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Ambulatory not office blood pressure predicts mortality also in the elderly

Journal of Human Hypertension volume 33, pages 701–702 (2019)Cite this article

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Prevalence of hypertension increases with aging, even for those who had a normotensive middle age [1]. The elderly have become the fastest growing segment of the population in most if not all industrialized countries, with a prevalence hypertension approaching 90% at advanced life decades [2]. Therefore when we consider care of hypertension, we are facing increasing numbers of older patients. The well-known “white coat” phenomenon seems to be also more prominent in the elderly. Assuming that older individuals should have a greater experience with the medical environment, this is somewhat surprising, as repeated office measurements usually attenuate the “white coat” phenomenon, perhaps it has to do with negative life experience hence situational anxiety in the doctors’ offices [3, 4]. As the difference between office blood pressure (BP) and ambulatory BP monitoring (ABPM) values, which are loosely considered in this “white coat” phenomenon, is greater as office BP is higher, it is not clear if this is an age or BP effect. A recent publication from the huge Spanish ABPM registry [5] suggests that it is mostly BP rather than age effect. This “white coat” effect in the elderly had reached about 36 mmHg systolic BP in the Hypertension in the very elderly trial [6]. However such amazing differences appear repeatedly in the scarce ABPM studies devoted exclusively for elderly subjects, for example, 27 mmHg in the Syst-Eur trial [7], and 29 mmHg in Dublin Outcome Study [8]. Such differences could be one of the reasons why in observational studies relying on office BP in the very elderly BP does not predict mortality [2].

Another facet of the difference between office BP and ABPM is the reverse phenomenon dubbed masking effect, when the office and ABPM difference is negative, the opposite of the “white coat” phenomenon. As office BP is lower the likelihood of such negative difference is more likely [4, 5]. Because both the “white coat” and masking phenomena were found to have higher BP variability [9], it may not be surprising that those with office BP near normal are at increased risk of having their BP misclassified. When it comes to drug treated subjects the appropriate terms may be masked uncontrolled hypertension (MUCH), white coat uncontrolled hypertension (WUCH), and sustained uncontrolled hypertension (SUCH). Some controversies had arisen regarding the prognostic value of the “white coat” and to a lesser degree that of the masking phenomena [10]. With the recent publication of outcome in the Spanish ABPM registry [11], it had even increased, as it reported a risk of an adverse outcome almost identical for “white coat” hypertension and WUCH as that of untreated hypertension and SUCH, respectively.

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  1. Hypertension Unit, Department of Medicine, Hadassah-Hebrew University Medical Center, Mount-Scopus, P.O. Box 24035, 1924001, Jerusalem, Israel

    Michael Bursztyn

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Bursztyn, M. Ambulatory not office blood pressure predicts mortality also in the elderly. J Hum Hypertens 33, 701–702 (2019). https://doi.org/10.1038/s41371-019-0220-0

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