Masked hypertension is defined as having elevated blood pressure based on ambulatory or home monitoring, despite normal clinic or office readings. It is common in patients with chronic kidney disease, diabetes, and cardiovascular risk factors. Ambulatory blood pressure monitoring is recommended to accurately diagnose masked hypertension, as treatment based solely on office readings may miss elevated out-of-office pressures. Masked hypertension is associated with increased target organ damage and cardiovascular risk.

1. HABIB
MPH

2.  Masked hypertension(MH) is an emerging clinical entity with
under-recognized prevalence and increased cardiovascular risk
 The frequency of MH is high in individuals with increased
cardiovascular risk factors and disease states, such as diabetes
and Chronic Kidney Diseases.
 It is needed to identify early and important in preventing
cardiovascular morbidity and mortality.
 Self-home monitoring of blood pressure and use of ambulatory
blood pressure monitoring as gold standard, for detection and
prognostic implications
BACKGROUND

3. The phenomenon of masked hypertension (MH) is defined
as a clinical condition in which a patient’s clinic blood
pressure (BP) level is <140/90 mm Hg but ambulatory or
home BP readings are in the hypertensive range.
WHAT IS MASKED HYPERTENSION (MH)?
THE Journal of Clinical Hypertension 956 VOL. 9 NO. 12 december 2007

4.  Young men
 Elderly patients with increased BP variability
 Patients with diabetes
 Patients with kidney disease
 Transiently elevated blood pressure
 Patients with unfavorable health-related lifestyle
(smoking, obesity, excess alcohol intake)
 High to normal clinic blood pressure level
 Patients at high cardiovascular risk
 Shortened sleep time
CATEGORIES OF PATIENTS IN WHOM MASKED
HYPERTENSION SHOULD BE SUSPECTED
THE Journal of Clinical Hypertension VOL. 9 NO. 12 December 2007

5. AMBULATORY AND HOME BLOOD
PRESSURE VALUES (MMHG)
J Hypertens 2013;31:1731–1768; Circulation 2007;115:2125–2152; Hypertension 2013;61:27–34.

6. PREVALENCE
About 1 in 7 or 8 persons with a
normal office BP level may have
masked hypertension.
THE Journal of Clinical Hypertension 956 VOL. 9 NO. 12 december 2007

7.  LVH is four times more frequent in the presence of MH.
 Nearly 60% of treated patients with CKD had masked uncontrolled
hypertension.
 The prevalence of masked uncontrolled hypertension is present in-
– 66% in patients with high-normal clinic systolic BP (SBP),
– 33% in normal clinic SBP, and
– 17% with optimal clinic SBP
 Thus, patients with CKD and pre-hypertension warrant ABPM screening
to identify masked uncontrolled hypertension.
IN CHRONIC KIDNEY DISEASE
J Am Soc Nephrol 2010;21:137–144; Clin J Am Soc Nephrol 2011;6:2003–2008.

8. PREVALENCE OF MASKED HYPERTENSION BY TREATMENT
STATUS IN DIABETICS AND NON-DIABETICS

9. WHY IS THE PREVALENCE OF MASKED UNCONTROLLED
HYPERTENSION HIGHER IN TREATED VS. UNTREATED
PERSONS?
 Patient non-compliance with medication.
 Treatment aimed at normalizing conventional office BP,
while ignoring out-of-office BP.
Hypertension 2013;61:964–971.

10. Brguljan-Hitij J, Thijs L, Li Y, et al;. Am J Hypertens. 2014;27:956–965.
Individuals with (MH) have been shown to have a greater-
than-normal prevalence of CV events

11. Brguljan-Hitij J, Thijs L, Li Y, et al;. Am J Hypertens. 2014;27:956–965.
Individuals with MH have been shown to have a greater-
than-normal prevalence of stroke events

12. Med Arch. 2016 Aug; 70(4): 274-279

13. Masked hypertension is common in patients with CKD and
associated with lower eGFR, proteinuria, and cardiovascular
target organ damage.
Clin J Am Soc Nephrol 11: ccc–ccc, April, 2016 Masked and Nocturnal Hypertension in CKD, Drawz et al.

14.  A meta-analysis concluded that neither office nor HBPM had
sufficient sensitivity nor specificity to replace ABPM as the
reference standard.
 Advantage of ABPM over HBPM is the ability to identify patients
with normal daytime but nocturnal masked hypertension.
 ABPM readings are taken during normal daily activity, whereas
HBPM readings are always taken at rest.
 Consequently, it has been recommended that masked
hypertension be confirmed by ABPM before commencing
antihypertensive therapy.
Diagnostic Strategies for Masked
Hypertension
BMJ 2011;342:286–294; J Hypertens 2011;29:1880–1888; Hypertension 2015;65:1258–1265

15. Screening

16.  Ensuring optimal’ antihypertensive treatment.
 Selecting long-acting antihypertensive medications.
 ABPM and/or HBPM.
 Out-of-office BP monitoring, has the best chance of
achieving sustained normotension without over treatment.
Role of physicians in the prevention and
management of masked hypertension
European Heart Journal (2016) 0, 1–7

17. Non-diabetic adults with CKD ND and urine albumin excretion of 30 to 300 mg per 24
hours.
Non-diabetic adults with CKD ND and urine albumin excretion >300 mg per 24 hours.
Adults with diabetes and CKD ND with urine albumin excretion of 30 to 300 mg per 24
hours.
Adults with diabetes and CKD ND with urine albumin excretion >300 mg per 24 hours.
Children with CKD ND in whom treatment with BP-lowering drugs is indicated,
irrespective of the level of proteinuria.
Elderly persons with CKD ND.
Recommendation of
ACE-Is and ARBs in CKD

18.  ACE-Is and ARBs are recommended for specific groups of CKD
patients, use of these agents associated with better kidney and
cardiovascular outcomes.
 In non-CKD patients, these drugs are indicated for the
treatment of heart failure and for use soon after myocardial
infarction, stroke, and in patients with high cardiovascular risk.
2012 KDIGO VOL 2 | ISSUE 5 | DECEMBER 2012

19.  The prevalence of masked hypertension in patients with treated and well-
controlled clinic BP is high.
 MH is more common in patients with CKD and associated with lower
eGFR, proteinuria, and cardiovascular target organ damage.
 Nocturnal BP is increasingly recognized as a strong predictor of risk in
many studies of ABPM.
 Clinic BP monitoring alone is not adequate to optimize BP control because
many patients have an elevated nocturnal BP.
 The US Preventive Services Task Force concluded that ABPM is the
diagnostic method of choice for detecting both outliers of white coat and
masked hypertension.
Med Arch. 2016 Aug; 70(4): 274-279; Clin J Am Soc Nephrol 11: ccc–ccc, April, 2016
TAKE HOME MESSAGES

20. TAKE HOME MESSAGES
Circulation. 2006;114:2850-2870.
• ACE inhibitors have the
best clinical evidence in
providing long-term
benefits for all types of
patients

21. 21
TAKE HOME MESSAGES
Antihypertensive