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Diagnosis and management of patients with white-coat and masked hypertension

Abstract

White-coat hypertension is characterized by an elevation in clinic blood pressure but normal home or ambulatory blood-pressure values, whereas patients with masked hypertension have normal clinic blood pressure and elevated ambulatory or home blood-pressure load. Both white-coat and masked hypertension are frequent clinical entities that need appropriate recognition and a close diagnostic follow-up. White-coat and masked hypertension seem to be associated with organ damage and increased cardiovascular risk, although not invariably. In addition, patients with masked or white-coat hypertension have an increased risk of abnormalities affecting their glucose and lipid profiles. Therefore, the diagnosis of these conditions should be accurate and include the assessment of cardiovascular as well as of metabolic risk. Once diagnosed, first-line therapeutic interventions should be nonpharmacological and aim at lifestyle changes, but drug treatment can be indicated, particularly when the patient's cardiovascular risk profile is elevated or when target-organ damage is detected.

Key Points

  • White-coat and masked hypertension are frequently seen in current clinical practice and are often characterized by the presence of subclinical organ damage and metabolic abnormalities

  • The pathophysiological mechanisms responsible for these conditions are still largely unknown, although a sympathetic activation is common in both these hypertensive states

  • White-coat and masked hypertension cannot be regarded as clinically benign; masked hypertension, in particular, is associated with increased cardiovascular risk and mortality

  • The cardiovascular risk profile of patients with white-coat or masked hypertension should be carefully monitored, and lifestyle interventions should be adopted early in the clinical course of disease

  • Antihypertensive drug treatment should be initiated, particularly in the case of elevated cardiovascular risk, target-organ damage, or both

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Figure 1: Quantifying the white-coat effect.
Figure 2: Kaplan–Meier curves depicting the survival of normotensive individuals, patients with white-coat hypertension, and patients with sustained hypertension.
Figure 3: Kaplan Meier curves depicting survival of normotensive subjects, patients with masked hypertension, and patients with sustained hypertension.
Figure 4: The diagnostic and therapeutic approaches suggested for patients white-coat and masked hypertension.

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M. Bombelli and G. Seravalle researched data for the article and provided a substantial contribution to the discussion of content. G. Mancia and G. Grassi wrote the article and reviewed and edited the manuscript before submission.

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Correspondence to Giuseppe Mancia.

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Mancia, G., Bombelli, M., Seravalle, G. et al. Diagnosis and management of patients with white-coat and masked hypertension. Nat Rev Cardiol 8, 686–693 (2011). https://doi.org/10.1038/nrcardio.2011.115

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