A 40 years old gentleman presented in outpatient department for routine check-up. Now his BP-150/95 mm Hg but patient informed that his home BP readings are always normal. How will you manage this case?

1. A 40 years old gentleman presented in outpatient
department for routine check-up. Now his BP-150/95
mm Hg but patient informed that his home BP
readings are always normal. How will you manage this
case?
Cardiology Round
Professor Dr Md Toufiqur Rahman
MBBS, FCPS, MD
Professor and Head of Cardiology, CMMC, Manikganj
drtoufiq1971@gmail.com
White Coat hypertension and Masked Hypertension

2. White-coat hypertension
untreated condition in which
BP is elevated in the office, but
is normal when measured by ABPM, HBPM, or
both.
Cardiology Round
‘masked hypertension’
 untreated patients in whom
 the BP is normal in the office,
 but is elevated when measured by HBPM or ABPM.

3. White-coat hypertension
‘True Normotension’
• is used when both office and out-of-office BP measurements
are normal,
‘Sustained Hypertension’
when both are abnormal.
White-coat effect’,
In white-coat hypertension, the difference between the higher
office and the lower out-of-office BP
• mainly reflect the pressor response to an alerting reaction
elicited by office BP measurements by a doctor or a nurse,
• although other factors are probably also involved.
Cardiology Round

4. Masked Uncontrolled Hypertension (MUCH)
(office BP controlled but home or ambulatory BP
elevated)
White-coat Uncontrolled Hypertension
(WUCH) (office BP elevated but home or
ambulatory BP controlled),
 Sustained Uncontrolled Hypertension
(SUCH)
(both office and home or ambulatory BP are
uncontrolled).
Cardiology Round
White-coat hypertension

5. The white-coat effect
The difference between an elevated office BP
(treated or untreated) and a lower home or
ambulatory BP in both untreated and treated
patients.
Cardiology Round

6.  up to 30 - 40% of people (and >50% in the very old) with
an elevated office BP.
 more common with increasing age, in women, and in
non-smokers.
 prevalence is lower in patients with HMOD, when office
BP is based on repeated measurements, or when a doctor
is not involved in the BP measurement.
A significant white-coat effect can be seen at all grades of
hypertension(including resistant hypertension),
but the prevalence of white-coat hypertension is greatest
in grade 1 hypertension.
Cardiology Round
White-coat hypertension

7. • HMOD is less prevalent in white-coat hypertension than
in sustained hypertension,
• the risk of cardiovascular events is also lower than that
in sustained hypertension.
• Compared with true normotensives, patients with
white-coat hypertension have
increased adrenergic activity,
a greater prevalence of metabolic riskfactors,
 more frequent asymptomatic cardiac and vascular
damage,
a greater long-term risk of new-onset diabetes
Progression to sustained hypertension and LVH.
Cardiology Round
White-coat hypertension

8. • although the out of- office BP values are, by definition,
normal in white-coat hypertension, they tend to be higher
than those of true normotensive people, which may explain
the increased long-term risk of CV events.
• White coat hypertension has also been shown to have a
greater CV risk in isolated systolic hypertension and older
patients, and does not appear to be clinically innocent.
• The diagnosis should be confirmed by repeated office and
out-of-office BP measurements, and should include an
extensive assessment of risk factors and HMOD.
• Both, ABPM and HBPM are recommended to confirm white-
coat hypertension, because the CV risk appears to be lower
(and close to sustained, normotension) in those in whom
both ABPM and HBPM are both normal;
Cardiology Round
White-coat hypertension

9. can be found in approximately 15% of patients with a normal office BP.
The prevalence is greater in younger people, men, smokers, and those with
higher levels of physical activity, alcohol consumption, anxiety, and job stress.
Obesity, diabetes, CKD, family history of hypertension, and high–normal office
BP are also associated with an increased prevalence of masked hypertension.
• Masked hypertension is associated with dyslipidaemia and dysglycaemia,
HMOD, adrenergic activation, and increased risk of developing diabetes and
sustained hypertension.
• the risk of CV events is substantially greater in masked hypertension
compared with normotension, and close to or greater than that of sustained
hypertension.
• Masked hypertension has also been found to increase the risk of CV and renal
events in diabetes, especially when the BP elevation occurs during the night.
Cardiology Round
Masked hypertension

10. Checklist for Accurate Measurement of BP
Key Steps for Proper BP Measurements
Step 1: Properly prepare the patient.
Step 2: Use proper technique for BP measurements.
Step 3: Take the proper measurements needed for diagnosis and treatment of elevated
BP/hypertension.
Step 4: Properly document accurate BP readings.
Step 5: Average the readings.
Step 6: Provide BP readings to patient.
Cardiology Round

