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Home BP monitoring essential for patients with ‘white coat’ hypertension

Patients with ‘white coat hypertension’ – normal BP at home but elevated BP at the physician’s office – often did not undergo out-of-office BP monitoring despite clinical guidelines due to physician skepticism stemming from unclear evidence to support home BP monitoring in these patients, according to a recent study published in the Annals of Internal Medicine. The study found that those with white coat hypertension who were not on antihypertensive medication had significantly increased risk for cardiovascular events, all-cause mortality and cardiovascular mortality, demonstrating the importance of out-of-office BP monitoring in those patients.

When patients with white coat hypertension (WCH) were treated – what researchers called white coat effect (WCE) – they did not experience elevated risk for cardiovascular events or mortality.

“Despite guideline recommendations, real-world practice has been slow to adopt out-of-ofce BP monitoring,” Jordana B. Cohen, MD, MSCE, of the Perelman School of Medicine at the University of Pennsylvania, and colleagues wrote. “The clinical inertia surrounding out-of-office BP monitoring seems to be driven by several provider-, patient-, and policy-related factors. A major barrier is skepticism over the utility of screening for isolated office hypertension (that is, untreated WHC and treated WCE) due to unclear evidence.”

Researchers conducted a meta-analysis of publications from PubMed and EMBASE from inception to Dec. 10, 2018. The search terms included “hypertension,” “blood pressure” and terms related to WCH, in-office BP, out-of-office BP monitoring and CV outcomes. Studies of adult humans who reported WCH or WCE with nonfatal CV events, fatal CV events or all-cause mortality, had a mean 3 years of follow-up data available and had a reference group of patients with controlled hypertension or normotension, were included.

Patients with ‘white coat hypertension’ – normal BP at home but elevated BP at the physician’s office - often did not undergo out-of-office BP monitoring despite clinical guidelines due to physician skepticism stemming from unclear evidence to support home BP monitoring in these patients, according to a recent study published in the Annals of Internal Medicine.

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The search yielded 27 publications with 29 unique cohorts for inclusion in the study. A total of 25,786 persons with WCH or WCE and 38,487 with normotension or controlled hypertension were included in the study results. Researchers found that compared with normotension, untreated WCH was associated with increased risk for CV events (HR = 1.36; 95% CI, 1.03-2), all-cause mortality (HR = 1.33; 95% CI, 1.07-1.67), and CV mortality (HR = 2.09; 95% CI, 1.23-4.48).

There was no significant association between treated WCE and CV events (HR = 1.12; 95% CI, 0.91-1.39), all-cause mortality (HR = 1.11; 95% CI, 0.89-1.46), or CV mortality (HR = 1.04; 95% CI, 0.65-1.66).

“For adults taking antihypertensive medication, the results are clear,” Daichi Shimbo, MD, of the Columbia University Medical Center, and Paul Muntner, PhD, of the University of Alabama at Birmingham, wrote in an editorial accompanying the study. “White coat effect is not associated with increased risk, and out-of-office monitoring seems warranted to prevent intensication of antihypertensive treatment.

“For adults not taking antihypertensive medication, the risk for CVD events and all-cause mortality is only moderately increased, and this risk is substantially lower than that associated with sustained hypertension,” they continued. “Therefore, out-of-office BP monitoring is useful for distinguishing between WCH and sustained hypertension among persons with high office BP.” – by Erin Michael

Disclosures: Cohen reports grants from the NIH, National Heart, Lung, and Blood Institute, during the conduct of the study.