blood pressure, hypertension, white coat

White Coat Hypertension Calls for Close Blood Pressure Monitoring Interview with:

Jordana Cohen, MD, MSCE Assistant Professor of Medicine and Epidemiology Renal-Electrolyte and Hypertension Division Center for Clinical Epidemiology and Biostatistics Perelman School of Medicine University of Pennsylvania

Dr. Jordana Cohen

Jordana Cohen, MD, MSCE
Assistant Professor of Medicine and Epidemiology
Renal-Electrolyte and Hypertension Division
Center for Clinical Epidemiology and Biostatistics
Perelman School of Medicine
University of Pennsylvania What is the background for this study?

Response: In the June 18, 2019 issue of Annals of Internal Medicine, we published a systematic review and meta-analysis evaluating the cardiovascular risks of white coat hypertension (WCH; i.e. elevated office blood pressure and normal out-of-office blood pressure). The goal of the meta-analysis was to clarify previous mixed results regarding the risks of untreated WCH and treated WCH. The meta-analysis examined 27 studies – including 64,273 patients – and demonstrated that untreated WCH is associated with an increased risk of cardiovascular events (36%), all-cause mortality (33%), and cardiovascular mortality (109%) compared to normotension. This risk was strongest in studies with a mean age ≥55 years or that included participants with cardiac risk factors, such as diabetes and chronic kidney disease. We found no increased cardiovascular risk associated with treated white coat hypertension. What are the main findings?

Response: I was invited to give a talk related to this research at the AHA Hypertension Scientific Sessions this past week on the topic of out-of-office BP patterns in women. A prior meta-analysis restricted to cross-sectional studies suggested that women may be at a 3-fold increased risk of white coat hypertension compared to men, though these findings are not consistently demonstrated in the large prospective cohorts that we included in our meta-analysis. Banegas’s New England Journal Study is the only study I have encountered that has specifically evaluated the sex-specific risk of WCH; the authors demonstrated no increased risk of cardiovascular or all-cause mortality among women with WCH compared to men with white coat hypertension. I performed new analyses for the talk, which demonstrated no increased cardiovascular risk associated with WCH among studies with a higher proportion of women who had white coat hypertension, supporting Banegas’s findings. What should readers take away from your report?

Response: The meta-analysis did not demonstrate that individuals with untreated WCH should be initiated on antihypertensive treatment. Instead, individuals with untreated WCH need to be closely monitored with out-of-office blood pressure monitoring. These individuals are at a high risk of developing sustained hypertension; the often-uncaptured transition to sustained hypertension likely drives their increased cardiovascular risk. We also recommend being cautious not to overtreat individuals with treated white coat hypertension, as they may be prone to out-of-office hypotension and unnecessary side effects from medications. What recommendations do you have for future research as a result of this work? 

Response: Future studies need to assess if initiating patients with white coat hypertension on antihypertensive therapy helps to reduce cardiovascular risk, balanced with the real risk of out-of-office hypotension. Is there anything else you would like to add?

Response: The Center for Medicare Services announced in July 2019 that they will expand reimbursement for ambulatory blood pressure monitoring – which provides the highest quality out-of-office blood pressure readings – to include treated and untreated white coat hypertension and masked hypertension. In individuals who require repeated monitoring over time (e.g., for medication titration), home blood pressure monitoring can be valuable, but requires training on correct technique and use of a validated monitor. The AMA will be coming out with a device listing of validated home BP monitors available in the US by the end of this year.

This research was funded by the nih_nhlbi K23-HL133843 


Hypertension 2019 Scientific Sessions abstract

Incidence and Prognosis of White Coat Hypertension in Women
Jordana Cohen, MD, MSCE 


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Last Updated on September 9, 2019 by Marie Benz MD FAAD