White Coat & Masked Hypertension: A Primary Care Guideline Topline

Recommendation #1. In adults with an untreated SBP >130 mm Hg but <160 mm Hg or DBP >80 mm Hg but <100 mm Hg, it is reasonable to screen for the presence of white coat hypertension (HTN) using either daytime ABPM or HBPM before diagnosis of HTN.

Evidence in Support. White coat HTN average prevalence is ~13% up to 35% in some populations with the disease. ABPM & HBPM are better predictors of HTN-related CVD risk than office BP measurements; ABPM is preferred. Overlap of HPBM with ABPM is only 60% to 70% for detection of white coat HTN.

Recommendation #2. In adults with white coat HTN, periodic monitoring with either ABPM or HBPM is reasonable to detect transition to sustained HTN.

Evidence in Support. Incidence of white coat HTN converting to sustained HTN (justifying addition of antihypertensive Rx to lifestyle modification) is 1% to 5% per year by ABPM or HBPM, with a higher incidence of conversion in those with elevated BP, older age, obesity, or black race.

Recommendation #3. In adults being treated for HTN with office BP readings not at goal and HBPM readings suggestive of a significant white coat effect, confirmation by ABPM can be useful.

Evidence in Support. Overlap between HBPM and both daytime & 24-hour ABPM in diagnosing white coat HTN is only 60-70%. Because a Dx of white coat HTN may result in a decision not to treat or intensify treatment in patients with elevated office BP, confirmation of BP control by ABPM in addition to HBPM provides added support for the decision.

Recommendation #4. In adults with untreated office BPs consistently between 120-129 mm Hg SBP or between 75-79 mm Hg DBP, screening for masked HTN with HBPM (or ABPM) is reasonable.

Evidence in Support. In contrast to white coat HTN, masked HTN is associated with a CVD & all-cause mortality risk 2x as high as that seen in normotensive individuals, with a risk range similar to that of patients with sustained hypertension. Therefore, out-of-office readings are reasonable to confirm BP control seen with office readings.

Recommendation #5. In adults on multiple-drug therapies for HTN & office BPs within 10 mm Hg above goal, it may be reasonable to screen for white coat effect with HBPM (or ABPM).

Evidence in Support. White coat effect has been implicated in office-measured uncontrolled HTN & pseudoresistant HTN; BP control may be underestimated when subsequently assessed by ABPM. Risk of vascular complications in patients with office-measured uncontrolled HTN with a white coat effect is similar to the risk in those with controlled HTN. White coat HTN & white coat effect raise concerns that unnecessary drug therapy for HTN may be initiated/intensified.

Recommendation #6. It may be reasonable to screen for masked uncontrolled HTN with HBPM in adults being treated for HTN and office readings at goal, in the presence of target organ damage or increased overall CVD risk.

Evidence in Support. Like masked HTN in untreated patients, masked uncontrolled HTN is defined in treated patients with HTN by office readings suggesting adequate BP control but out-of-office readings (HBPM) that remain consistently above goal. The CVD risk profile for masked uncontrolled HTN appears to follow the risk profile for masked HTN.

Recommendation #7. In adults being treated for hypertension with elevated HBPM readings suggestive of masked uncontrolled hypertension, confirmation of the diagnosis by ABPM might be reasonable before intensification of antihypertensive drug treatment.