11. Selection Criteria for BP Cuff Size for Measurement of BP in Adults
Arm Circumference Usual Cuff Size
22–26 cm Small adult
27–34 cm Adult
35–44 cm Large adult
45–52 cm Adult thigh
Cardiology Round

12. Out-of-Office and Self-Monitoring of BP
COR LOE Recommendation for Out-of-Office and Self-Monitoring of BP
I ASR
Out-of-office BP measurements are
recommended to confirm the diagnosis
of hypertension and for titration of BP-
lowering medication, in conjunction
with telehealth counseling or clinical
interventions.
SR indicates systematic review.
Cardiology Round

13. BP Patterns Based on Office and Out-of-Office Measurements
ABPM indicates ambulatory blood pressure monitoring; and BP, blood pressure.
Office/Clinic/Healthcare Setting
Home/Nonhealthcare/ABPM
Setting
Normotensive No hypertension No hypertension
Sustained
hypertension
Hypertension Hypertension
Masked
hypertension
No hypertension Hypertension
White coat
hypertension
Hypertension No hypertension
Cardiology Round

14. Detection of White Coat Hypertension or Masked Hypertension in Patients
Not on Drug Therapy
Daytime ABPM
or HBPM
BP <130/80 mm Hg
Yes
White Coat Hypertension
 Lifestyle modification
 Annual ABPM or HBPM
to detect progression
(Class IIa)
No No
Daytime ABPM
or HBPM
BP ≥130/80 mm Hg
Yes
Office BP: ≥130/80 mm Hg but <160/100 mm Hg
after 3 mo trial of lifestyle modification and
suspected white coat hypertension
Office BP: 120–129/<80 mm Hg
after 3 mo trial of lifestyle modification and
suspected masked hypertension
Hypertension
Continue lifestyle modification
and start antihypertensive drug
therapy
(Class IIa)
Elevated BP
 Lifestyle modification
 Annual ABPM or ABPM
to detect masked
hypertension or progression
(Class IIa)
Masked Hypertension
Continue lifestyle modification
and start antihypertensive drug
therapy
(Class IIa)
Cardiology Round

15. Detection of White Coat Effect or Masked Uncontrolled Hypertension in Patients on Drug Therapy
Office BP
≥5–10 mm Hg
above goal on
≥3 agents
Continue titrating
therapy
Yes
Screening
not necessary
(No Benefit)
Screen for
white coat effect with
HBPM
(Class IIb)
White coat effect:
Confirm with ABPM
(Class IIa)
No
Yes
HBPM BP
at goal
No
Increased
CVD risk or
target organ
damage
Continue current
therapy
Yes
Screening
not necessary
(No Benefit)
Screen for
masked uncontrolled
hypertension with HBPM
(Class IIb)
Masked uncontrolled
hypertension:
Intensify therapy
(Class IIb)
No
Yes
HBPM BP
above goal
No
Yes No
Detection of white coat effect or masked uncontrolled
hypertension in patients on drug therapy
Office BP
at goal
ABPM BP
above goal
Cardiology Round

16. Masked and White Coat Hypertension
COR LOE Recommendations for Masked and White Coat Hypertension
IIa B-NR
In adults with an untreated SBP greater than 130 mm Hg but
less than 160 mm Hg or DBP greater than 80 mm Hg but less
than 100 mm Hg, it is reasonable to screen for the presence
of white coat hypertension by using either daytime ABPM or
HBPM before diagnosis of hypertension.
IIa C-LD
In adults with white coat hypertension, periodic monitoring
with either ABPM or HBPM is reasonable to detect transition
to sustained hypertension.
IIa C-LD
In adults being treated for hypertension with office BP
readings not at goal and HBPM readings suggestive of a
significant white coat effect, confirmation by ABPM can be
useful.
Cardiology Round

17. Masked and White Coat Hypertension (cont.)
COR LOE Recommendations for Masked and White Coat Hypertension
IIa B-NR
In adults with untreated office BPs that are consistently between 120
mm Hg and 129 mm Hg for SBP or between 75 mm Hg and 79 mm Hg
for DBP, screening for masked hypertension with HBPM (or ABPM) is
reasonable.
IIb C-LD
In adults on multiple-drug therapies for hypertension and office BPs
within 10 mm Hg above goal, it may be reasonable to screen for white
coat effect with HBPM (or ABPM).
IIb C-EO
It may be reasonable to screen for masked uncontrolled hypertension
with HBPM in adults being treated for hypertension and office readings
at goal, in the presence of target organ damage or increased overall
CVD risk.
IIb C-EO
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.
Cardiology Round

18. Cardiology Round