White-coat hypertension: a clinical review

  • Hilde Celis
    Correspondence
    Corresponding author. Tel.: +32 16 34 36 31; fax: +32 16 34 37 66.
    Affiliations
    Hypertension and Cardiovascular Rehabilitation Unit, Department of Molecular and Cardiovascular Research, University of Leuven, U.Z. Gasthuisberg–Dienst Hypertensie, Herestraat 49, 3000 Leuven, Belgium
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  • Robert H. Fagard
    Affiliations
    Hypertension and Cardiovascular Rehabilitation Unit, Department of Molecular and Cardiovascular Research, University of Leuven, U.Z. Gasthuisberg–Dienst Hypertensie, Herestraat 49, 3000 Leuven, Belgium
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      Abstract

      White-coat hypertension (WCHT), also called ‘isolated office or clinic hypertension’, is defined as the occurrence of blood pressure (BP) values higher than normal when measured in the medical environment, but within the normal range during daily life, usually defined as average daytime ambulatory BP (ABP) or home BP values (<135 mm Hg systolic and <85 mm Hg diastolic). The prevalence of WCHT varies from 15% to over 50% of all patients with mildly elevated office BP (OBP) values. In untreated hypertensive patients, the probability of WCHT especially increases with female gender and a mildly elevated OBP level. The value of other possible determinants such as (non) smoking status, duration of hypertension, left ventricular mass, number of OBP measurements, educational level, etc. is less consistently shown. Although, for various reasons, studies evaluating the long-term effects of WCHT are not always easy to interpret, most data indicate that persons with WCHT have a worse or equal cardiovascular prognosis than normotensives, but a better one than those with sustained hypertension. WCHT is sometimes considered a prehypertensive state, but data on the long-term evolution of subjects with WCHT are scarce. Patients with WCHT and a high cardiovascular risk or proven target organ damage should be pharmacologically treated. Subjects with uncomplicated WCHT should probably not receive medical therapy, but a close follow-up, including regular assessment of other risk factors and measurement of OBP (every 6 months) and ABP (every 1 or 2 years), is warranted.

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      References

        • O'Brien E.T.
        • Asmar R.
        • Beilin L.
        • et al.
        European society of hypertension recommendations for conventional, ambulatory and home blood pressure measurement.
        J. Hypertens. 2003; 21: 821-848
        • Verdecchia P.
        • Staessen J.A.
        • White W.B.
        • Imai Y.
        • O'Brien E.T.
        Properly defining white coat hypertension.
        Eur. Heart J. 2001; 23: 106-109
        • Chobanian A.V.
        • Bakris G.L.
        • Black H.R.
        • et al.
        The seventh report of the joint national committee on prevention, detection, evaluation, and treatment of high blood pressure.
        JAMA. 2003; 289: 2560-2572
        • Guidelines Committee
        2003 European Society of Hypertension—European Society of Cardiology guidelines for the management of arterial hypertension.
        J. Hypertens. 2003; 21: 1011-1053
        • Verdecchia P.
        • O'Brien E.
        • Pickering T.G.
        • et al.
        When can the practicing physician suspect white coat hypertension? Statement from the working group on blood pressure monitoring of the European society of hypertension.
        Am. J. Hypertens. 2003; 16: 87-91
        • Pickering T.G.
        • James G.D.
        • Boddie C.
        • Harshfield G.A.
        • Blank S.
        • Laragh J.H.
        How common is white coat hypertension?.
        JAMA. 1988; 259: 225-228
        • Khattar R.S.
        • Senior R.
        • Lahiri A.
        Cardiovascular outcome in white-coat versus sustained mild hypertension—a 10-year follow-up study.
        Circulation. 1998; 98: 1892-1897
        • Verdecchia P.
        • Schillaci G.
        • Borgioni C.
        • Ciucci A.
        • Porcellati C.
        White coat hypertension.
        Lancet. 1996; 348: 1444-1445
        • Martinez M.A.
        • Garcia-Puig J.
        • Martin J.C.
        • et al.
        Frequency and determinants of white coat hypertension in mild to moderate hypertension. A primary care-based study.
        Am. J. Hypertens. 1999; 12: 251-259
        • Verdecchia P.
        • Porcellati C.
        • Schillaci G.
        • et al.
        Ambulatory blood pressure: an independent predictor of prognosis in essential hypertension.
        Hypertension. 1994; 24: 793-801
        • Zakopoulos N.
        • Papamichael C.
        • Papaconstantinou H.
        • et al.
        Isolated clinic hypertension is not an innocent phenomenon. Effect on the carotid artery structure.
