Progression of White Coat Hypertension to Sustained Hypertension
After 10 Years

The long-term outcome of white coat hypertension (WCH) is still controversial despite the extensive information currently available.
To evaluate the cumulative incidence of sustained hypertension (SH) among patients with white coat hypertension compared to normotensive patients after 10 years of Two hundred and fifty patients of both genders were prospectively included in the study with the following office blood pressure (OBP) and 24-hour ambulatory blood Hypertension
The patients were divided into two groups: 129 patients with WCH and 121 normotensive patients, and were evaluated after 10 years of follow-up.
Glucose blood level, lipid profile and left ventricular mass index (LVMI) were Age, gender, smoking habits and glucose blood level were similar at baseline among normotensive patients and patients with white coat hypertension.
However, body mass index, total cholesterol levels, lipid levels and LVMI were significantly greater in white-coat hypertensive patients. Sustained hypertension was developed by 48 patients with WCH and 21 normotensive patients. We found an independent association between WCH and SH at 10 years of follow-up [OR: 2.5 Conclusion
Progression to sustained hypertension was greater in patients with white coat hypertension compared to normotensive patients.
REV ARGENT CARDIOL 2012;80:217-221.
Key words > White coat hypertension – Prognosis
Abbreviations > AHR Heart rate
OHR Office heart rate
WCH White coat hypertension
DT BP ABPM Daytime blood pressure on ABPM
HT Hypertension
BMI Body mass index
LVMI Left ventricular mass index
MTSAC Full Member of the Argentine Society of Cardiology † To apply as full member of the Argentine Society of Cardiology 1 Hospital Santojanni, Hypertension Unit, Autonomous City of Buenos Aires REVISTA ARGENTINA DE CARDIOLOGÍA / VOL 80 Nº 3 / MAY-JUNE 2012 White coat hypertension (WCH) is defined as were excluded from the study.
hypertension (HT) in the clinical setting with normal A smoker was defined as someone smoking at least one values of home blood pressure (BP) or normal 24- cigarette daily during the last month of the visit.
hour ambulatory blood pressure monitoring (ABPM) Patients underwent lipid profile determination and measurements. (1, 2) The prevalence of WCH varies ABPM one week after OBP was measured.
Ambulatory blood pressure was measured using the between 20% and 45% depending on the population oscillometric Spacelabs 90207 monitor programmed to studied, the value of office HT, gender and age.
take readings every 15 minutes during daytime and every One of the main causes of the real prevalence of 30 minutes during night-time, adjusted according to the WCH is threshold BP used to define HT in ABPM. sleeping habits of each patient.
(4) However, the cutoff value may underestimate or Statistical Analysis
In general, WCH is considered a benign condition Quantitative variables are presented as mean and standard in its outcome and treatment (5). One of the criteria deviation and qualitative variables as percentage. A t test was used to characterize this outcome is the greater linear used for the analysis and comparison of quantitative variables relationship of daytime ambulatory blood pressure with normal distribution, according to the the Kolmogorov– compared to office blood pressure (OBP) with respect Smirnov test and homoscedasticity. The non-parametric to target organ damage. However, this relationship Kruskall-Wallis test was used when the distribution was not normal. Qualitative variables were analyzed using the chi should not be the only influence of clinical WCH square test and a p value < 0.05 was considered statistically characterization. This concept has been supported significant. The percentage of patients with normotension by several studies demonstrating that the outcome of and with white coat hypertension at the beginning of the WCH is not as benign as it was thought. (6-8) study who developed SH after 10 years of follow-up was Despite ample bibliographic information on calculated.
the characterization of WCH, it is still unclear A stepwise multivariate analysis was performed to if its outcome and prognosis is similar to that of evaluate association among variables. The model used SH after 10 years of follow-up as the dependent variable and OBP, daytime BP on ABPM (DT BP ABPM), body The goal of the present study is to evaluate the mass index (BMI), smoking habits, hypercholesterolemia, cumulative incidence of sustained hypertension hyperglycemia, LVMI, heart rate (HR), and WCH at baseline (SH) among patients with white coat hypertension as independent variables. A p value < 0.05 was used to compared to normotensive patients after 10 years of determine a significant association. A logistic regression analysis was used to estimate the odds ratio for developing SH including the same variables described in the former model, adjusted for age, BMI and gender. We conducted a prospective longitudinal study with control Statistical analysis was performed using SPSS 17.0 group which was approved by the Ethics Committee of the statistical package for Windows (SPSS Inc., Chicago, III, USA). A two-tailed p value < 0.05 was considered statistically The patients were evaluated at baseline and after 10 significant.
years. Since de beginning of 1999, patients attending the outpatient clinic at the Hospital Santojanni were invited to participate in the study. The recruitment ended in 2000.
