INVITED COMMENTARY

Are we Evaluating Correctly the Risk Accompanying BloodPressure? The Case of White Coat and Masked Hypertensionand Blood Pressure Variability

Luis M. Ruilope & José R. Banegas

Published online: 20 October 2013# Springer Science+Business Media New York 2013

Office blood pressure (BP) is the gold standard to characterizethe risk attributable to BP in a given person. According toESH/ESC Guidelines published this year [1], values of officeBP equal to or above 140/90mmHg represent the threshold toconsider someone as being hypertensive and values below thesame figure represent an adequate goal of BP control. Deter-mination of office BP does not, however, recognize 2 situa-tions that deserve to be known to obtain an adequate BPcontrol; these are white coat and masked hypertension [2].Even more, the level of day-to-day office BP variability canalso influence in a relevant manner the outcome of hyperten-sive patients [3]. The term white coat (or isolated office)hypertension refers to the condition in which BP is elevatedin the office at repeated visits but normal out of the officewhen measured using ambulatory blood pressure monitoring(ABPM) or home blood pressure monitoring (HBPM). Gene-rally considered as a situation where cardiovascular (CV) riskis similar to that of normotensive subjects, recent data indicatethat it is accompanied by a significant increase in CV risk thattranslates into an increased CV mortality [4]. The need ofpharmacologic therapy under these circumstances requires adebate followed by trials but under certain conditions such asin very elderly patients with white coat hypertension, pharma-cologic therapy may be beneficial [5]. A different situation isthe presence of masked hypertension characterized by normal

BP values in the office and an elevation of BP on ABPM orHBPM. This situation is recognized by guidelines in untreatedhypertensives and is accompanied by a significant increase inCV risk that requires pharmacologic therapy [1]. However, theprevalence of elevated BP outside the office is even higher intreated hypertensives [6] and forces the need for a wider use ofABPM or HBPM and for an increase in therapy to control BP.

Recently, the relevance of the control of variability, insta-bility, and episodic hypertension in usual visits to the clinichas been demonstrated to be of value for the prevention of CVevents, in particular stroke [3]. Albeit trials, looking specifi-cally at the problem are lacking; the post-hoc analysis ofrelevant trials has demonstrated the importance of visit-to-visit variability in systolic BP (SBP) on the development ofmacro- and microvascular complications [7]. It has also beendefined that the effects of antihypertensive drugs on SBPvariability are dose dependent and persist when used in com-binations and that the use of a calcium channel blocker aloneor in combination with other agents seems to be particularlyeffective in prevention of stroke [8]. Intervisit differences inSBP above 20 mm Hg reveal an increased variability anddifferences above 40 mm Hg are accompanied by a verysignificant risk (Peter Rothwell personal communication).

In summary, the need to investigate the presence of any ofthe 3 situations here described will no doubt contribute togreatly improve the outcome of hypertensive patients.

Compliance with Ethics Guidelines

Conflict of Interest LuisMRuilope has been a consultant for Novartis,Daiichi-Sankyo, Medtronic, BMS, and MSD, and has received paymentfor development of educational presentations from Medtronic. José RBanegas declares that he has no conflicts of interest.

Human and Animal Rights and Informed Consent This article doesnot contain any studies with human or animal subjects performed by anyof the authors.

L. M. Ruilope (*)Instituto de Investigación, Hospital 12 de Octubre,28041 Madrid, Spaine-mail: ruilope@ad-hocbox.com

L. M. Ruilope : J. R. BanegasDepartment of Preventive Medicine and Public Health,Universidad Autónoma deMadrid/IdiPaz CIBERESP,Madrid, Spain

J. R. BanegasCátedra de Riesgo Cardiovascular, Madrid, Spain

Curr Cardiovasc Risk Rep (2013) 7:431–432DOI 10.1007/s12170-013-0360-7

References

1. Mancia G, Fagard R, Narkiewicz K, Redon J, Zanchetti A, Böhm M,et al. 2013 ESH/ESC Guidelines for the management of arterialhypertension: the Task Force for the management of arterialhypertension of the European Society of Hypertension (ESH)and of the European Society of Cardiology (ESC). J Hypertens.2013;31:1281–357.

2. Ruilope LM. Current challenges in the clinical management of hyper-tension. Nat Rev Cardiol. 2012;9:267–75.

3. Rothwell PM. Limitations of the usual blood-pressure hypothesis andimportance of variability, instability, and episodic hypertension.Lancet. 2010;375:938–48.

4. Mancia G, Bombelli M, Brambilla G, Facchtti G, Schwartz R, Sega R,et al. Long-term prognostic value of white coat hypertension: an

insight from diagnostic use of both ambulatory and home bloodpressure measurements. Hypertension. 2013;62:168–74.

5. Bulpitt CJ, Beckett N, Peters R, Staessen JA, Wang JG, Comsa M,et al. Does white coat hypertension require treatment over age 80?results of the hypertension in the very elderly trial ambulatory bloodpressure side project. Hypertension. 2013;61:89–94.

6. Banegas JR, Segura J, Sobrino J, Rodriguez-Artalejo F, de la Sierra A,de la Cruz JJ, et al. Effectiveness of blood pressure control outside theclinical setting. Hypertension. 2007;49:62–8.

7. Hata J, Arima H, Rothwell PM,WoodwardM, Zoungas S, Anderson C,et al. Effects of visit-to-visit variability in systolic blood pressure onmacrovascular and microvascular complications in patients with type 2diabetes: the ADVANCE trial. Circulation. 2013; [Epub ahead of print].

8. Webb AJ, Rothwell PM. Effect of dose and combination of antihyper-tensives on interindividual blood pressure variability: a systematicreview. Stroke. 2011;42:2860–5.

432 Curr Cardiovasc Risk Rep (2013) 7:431–432