        Am. J. Hypertens. 1999; 12: 245-250
        • Grandi A.M.
        • Broggi R.
        • Colombo S.
        • et al.
        Left ventricular changes in isolated office hypertension.
        Arch. Intern. Med. 2001; 161: 2677-2681
        • Sega R.
        • Trocino G.
        • Lanzarotti A.
        • et al.
        Alterations of cardiac structure in patients with isolated office, ambulatory, or home hypertension. Data from the general population (Pressione Arteriose Monitorate E Loro Associazioni [PAMELA] Study).
        Circulation. 2001; 104: 1385-1392
        • Hermida R.C.
        • Calvo C.
        • Ayala D.E.
        • Fernandez J.R.
        • Ruilope L.M.
        • Lopez J.E.
        Evaluation of the extent and duration of the 'ABPM effect' in hypertensive patients.
        J. Am. Coll. Cardiol. 2002; 40: 710-717
        • Palatini P.
        • Dorigatti F.
        • Roman E.
        • et al.
        White-coat hypertension: a selection bias?.
        J. Hypertens. 1998; 16: 977-984
        • Stergiou G.S.
        • Alamara C.V.
        • Skeva I.I.
        • Mountokalakis T.D.
        Diagnostic value of strategy for the detection of white coat hypertension based on ambulatory and home blood pressure monitoring.
        J. Hum. Hypertens. 2004; 18: 85-89
        • Den Hond E.
        • Celis H.
        • Fagard R.
        • et al.
        Self-measured versus ambulatory blood pressure in the diagnosis of hypertension.
        J. Hypertens. 2003; 21: 717-722
        • Nesbitt S.D.
        • Amerena J.V.
        • Grant E.
        • et al.
        Home blood pressure as a predictor of future blood pressure stability in borderline hypertension. The Tecumseh study.
        Am. J. Hypertens. 1997; 10: 1270-1280
        • Verdecchia P.
        • Palatini P.
        • Schillaci G.
        • Mormino P.
        • Porcellati C.
        • Pessina A.C.
        Independent predictors of isolated clinic (‘white coat’) hypertension.
        J. Hypertens. 2001; 19: 1015-1020
        • Björklund K.
        • Lind L.
        • Vessby B.
        • Andrén B.
        • Lithell H.
        Different metabolic predictors of white-coat and sustained hypertension over a 20-year follow-up period.
        Circulation. 2002; 106: 63-68
        • Julius S.
        • Jamerson K.
        • Gudbrandsson T.
        • Schork N.
        White coat hypertension: a follow-up.
        Clin. Exp. Hypertens., Part A Theory Pract. 1992; 14: 45-53
        • Mancia G.
        White coat effect. Innocuous or adverse phenomenon?.
        Eur. Heart J. 2000; 21: 1647-1648
        • Segre C.A.
        • Ueno R.K.
        • Warde K.R.
        • et al.
        White-coat hypertension and normotension in the league of hypertension of the Hospital das Clínicas, FMUSP. Prevalence, clinical and demographic characteristics.
        Arq. Bras. Cardiol. 2003; 80: 122-126
        • Staessen J.A.
        • O'Brien E.T.
        • Atkins N.
        • Amery K.A.
        On behalf of the ‘Ad Hoc’ working group. Short report: ambulatory blood pressure in normotensive compared with hypertensive subjects.
        J. Hypertens. 1993; 11: 1289-1297
        • Cardillo C.
        • DeFelice F.
        • Campia U.
        • Folli G.
        Psychophysiological reactivity and cardiac end-organ changes in white coat hypertension.
        Hypertension. 1993; 21: 836-844
        • Kuwajima I.
        • Suzuki Y.
        • Fujusawa A.
        • Kuramoto K.
        Is white coat hypertension innocent?.
        Hypertension. 1993; 22: 826-831
        • Trenkwalder P.
        • Plaschke M.
        • Steffes-Tremer I.
        • Lydtin H.
        “White coat” hypertension and alerting reaction in elderly and very elderly hypertensive patients.
        Blood Press. 1993; 2: 262-271
        • Weber M.A.
        • Neutel J.M.
        • Smith D.H.G.
        • Graettinger W.F.
        Systemic arterial hypertension and vascular reactivity: diagnosis of mild hypertension by ambulatory blood pressure monitoring.
        Circulation. 1994; 90: 2291-2298
        • Cavallini M.C.
        • Roman M.J.
        • Pickering T.G.
        • Schwartz J.E.
        • Pini R.
        • Devereux R.B.
        Is white coat hypertension associated with arterial disease or left ventricular hypertrophy?.
