Target organ status in white-coat hypertensives: usefulness of serum procollagen type I propeptide in the respect of left ventricular diastolic dysfunction

Cardiovascular Alterations and Management of Patients With White Coat Hypertension: A Meta-Analysis

A large and growing body of literature has focused on the association between "white coat hypertension" (WCH) and the underlying target organ damage. The evidence suggests that WCH is may not an entirely benign phenomenon. However, whether patients with WCH should receive antihypertensive drugs is unresolved. Therefore, we performed a meta-analysis to fully determine the ability of WCH to alter cardiovascular structure and to determine whether patients with WCH could benefit from drug intervention. Medline, EMBASE, and the Cochrane Library were searched from inception through 21 Oct 2019. A total of 25 studies (8,100 individuals) were included. In participants with WCH, values of aortic pulse wave velocity, augmentation index, intima-media thickness, interventricular septum thickness, left ventricular posterior wall thickness, and left ventricular mass index were lower than those with sustained hypertension, but greater than those in the normotensive group. Of note, antihypertensive drug therapy did not reduce the risk of cardiovascular events in patients with WCH. WCH is accompanied by alterations of cardiovascular structure; however, the benefits from antihypertensive therapy are limited.

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.

The evaluation of arterial stiffness of essential hypertension and white coat hypertension in children: a case-control study

BACKGROUND

The aim of this study was to determine and compare cardiovascular risks by assessing arterial stiffness in children with essential hypertension and white coat hypertension.

METHODS

Paediatric patients followed up with essential hypertension and white coat hypertension diagnoses and with no established end organ damage were involved in the study. Arterial stiffness in children included in the study was evaluated and compared by using the oscillometric device (Mobil-O-Graph) method.

RESULTS

A total of 62 essential hypertension (34 male, 28 female), 38 white coat hypertension (21 male, 17 female), and 60 healthy controls (33 male, 27 female) were assessed in the present study. Pulse wave velocity of the essential hypertension, white coat hypertension, and control group was, respectively, as follows: 5.3±0.6 (m/s), 5.1±0.4 (m/s), 4.3±0.4 (m/s) (p<0.001); augmentation index outcomes were, respectively, determined as follows: 21.3±6.5, 19.3±6.4, 16.0±0.3 (p<0.001). Pulse wave velocity and augmentation index values of children with essential hypertension and white coat hypertension were found to be higher compared with the control group. This level was identified as correlated with the duration of hypertension in both patient groups (p<0.01).

CONCLUSION

Arterial stiffness in children with essential hypertension and white coat hypertension was impaired compared with healthy children. This finding has made us think that white coat hypertension is not an innocent clinical situation. This information should be taken into consideration in the follow-up and treatment approaches of the patients.

Decoding white coat hypertension

There is arguably no less understood or more intriguing problem in hypertension that the "white coat" condition, the standard concept of which is significantly blood pressure reading obtained by medical personnel of authoritative standing than that obtained by more junior and less authoritative personnel and by the patients themselves. Using hospital-initiated ambulatory blood pressure monitoring, the while effect manifests as initial and ending pressure elevations, and, in treated patients, a low daytime profile. The effect is essentially systolic. Pure diastolic white coat hypertension appears to be exceedingly rare. On the basis of the studies, we believe that the white coat phenomenon is a common, periodic, neuro-endocrine reflex conditioned by anticipation of having the blood pressure taken and the fear of what this measurement may indicate concerning future illness. It does not change with time, or with prolonged association with the physician, particularly with advancing years, it may be superimposed upon essential hypertension, and in patients receiving hypertensive medication, blunting of the nighttime dip, which occurs in about half the patients, may be a compensatory mechanisms, rather than an indication of cardiovascular risk. Rather than the blunted dip, the morning surge or the widened pulse pressure, cardiovascular risk appears to be related to elevation of the average night time pressure.

