How to manage a patient who is normotensive in the office but hypertensive at home?

Managing Masked Hypertension: When Office BP is Normal but Home BP is Elevated

Patients who are normotensive in the office but hypertensive at home have masked hypertension and should be treated with antihypertensive medication to normalize out-of-office blood pressure, as they carry similar cardiovascular risk as patients with sustained hypertension. 1

Understanding Masked Hypertension

Masked hypertension is defined as having normal blood pressure (BP) in the office (<130/80 mmHg) but elevated BP outside the clinical setting (≥135/85 mmHg for home BP or daytime ambulatory BP). This condition:

• Affects approximately 10-15% of the general population 1
• Carries similar cardiovascular risk as sustained hypertension 1
• Requires confirmation with repeated office and out-of-office measurements 1

Diagnostic Algorithm

1. Confirm the diagnosis:

   • Verify proper technique for both office and home measurements
   • Ensure home BP monitoring is performed with a validated device
   • Obtain at least 12-14 home readings over 7 days (morning and evening) 1
   • Consider 24-hour ambulatory blood pressure monitoring (ABPM) for definitive diagnosis 1

2. Rule out causes of BP variability:

   • Medication non-adherence or timing issues
   • White coat normotension (artificially low readings in office)
   • Lifestyle factors affecting home readings (caffeine, stress, improper technique)

Treatment Approach

Once masked hypertension is confirmed:

• Initiate antihypertensive therapy targeting normalization of out-of-office BP 1
• First-line options include:
  • Thiazide or thiazide-like diuretics
  • ACE inhibitors or ARBs
  • Calcium channel blockers 2
• Target BP goal: <135/85 mmHg for home BP measurements 1
• Monitor response primarily using home BP measurements

Follow-up and Monitoring

• Home BP monitoring should be continued long-term to assess treatment efficacy
• Office BP should still be measured at regular intervals
• Consider periodic ABPM to comprehensively evaluate BP control, especially nocturnal patterns 3
• Evaluate for target organ damage (microalbuminuria, left ventricular hypertrophy) 4

Special Considerations

• Medication timing: Consider chronotherapy (evening dosing) if nocturnal hypertension is present 5
• Combination therapy: May be needed to achieve adequate control of out-of-office BP
• Risk assessment: Evaluate overall cardiovascular risk to guide treatment intensity

Common Pitfalls to Avoid

1. Ignoring home BP readings when office readings are normal
2. Inadequate home BP monitoring technique - ensure proper patient education
3. Insufficient number of home readings - single readings are unreliable
4. Failing to confirm the diagnosis before initiating treatment
5. Not addressing lifestyle modifications alongside pharmacological treatment

Masked hypertension represents a significant diagnostic challenge but carries substantial cardiovascular risk. The 2020 International Society of Hypertension guidelines clearly state that these patients require drug treatment aiming to normalize out-of-office BP 1. Regular monitoring with both office and home measurements is essential for optimal management of this condition.