        Hypertension. 1995; 26: 413-419
        • Pierdomenico S.D.
        • Lapenna D.
        • Guglielmi M.D.
        • et al.
        Target organ status and serum lipids in patients with white coat hypertension.
        Hypertension. 1995; 26: 801-807
        • Cerasola G.
        • Cottone S.
        • Nardi E.
        • et al.
        White-coat hypertension and cardiovascular risk.
        J. Cardiovasc. Risk. 1995; 2: 545-549
        • Soma J.
        • Wideroe T.E.
        • Dahl L.
        • Rossvoll O.
        • Skjaerpe T.
        Left ventricular systolic and diastolic function assessed with two-dimensional and Doppler echocardiography in 'white coat' hypertension.
        J. Am. Coll. Cardiol. 1996; 24: 101-105
        • Glen S.K.
        • Elliott H.L.
        • Curzio J.L.
        • Rees K.R.
        • Reid J.L.
        White-coat hypertension as a cause of cardiovascular dysfunction.
        Lancet. 1996; 348: 654-657
        • Rizzo V.
        • Ciccinetti P.
        • Bianchi A.
        • et al.
        White-coat hypertension and cardiac organ damage in elderly subjects.
        J. Hum. Hypertens. 1996; 10: 293-298
        • Ferrara L.A.
        • Guida L.
        • Pasanisi F.
        • et al.
        Isolated office hypertension and end-organ damage.
        J. Hypertens. 1997; 15: 979-985
        • Polonia J.J.
        • Santos A.R.
        • Gama G.M.
        • Basto F.
        • Bettencourt P.M.
        • Martins L.R.
        Follow-up clinic and ambulatory blood pressure in untreated white-coat hypertensive patients (evaluation after 2–5 years).
        Blood Press. Monit. 1997; 1997: 289-295
        • Palatini P.
        • Mormino P.
        • Santonastaso M.
        • et al.
        Target-organ damage in stage I hypertensive subjects with white coat and sustained hypertension: results from the HARVEST study.
        Hypertension. 1998; 31: 57-63
        • Owens P.E.
        • Lyons S.P.
        • Rodriguez S.A.
        • O'Brien E.T.
        Is elevation of clinic blood pressure in patients with white coat hypertension who have normal ambulatory pressure associated with target organ changes?.
        J. Hum. Hypertens. 1998; 12: 743-748
        • Muscholl M.W.
        • Hense H.-W.
        • Bröckel U.
        • Döring A.
        • Riegger G.A.J.
        • Schunkert H.
        Changes in left ventricular structure and function in patients with white coat hypertension: cross sectional survey.
        BMJ. 1998; 317: 565-570
        • Hoegholm A.
        • Kristensen K.S.
        • Bang L.E.
        • Nielsen J.W.
        White coat hypertension and target organ involvement: the impact of different cut-off levels on albuminuria and left ventricular mass and geometry.
        J. Hum. Hypertens. 1998; 12: 433-439
        • Manning G.
        • Rushton L.
        • Millar-Craig M.W.
        Clinical implications of white coat hypertension: an ambulatory blood pressure monitoring study.
        J. Hum. Hypertens. 1999; 12: 817-822
        • Pose-Reino A.
        • Rodriguez-Fernandez M.
        • Lopez-Barreiro L.
        • Coleman I.-C.
        • Estevez-Nunez J.C.
        • Mendez-Naya I.
        Diagnostic criteria of white-coat hypertension (WCH): consequences for the implications of WCH for target organs.
        Blood Press. 2002; 11: 144-150
        • Karter Y.
        • Curgunglu A.
        • Altinisik S.
        • et al.
        Target organ damage and changes in arterial compliance in white coat hypertension. Is white coat innocent?.
        Blood Press. 2003; 12: 307-313
        • Landray M.J.
        • Sagar G.
        • Murray S.
        • Beevers M.
        • Beevers D.G.
        • Lip G.Y.H.
        White coat hypertension and carotid atherosclerosis.
        Blood Press. 1999; 8: 134-140
        • Muldoon M.F.
        • Nazzaro P.
        • Sutton-Tyrrell K.
        • Manuck S.B.
        White-coat hypertension and carotid artery atherosclerosis. A matching study.
        Arch. Intern. Med. 2000; 160: 1507-1512
        • Pitiriga V.C.
        • Kotsis V.T.
        • Papamichail C.M.
        • et al.
        High prevalence of Chlamydia pneumoniae antibodies in white-coat hypertensives.
        Atherosclerosis. 2003; 167: 231-235
        • Kario K.