A total of 250 men and women between 45 to 55 years Characteristics of the population
were selected and divided into two groups: 129 with WCH Of the original 250 patients, 20 patients were lost and 121 with normotension. The diagnosis was based on to follow-up in 2010. Sustained hypertension was systolic office blood pressure (SOBP) and/or diastolic office developed by 48 patients with WCH and by 21 blood pressure measurements plus daytime systolic and/or normotensive patients during follow-up (Figure 1).
Age, gender, BP on ABPM, office heart rate (OHR), In 2010, 230 patients of the 250 original participants smoking habits and glucose blood levels were similar were examined again, as it was impossible to contact 9 in both normotensive and WCH patients at baseline patients with WCH and 11 with normal BP.
The following procedures were performed at the first examination (Table 1) and after 10 years evolution medical visit and after 10 years of follow-up: (Table 2). However, BMI was greater and triglycerides Blood pressure was measured on three different visits and total cholesterol levels were higher in patients using a Baum Manometer mercury sphygmomanometer, with WCH compared to those with normotension.
following the Argentine Council of Hypertension (9) and the In 2010, patients with SH presented mild American Heart Association guidelines. (10) to moderate HT, 28 of which were receiving Patients’ weight and height were recorded. A 12-lead antihypertensive agents (9 patients: enalapril electrocardiogram was taken to all the patients in order to 15 mg, 3 patients: enalapril 10 mg, 4 patients: exclude those with left ventricular hypertrophy, complete left hydrochlorothiazide 25 mg, 10 patients: enalapril 10 bundle branch block or arrhythmias. These anomalies were neither present during the second exam. At the first visit, mg + hydrochlorothiazide 25 mg, 2 patients enalapril the patients were not receiving any medication, including 20 mg). Treatment was discontinued seven days Patients with diabetes, metabolic syndrome, history of The average time between patient inclusion in the kidney or cardiovascular disease or any systemic condition study and the new diagnosis of SH was over five years PROGRESSION OF WHITE COAT HYPERTENSION TO SUSTAINED HYPERTENSION AFTER 10 YEARS / Olga B. Paez et col.
Table 2. Characteristics of population variables analyzed 10 years
WCH (n = 120) N (n = 110) P
Fig. 1. Progression to sustained hypertension in the population
studied. WCH: White coat hypertensive patients. N: Normoten- sion SF: Sustained hypertension. -: Minus. The graph represents the population according to the characteristics of office and ABPM blood pressure from the first medical visit to the 10-year . Characteristics of the population: basal variables analyzed Values are expressed as mean ± standard deviation. WCH: White coat WCH (n = 120) N (n = 110) P
hypertension. SH: Sustained hypertension N: Normotension. ns: Non significant. BMI: Body mass index. SOBP: Systolic office blood pressure. DOBP: Diastolic office blood pressure. LVMI: Left ventricular mass index. TC: Total cholesterol. HDL: High density lipoprotein. TG: Triglycerides. w/m: Women/men. OHR: Office heart rate. bpm: Beats per minute. ABPM: Ambulatory blood pressure monitoring. DT SBP ABPM: Daytime in all the 69 patients. The information was obtained There were no data on the physical examination Anamnesis detected the presence of type 2 diabetes (treated with metformin) in 3 patients with SH, 1 with WCH and 1 with normotension. None of the patients had cardiovascular events as myocardial infarction, heart failure or kidney disease during that period.
The analysis of association among variables identified SOBP [OR: 2.16 (95% CI 1.05-5.4)] and WCH [OR: 2.5 (95% CI 1.7-3.5)] as predictors of SH (Table 3). The other variables, including LVMI (B: 0.612; chi square: 1.8; p = 0.1) did not present a significant association with the development of SH (p DISCUSSION
WCH: White coat hypertension. N: Normotension. w/m: Women/men. There is no agreement about morbidity and mortality BMI: Body mass index. SOBP: Systolic office blood pressure. DOBP: Diastolic office blood pressure. ABPM: Ambulatory blood pressure In the different studies conducted on this monitoring. DT SBP ABPM: Daytime systolic blood pressure on ABPM. DT condition some authors found a greater risk of events DBP ABPM: Daytime diastolic blood pressure on ABPM. NT SPB ABPM: Night-time systolic blood pressure on ABPM. NT DPB ABPM: Night-time in this population; (11, 12); however, the predominant diastolic blood pressure on ABPM. OHR: Office heart rate. bpm: Beats concept is that the prognosis of WCH does not differ per minute. TC: Total cholesterol. HDL: High density lipoprotein. TG: from that of normotension. (13, 14) Based on our Triglycerides. LVMI: Left ventricular mass index. Values are expressed as mean ± standard deviation. Values were analysed using a t test or the previous results (8) and on those published by other Kruskal-Wallis test with a significance level < 0.05. ns: Non significant.