White-coat hypertension, as defined by ambulatory blood pressure monitoring, and subclinical cardiac organ damage: a meta-analysis

AIM

: The clinical and prognostic relevance of white-coat hypertension (WCH) has not been fully elucidated; in particular, the association of this blood pressure phenotype with suclinical organ damage remains unclear. We performed a systematic meta-analysis in order to provide a comprehensive information on cardiac structural and functional changes in WCH, as defined by ambulatory blood pressure monitoring.

DESIGN

Studies were identified by the following search terms: 'white-coat hypertension', 'isolated clinic hypertension', 'cardiac organ damage', 'target organ damage', 'left ventricle', 'left ventricular hypertrophy', 'cardiac hypertrophy', 'ventricular dysfunction', and 'echocardiography'.

RESULTS

A total of 7382 untreated adult patients (2493 normotensive, 1705 WCH, and 3184 hypertensive individuals) included in 25 studies were considered. Left ventricular mass index was higher in WCH than in normotensive patients [standardized difference in mean (SDM) 0.50, P < 0.01]; mitral E/A ratio was lower (SDM -0.27, P < 0.01) and left atrium larger (SDM 0.29, P < 0.05) in WCH than in the normotensive counterparts. Hypertensive patients showed a greater left ventricular mass index (SDM 0.42, P < 0.01), reduced E/A (SDM -0.15, P < 0.01), and larger left atrium diameter (SDM 0.27, P < 0.01) than WCH patients.

CONCLUSIONS

Our meta-analysis shows that alterations in cardiac structure and function in WCH patients, as defined by ambulatory blood pressure monitoring, are intermediate between sustained hypertensive patients and normotensive controls. The study supports the view that WCH should not be further considered a fully benign entity.

White-coat hypertension

1. Numerous studies have examined whether white-coat hypertension (WCHT) is associated with increased cardiovascular risk, but with definitions of WCHT that were not sufficiently robust, results have been inconsistent. The aim of the present review was to standardize the evidence by only including studies that used a definition of WCHT consistent with international guidelines. 2. Published studies were reviewed for data on vascular dysfunction, target organ damage, risk of future sustained hypertension and cardiovascular events. 3. White-coat hypertension has a population prevalence of approximately 15% and is associated with non-smoking and slightly elevated clinic blood pressure. Compared with normotensives, subjects with WCHT are at increased cardiovascular risk due to a higher prevalence of glucose dysregulation, increased left ventricular mass index and increased risk of future diabetes and hypertension. 4. In conclusion, management of a patient with WCHT should focus on cardiovascular risk factors, particularly glucose intolerance, not blood pressure alone.

Detection of masked hypertension and the 'mask effect' in patients with well-controlled office blood pressure

BACKGROUND

Masked hypertension (MH) is characterized by its hidden nature and poor prognosis. However, it is not practical to routinely recommend home or ambulatory blood pressure monitoring (HBP or AMBP) to all patients with apparently well-controlled BP. The purpose of this study is to present, within the group of patients with well-controlled office BP (OBP), the clinical predictors of MH and to evaluate the gap (ie, the `mask effect' (ME)) between OBP and HBP.

METHODS AND RESULTS

BP was measured at the outpatient clinic and at home in 1,019 treated hypertensive patients. Candidate predictors for MH were analyzed within 511 patients with well-controlled OBP (45.6% men, 57.1±9.0 years). Among them, the prevalence of MH was 20.9% (n=107). In the multivariate-adjusted analysis, the risk of MH increased with high serum fasting blood glucose level (odds ratio (OR) 1.009, 95% confidence interval (CI): 1.001-1.018, P=0.020), higher systolic OBP (OR 1.075, 95%CI 1.045-1.106, P<0.001), higher diastolic OBP (OR 1.045, 95%CI 1.007-1.084, P=0.019) and the number of antihypertensive medications (OR 1.320, 95%CI 1.113-1.804, P=0.021). Furthermore, systolic HBP correlated well with systolic OBP (r=0.351, P<0.001) and with the degree of systolic ME (r=-0.672, P<0.001).

CONCLUSIONS

To recognize MH, it is practical to investigate those patients who are taking multiple antihypertensive drugs and have a high OBP with a high FBG level. The term "ME" identifies MH more appropriately than the term "negative white-coat effect".