ambulatory BP monitoring parameters. Whether reduction of short-term BPV with therapy may reduce the cardiovascular risk independently from the effects on 24-hour BP is a matter for future research.

Arterial stiffness in children and adolescents with masked and sustained hypertension

This study recruited 85 healthy children and adolescents, aged 6-18 years, from a school-based blood pressure (BP) screening study and performed office BP measurements, 24-h ambulatory blood pressure monitoring (24-h ABPM) and 24-h pulse wave analysis. Prevalence of BP phenotypes was assessed, factors that may predict hypertension (HTN) in ABPM were examined and the effect of BP phenotypes, as well as school, office, and ambulatory BP parameters on pulse wave velocity (PWV), was investigated. Forty-five (54.9%) of the children were normotensives, 8 (9.7%) were white coat hypertensives (WCH), 19 (23.2%) had masked hypertension (MH), and 10 (12.2%) had sustained HTN. Estimated adjusted marginal means for 24-h PWV were 4.79 m/s (95% CI 4.65-4.94) for sustained hypertensives, 4.72 m/s (95% CI 4.62-4.82) for MH, 4.38 m/s (95% CI 4.23-4.54) for WCH, and 4.33 m/s (95% CI 4.26-4.40) for normotensives (sustained hypertensives versus normotensives and WCH, p < 0.001, MH versus normotensives and WCH, p < 0.005). Neither body mass index (BMI) z-score nor school systolic BP (SBP) z-score could predict HTN by ABPM. Office SBP z-score was associated with 1.74 times increased odds ratio to have HTN in ABPM. Sustained HTN and MH were independent predictors of 24-h PWV after adjustment for age, sex, and BMI z-score. In conclusion, arterial stiffness in children and adolescents was assessed by 24-h PWV associates with mean ambulatory BP. Both school and office BP measurements could not predict HTN in ABPM or increasing PWV. HTN in ABPM was independently associated with the risk of higher PWV compared with normotensive and WCH phenotype.

Isolated systolic hypertension in the young: a position paper endorsed by the European Society of Hypertension

: Whether isolated systolic hypertension in the young (ISHY) implies a worse outcome and needs antihypertensive treatment is still a matter for dispute. ISHY is thought to have different mechanisms than systolic hypertension in the elderly. However, findings from previous studies have provided inconsistent results. From the analysis of the literature, two main lines of research and conceptualization have emerged. Simultaneous assessment of peripheral and central blood pressure led to the identification of a condition called pseudo or spurious hypertension, which was considered an innocent condition. However, an increase in pulse wave velocity has been found by some authors in about 20% of the individuals with ISHY. In addition, obesity and metabolic disturbances have often been documented to be associated with ISHY both in children and young adults. The first aspect to consider whenever evaluating a person with ISHY is the possible presence of white-coat hypertension, which has been frequently found in this condition. In addition, assessment of central blood pressure is useful for identifying ISHY patients whose central blood pressure is normal. ISHY is infrequently mentioned in the guidelines on diagnosis and treatment of hypertension. According to the 2013 European Guidelines on the management of hypertension, people with ISHY should be followed carefully, modifying risk factors by lifestyle changes and avoiding antihypertensive drugs. Only future clinical trials will elucidate if a benefit can be achieved with pharmacological treatment in some subgroups of ISHY patients with associated risk factors and/or high central blood pressure.

White coat syndrome and its variations: differences and clinical impact

Hypertension is closely linked to increased cardiovascular risk and development of target organ damage (TOD). Therefore, proper clinical follow-up and treatment of hypertensive subjects are mandatory. A great number of individuals present a variation on blood pressure (BP) levels when they are assessed either in the office or in the out-of-office settings. This phenomenon is defined as white coat syndrome - a change in BP levels due to the presence of a physician or other health professional. In this context, the term "white coat syndrome" may refer to three important and different clinical conditions: 1) white coat hypertension, 2) white coat effect, and 3) masked hypertension. The development of TOD and the increased cardiovascular risk play different roles in these specific subgroups of white coat syndrome. Correct diagnose and clinical guidance are essential to improve the prognosis of these patients. The aim of this review was to elucidate contemporary aspects of these types of white coat syndrome on general and hypertensive population.