authors, (15) we assume that the clinical situation of REVISTA ARGENTINA DE CARDIOLOGÍA / VOL 80 Nº 3 / MAY-JUNE 2012 of HT, probably due to the small sample size.
Table 3. Determinants of sustained hypertension by logistic
regression analysis
In this study, WCH did not behave as a harmless condition, showing a cardiovascular risk that was Independent
Chi square
different from that of normotension. These results variables
suggest the need for a tight follow-up of these patients in order to achieve a strict control of risk factors and SOBP: Systolic office blood pressure. WCH: White coat hypertension B: Regression coefficient.
In patients with WCH, progression to SH was greater
compared with normotensive patients after 10 years WCH is intermediate between normotension and SH.
The results of the present study show that 40% (95% CI 31-48) of patients with WCH developed SH compared with 19% (95% CI 18.7-19.27) of those with RESUMEN
normotension after 10 years of follow-up.
Hipertensión de guardapolvo blanco: evolución a hiper-
In general, the factors determining the clinical tensión sostenida luego de 10 años de seguimiento
outcome of WCH are not completely known, generating Introducción
controversy. For example, daytime ambulatory blood No obstante la amplia información en la bibliografía sobre pressure is tightly related with target organ damage as la caracterización de la hipertensión de guardapolvo blanco left ventricular hypertrophy, heart failure and kidney (HGB), su evolución alejada es hasta el presente tema de failure. In patients with WCH, daytime ambulatory blood pressure is normal and not significantly greater Objetivo
Evaluar la incidencia acumulada de hipertensión sostenida The correlation between office blood pressure, (HS) en hipertensos de guardapolvo blanco respecto de normotensos a los 10 años de su inclusión en el estudio.
another determinant in the outcome of WCH, and target organ damage is lower than that of ambulatory Material y Métodos
blood pressure. However, a linear relationship Se incorporaron en forma prospectiva 250 pacientes de between OBP and cardiovascular events has been ambos sexos, según los siguientes valores de presión de consultorio (PC) y de monitoreo ambulatorio de la presión demonstrated, even in normotensive ranges. This arterial (MAPA) de 24 horas: finding agrees with the results of the present study, as SOBP was a predictor of the progression to SH in the HGB
HS Normotensión
≥140 y/o 90 ≥140 y/o 90 ≤140 y/o 90 In the present study, subjects with WCH had higher lipid values compared to normotensive patients since Se conformaron dos grupos: 129 hipertensos de guardapolvo this population is more predisposed to atherogenesis blanco y 121 normotensos, los cuales fueron evaluados and metabolic syndrome (16, 17). However, the nuevamente a los 10 años de seguimiento.
multivariate analysis showed that this was not a Se midieron la glucemia, el perfil lipídico y el índice de masa major determinant of greater risk to develop SH.
The characterization of WCH as “low risk” is Resultados
mainly due to the level of daytime BP established as Las variables edad, sexo, tabaquismo y glucemia de normal by ABPM. This means that the higher the normotensos e hipertensos de guardapolvo blanco fueron value of chosen normal daytime BP, the greater the Los hipertensos de guardapolvo blanco, por el contrario, likelihood of developing organ damage. On this issue, presentaron valores significativamente superiores en IMC, Staessen et al. (18) defined WCH when daytime BP on colesterol total, hipertrigliceridemia e IMVI. Cuarenta y ABPM was ≤ 146/91 mm Hg, and Pickering et al. (1) ocho hipertensos de guardapolvo blanco y 21 normotensos originales evolucionaron a HS. La HGB se asoció en forma independiente con HS a los 10 años de seguimiento [OR: 2,5 We considered normal BP when the value of (IC 95% 1,2-4,2)].
daytime BP on ABPM was ≤ 135/85 mm Hg so as not to overestimate target organ damage in patients with Conclusión
La evolución a hipertensión sostenida fue mayor en los WCH. In this way, we ensured that patients with SH hipertensos de guardapolvo blanco que en los normotensos.
Left ventricular mass index, a well-known predictor Palabras clave > Hipertensión de guardapolvo blanco -
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