        • Matsuo T.
        • Kobayashi H.
        • Imaya M.
        • Matsuo M.
        • Shimada K.
        Nocturnal fall of blood pressure and silent cerebrovascular damage in elderly hypertensive patients: advanced silent cerebrovascular damage in extreme dippers.
        Hypertension. 1996; 27: 130-135
        • Fagard R.
        • Staessen J.A.
        • Thijs L.
        • et al.
        Response to antihypertensive therapy in older patients with sustained and nonsustained systolic hypertension.
        Circulation. 2000; 102: 1139-1144
        • Kario K.
        • Shimada K.
        • Schwartz J.E.
        • Matsuo T.
        • Hoshide S.
        • Pickering TG.
        Silent and clinically overt stroke in older japanese subjects with white-coat and sustained hypertension.
        J. Am. Coll. Cardiol. 2001; 38: 238-245
        • Pierdomenico S.D.
        • Cipollone F.
        • Lapenna D.
        • Bucci A.
        • Cuccurullo F.
        • Mezzetti A.
        Endothelial function in sustained and white coat hypertension.
        Am. J. Hypertens. 2002; 15: 946-952
        • Gómez-Cerezo J.
        • Ríos Blanco J.J.
        • Suárez García I.
        • et al.
        Noninvasive study of endothelial function in white coat hypertension.
        Hypertension. 2002; 40: 304-309
        • Pierdomenico S.D.
        • Bucci A.
        • Lapenna D.
        • et al.
        Circulating homocysteine levels in sustained and white coat hypertension.
        J. Hum. Hypertens. 2003; 17: 165-170
        • Redon J.
        • Campos C.
        • Narciso M.L.
        • Rodicio J.L.
        • Pascual J.M.
        • Ruilope M.
        Prognostic value of ambulatory blood pressure monitoring in refractory hypertension: a prospective study.
        Hypertension. 1998; 31: 712-718
        • Strandberg T.E.
        • Salomaa V.
        White coat effect, blood pressure and mortality in men: prospective cohort study.
        Eur. Heart J. 2000; 21: 1714-1718
        • Celis H.
        • Staessen J.A.
        • Thijs L.
        • et al.
        Cardiovascular risk in white-coat and sustained hypertensive patients.
        Blood Press. 2002; 11: 352-356
        • Gustavsen P.H.
        • Hoegholm A.
        • Bang L.E.
        • Kristensen K.S.
        White coat hypertension is a cardiovascular risk factor: a 10-year follow-up study.
        J. Hum. Hypertens. 2003; 17: 811-817
        • Eguchi K.
        • Kario K.
        • Shimada K.
        Greater impact of coexistence of hypertension and diabetes on silent cerebral infarcts.
        Stroke. 2003; 34: 2471-2474
        • Bobrie G.
        • Chatellier G.
        • Genès N
        • et al.
        Cardiovascular prognosis of "masked hypertension" detected by blood pressure self-measurement in elderly treated hypertensive patients.
        JAMA. 2004; 291: 1342-1349
        • Çoban E.
        • Timuragaoglu A.
        • Özdogan M.
        Research letter: Endothelial dysfunction in patients with white coat hypertension.
        J. Hum. Hypertens. 2004; 18: 71-72
        • Karter Y.
        • Ertürk N.T.
        • Aydín S.
        • et al.
        Letter to the Editor: Endothelial dysfunction in sustained and white coat hypertension.
        Am. J. Hypertens. 2003; 16: 892-893
        • Çoban E.
        • Özdogan M.
        • Akçit F.
        Levels of plasma fibrinogen and d-dimer in subjects with white-coat hypertension.
        J. Hum. Hypertens. 2004; 18: 291-292
        • Smith P.A.
        • Graham L.N.
        • Mackintosh A.F.
        • Stoker J.B.
        • Mary D.A.S.G.
        Sympathetic neural mechanisms in white-coat hypertension.
        J. Am. Coll. Cardiol. 2002; 40: 126-132
        • Smith P.A.
        • Graham L.N.
        • Mackintosh A.F.
        • Stoker J.B.
        • Mary D.A.S.G.
        Relation between central sympathetic activity and stages of human hypertension.
        Am. J. Hypertens. 2004; 17: 217-222
        • Fagard R.F.
        • Pardaens K.
        • Staessen J.A.
        Relationship of heart rate and heart rate variability with conventional and ambulatory blood pressure in the population.
        J. Hypertens. 2001; 19: 389-397
        • Uzun H.
        • Karter Y.
        • Aydín S.
        • et al.