Visit-to-visit blood pressure variability in children and adolescents with renal disease

BACKGROUND

Increase in blood pressure (BP) variability (BPV) is associated with cardiovascular events, target organ damage, and arterial stiffness in adults. We previously reported that 24-h BPV may be associated with arterial stiffness and underlie white-coat hypertension (WCH). In this study, we examined whether visit-to-visit variability (VVV) could predict WCH and whether VVV correlated with eGFR, eGFR slope, and albuminuria/proteinuria in children and adolescents with renal diseases.

METHODS

VVV was determined as average real variability of office BP measurements between visits, and 24-h BPV as the standard deviation of 24-h ambulatory BP. In 35 renal patients (25 boys and 10 girls, 7-18 years of age), divided into normotension (NT), WCH, and hypertension (HTN), the relationships between VVV and 24-h BPV and VVV in each BP category were studied. In separate 48 renal patients (24 boys and 24 girls, 2-18 years of age), the correlation between VVV and eGFR, eGFR slope, urine albumin or protein excretion was examined.

RESULTS

Systolic VVV was significantly correlated with systolic office BP index. There was no correlation between VVV and 24-h BPV or 24-h pulse pressure. In addition, VVV was not different among NT, WCH, and HTN. Systolic VVV was significantly negatively correlated with eGFR but not with eGFR slope, albuminuria, or proteinuria. A cut-off value of systolic VVV for detecting eGFR < 60 ml/min per 1.73 m² was 8.5.

CONCLUSION

VVV could not predict WCH. Systolic VVV correlated with eGFR but not with eGFR slope, albuminuria/proteinuria. Increased VVV could be a marker of decreased eGFR.

Masked Isolated Nocturnal Hypertension in Children and Young Adults

Isolated nocturnal hypertension (INH) is characterized by normal daytime blood pressure (BP) and elevated nighttime BP diagnosed by ambulatory BP monitoring. Masked isolated nocturnal hypertension (MINH) is a subtype of INH in which office BP is normal. We studied the frequency and characteristics of INH and MINH in children and young adults. One hundred and ninety-eight subjects seen by the pediatric nephrology service were studied retrospectively. Isolated nocturnal hypertension (INH) and MINH were diagnosed according to daytime and nighttime ABP and office BP in the case of the latter. One hundred and eighteen subjects (60%) had normotension, 6 (3%) had isolated daytime hypertension, 32 (16%) had INH, and 42 (21%) had day-night hypertension. Sixteen subjects had MINH (8.1%). The underlying diseases of MINH were as follows: no underlying disease 9 (56%), renal disease 6 (38%), and endocrine disease 1 (6%). There was no significant difference in the underlying disease, gender, age, and BMI between MINH and INH with elevated office BP. In conclusion, MINH is present in children and young adults. Since there were no specific features for MINH, screening with ambulatory or home BP monitoring during sleep may be appropriate.

Poor Reliability of Wrist Blood Pressure Self-Measurement at Home

The reliability of blood pressure measurement with wrist devices, which has not previously been assessed under real-life circumstances in general population, is dependent on correct positioning of the wrist device at heart level. We determined whether an error was present when blood pressure was self-measured at the wrist in 721 unselected subjects from the general population. After training, blood pressure was measured in the office and self-measured at home with an upper-arm device (the UA-767 Plus) and a wrist device (the UB-542, not provided with a position sensor). The upper-arm−wrist blood pressure difference detected in the office was used as the reference measurement. The discrepancy between office and home differences was the home measurement error. In the office, systolic blood pressure was 2.5% lower at wrist than at arm ( P =0.002), whereas at home, systolic and diastolic blood pressures were higher at wrist than at arm (+5.6% and +5.4%, respectively; P <0.0001 for both); 621 subjects had home measurement error of at least ±5 mm Hg and 455 of at least ±10 mm Hg (bad measurers). In multivariable linear regression, a lower cognitive pattern independently determined both the systolic and the diastolic home measurement error and a longer forearm the systolic error only. This was confirmed by logistic regression having bad measurers as dependent variable. The use of wrist devices for home self-measurement, therefore, leads to frequent detection of falsely elevated blood pressure values likely because of a poor memory and rendition of the instructions, leading to the wrong position of the wrist.