What is the best next step in managing a patient with elevated blood pressure readings, suspected of having white coat hypertension?

From the Guidelines

The best next step for a patient with elevated blood pressure readings suspected of having white coat hypertension is to implement ambulatory blood pressure monitoring (ABPM) or home blood pressure monitoring (HBPM). This approach is supported by the 2020 international society of hypertension global hypertension practice guidelines 1, which emphasize the importance of using office and out-of-office blood pressure measurements to identify individuals with white coat hypertension.

Key Considerations

• The patient should be instructed to measure their blood pressure at home twice daily, once in the morning and once in the evening, for at least 7 days.
• Each session should include two readings taken 1-2 minutes apart, with the patient seated comfortably for 5 minutes before measurement, arm supported at heart level, and using a validated device with appropriate cuff size.
• For ABPM, the device is worn for 24 hours and takes measurements every 15-30 minutes during the day and every 30-60 minutes at night.
• These out-of-office measurements provide a more accurate assessment of the patient's true blood pressure status by eliminating the anxiety-induced elevation that occurs in clinical settings.

Rationale

• White coat hypertension affects 10-30% of patients with elevated office readings and should be distinguished from sustained hypertension before initiating lifelong medication therapy 1.
• The 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults also supports the use of ABPM or HBPM to diagnose white coat hypertension 1.
• If out-of-office readings confirm normal blood pressure (typically <135/85 mmHg for home monitoring), lifestyle modifications should be recommended rather than antihypertensive medications, with continued periodic monitoring to detect possible progression to sustained hypertension.

Management

• The patient's blood pressure readings outside of healthcare settings averaged 128/78 mm Hg, which suggests that they may have white coat hypertension.
• Performing ambulatory blood pressure monitoring (C) is the most appropriate next step in managing this patient, as it will provide a more accurate assessment of their blood pressure status and help to confirm the diagnosis of white coat hypertension.
• The other options, such as beginning chlorthalidone (A), obtaining renal artery imaging (B), or rechecking blood pressure in the office in 3 months (D), are not the most appropriate next steps in this scenario.

From the Research

Management of Suspected White Coat Hypertension

The patient's blood pressure readings show a significant difference between measurements taken in healthcare settings and those taken outside of these settings, suggesting possible white coat hypertension.

• The average blood pressure in healthcare settings is 150/90 mm Hg, while the average outside of these settings is 128/78 mm Hg.
• The physical examination blood pressure is 144/92 mm Hg, which is elevated.

Appropriate Management Steps

Given the discrepancy in blood pressure readings, the most appropriate next step would be to confirm whether the patient has white coat hypertension or true hypertension.

• Ambulatory Blood Pressure Monitoring (ABPM): This method provides a comprehensive picture of blood pressure patterns over 24 hours, including during sleep and daily activities 2, 3, 4.
• ABPM can help diagnose white coat hypertension, masked hypertension, and other blood pressure phenotypes, guiding appropriate treatment decisions 4, 5.
• It is also useful for assessing the effectiveness of antihypertensive therapy and for identifying patients with resistant or pseudo-resistant hypertension 3, 6.

Recommendation

Based on the evidence, the best next step in managing this patient would be to perform ambulatory blood pressure monitoring to accurately diagnose and manage the patient's condition 2, 3, 4.

• This approach will help determine if the patient has white coat hypertension or another form of hypertension, guiding the decision on whether to initiate or adjust antihypertensive treatment.
• The use of ABPM is supported by studies that demonstrate its effectiveness in diagnosing and managing hypertension, including its ability to identify white coat hypertension and masked hypertension 2, 3, 4, 5.