        Oxidative stress in white coat hypertension; role of paraoxonase.
        J. Hum. Hypertens. 2004; ([advance online publication: 26 February 2004; doi:10.1038/sj.jhh.1001697])
        • Pierdomenico S.D.
        • Costantini F.
        • Bucci A.
        • DeCesare D.
        • Cuccurullo F.
        • Mezzetti A.
        Low-density lipoprotein oxidation and vitamins E and C in sustained and white-coat hypertension.
        Hypertension. 1998; 31: 621-626
        • Bidlingmeyer I.
        • Burnier M.
        • Bidlingmeyer M.
        • Waeber B.
        • Brunner H.R.
        Isolated office hypertension: a prehypertensive state?.
        J. Hypertens. 1996; 14: 327-332
        • Verdecchia P.
        • Schillaci G.
        • Borgioni C.
        • Ciucci A.
        • Sacchi N.
        • Reboldi G.
        Reassessment of definition and prognosis of white-coat hypertension.
        Circulation. 1996; 94: I340
        • Staessen J.A.
        • Byttebier G.
        • Buntinx F.
        • Celis H.
        • O'Brien E.T.
        • Fagard R.F.
        Antihypertensive treatment based on conventional or ambulatory blood pressure measurement. A randomised controlled trial.
        JAMA. 1997; 278: 1065-1072
        • Staessen J.A.
        • Den Hond E.
        • Celis H.
        • et al.
        Antihypertensive treatment based on blood pressure measurement at home or in the physician's office.
        JAMA. 2004; 291: 955-964
        • Tsai P.-S.
        Review: white coat hypertension: understanding the concept and examining the significance.
        J. Clin. Nurs. 2002; 11: 715-722
        • Parati G.
        • Mancia G.
        White coat effect: semantics, assessment and pathophysiological implications.
        J. Hypertens. 2003; 21: 481-486
        • Lantelme P.
        • Milon H.
        • Vernet M.
        • Gayet C.
        Difference between office and ambulatory blood pressure or real white coat effect: does it matter in terms of prognosis?.
        J. Hypertens. 2000; 18: 383-389
        • Stergiou G.S.
        • Efstathiou S.P.
        • Argyraki C.K.
        • Roussias L.G.
        • Mountokalakis T.D.
        White coat effect in treated versus untreated hypertensive individuals: a case control study using ambulatory and home blood pressure monitoring.
        Am. J. Hypertens. 2004; 17: 124-128
        • Den Hond E.
        • Celis H.
        • Vandenhoven G.
        • O'Brien E.
        • Staessen J.A.
        for the THOP investigators. Determinants of white-coat syndrome assessed by ambulatory blood pressure or self-measured home blood pressure.
        Blood Press. Monit. 2003; 8: 37-40
        • Munakata M.
        • Saito Y.
        • Nunokawa T.
        • Ito N.
        • Fukudo S.
        • Yoshinaga K.
        Clinical significance of blood pressure response triggered by a doctor's visit in patients with essential hypertension.
        Hypertens. Res. 2002; 25: 343-349
        • Mulè G.
        • Nardi E.
        • Cottone S.
        • et al.
        Relationship between ambulatory white coat effect and left ventricular mass in arterial hypertension.
        Am. J. Hypertens. 2003; 16: 498-501
        • Palatini P.
        • Penzo M.
        • Canali C.
        • Dorigatti F.
        • Pessina A.C.
        Interactive action of the white-coat effect and the blood pressure levels on cardiovascular complications in hypertension.
        Am. J. Med. 1997; 103: 208-216
        • Guida L.
        • Iannuzzi R.
        • Crivaro M.
        • et al.
        Clinic-daytime blood pressure difference and cardiovascular damage.
        J. Hypertens. 1999; 17: 331-337
        • Gosse P.
        • Promax H.
        • Durandet P.
        • Clementy J.
        White coat hypertension. No harm for the heart.
        Hypertension. 1993; 22: 766-770
        • Verdecchia P.
        • Schillaci G.
        • Borgioni C.
        • et al.
        White coat hypertension and white coat effect: similarities and differences.
        Am. J. Hypertens. 1995; 8: 790-798
        • Verdecchia P.
        • Schillaci G.
        • Borgioni C.
        • Ciucci A.
        • Porcellati C.
        Prognostic significance of the white coat effect.
        Hypertension. 1997; 29: 1218-1224
        • Parati G.
        • Ulian L.
        • Sampieri L.
        • et al.
        Attenuation of the 'white-coat effect' by antihypertensive treatment and regression of target organ damage.
        Hypertension. 2000; 35: 614-620