When to treat white coat hypertension?

From the Guidelines

White coat hypertension should only be treated with lifestyle modifications, and not with antihypertensive medication, unless there is evidence of target organ damage, cardiovascular risk factors, or consistently elevated readings outside the clinical setting, as the risk of cardiovascular disease and all-cause mortality is minimal to slightly increased 1. The initial management of white coat hypertension should focus on lifestyle modifications, including weight reduction, adopting the DASH diet, reducing sodium intake to <1500 mg/d, increasing physical activity to 90–150 min/week, and moderating alcohol intake to ≤2 drinks per day in men and ≤1 per day in women 1. Some key points to consider in the management of white coat hypertension include:

• Home blood pressure monitoring is essential, with readings taken twice daily for at least one week before appointments 1.
• If blood pressure remains elevated (≥135/85 mmHg) on home monitoring or if the patient has diabetes, chronic kidney disease, or cardiovascular disease, pharmacological treatment should be considered 1.
• First-line medications for white coat hypertension with elevated risk include ACE inhibitors, ARBs, calcium channel blockers, or thiazide diuretics 1.
• Regular follow-up every 3-6 months is recommended to assess treatment efficacy and adjust medications as needed 1. It is also important to note that the incidence of white coat hypertension converting to sustained hypertension is 1% to 5% per year, with a higher incidence of conversion in those with elevated BP, older age, obesity, or black race 1.

From the Research

Definition and Prevalence of White Coat Hypertension

• White coat hypertension is defined as the persistent elevation of blood pressure at the clinic or office only, with normal daily ambulatory blood pressure 2.
• The prevalence of white coat hypertension varies from 15% to 45% and is more frequent in women, older patients, and persons with mild hypertension 2, 3, 4.
• The condition is generated by fear and anxiety of whether an abnormal value could be found and indicate the existence of hypertension 3.

Treatment of White Coat Hypertension

• Initially, white coat hypertension was considered a benign condition and did not require treatment 2, 4.
• However, recent studies have shown that white coat hypertension is associated with hypertension-mediated organ damage and cardiovascular events, and treatment should be considered if lifestyle modifications do not work or in the presence of cardiovascular risk factors 3, 5.
• Pharmacologic treatment should be withheld for patients with white coat hypertension without cardiovascular risk factors, and instead, treatment should consist of lifestyle modification, moderate salt restriction, weight reduction, regular exercise, smoking cessation, and correction of glucose and lipid abnormalities 2.
• Patients with white coat hypertension and a high cardiovascular risk or proven target organ damage should be pharmacologically treated 4.

Diagnostic Criteria and Cardiovascular Risk

• The diagnostic criteria for white coat hypertension should consider the normality of all ambulatory periods, including daytime, night-time, and 24-h blood pressure 6.
• Patients with white coat hypertension defined by normal daytime, night-time, and 24-h blood pressure do not significantly differ from normotensive patients in terms of cardiovascular risk factors or organ damage 6.
• The prevalence of white coat hypertension is dependent on the definition criteria used, and only diagnostic criteria that consider the normality of all ambulatory periods identify patients with cardiovascular risk similar to normotensive patients 6.