What is the management for a patient with normal blood pressures at home but elevated blood pressures in the office, also known as white coat hypertension?

From the Guidelines

For a patient with consistently normal blood pressure readings at home but elevated readings in the office, the most appropriate management approach is to first confirm the presence of white coat hypertension through ambulatory blood pressure monitoring (ABPM) or continued home blood pressure monitoring (HBPM), and if confirmed, emphasize lifestyle modifications rather than initiating or intensifying antihypertensive medications. This approach is supported by the 2020 international society of hypertension global hypertension practice guidelines 1, which suggest that patients with white coat hypertension are at intermediate cardiovascular risk and may not require drug treatment if their total cardiovascular risk is low and there is no hypertension-mediated organ damage.

Key Considerations

• The diagnosis of white coat hypertension needs confirmation with repeated office and out-of-office BP measurements 1.
• Lifestyle modifications should include maintaining a healthy weight, following a DASH diet low in sodium, regular physical activity, limiting alcohol consumption, and avoiding tobacco.
• Regular follow-up is essential, with home blood pressure monitoring continuing at least twice daily (morning and evening), with two readings each time, and bringing these records to appointments.
• The use of home blood pressure monitoring (HBPM) is recommended as a routine component of BP measurement in the majority of patients with known or suspected hypertension, as it overcomes many of the limitations of traditional office BP measurement and is both cheaper and easier to perform than ambulatory BP monitoring (ABPM) 1.

Monitoring and Follow-Up

• Home blood pressure monitoring should be performed with an oscillometric monitor that measures BP on the upper arm with an appropriate cuff size, and which has been shown to be accurate according to standard international protocols 1.
• Two to three readings should be taken while resting in the seated position, both in the morning and at night, over a period of 1 week, with a total of 12 readings or more recommended for making clinical decisions 1.
• Annual monitoring is important, as evidence suggests that patients with white coat hypertension may have a slightly increased cardiovascular risk compared to those with normal office and home readings 1.

From the Research

Management of White Coat Hypertension

The management of patients with normal blood pressures at home but elevated blood pressures in the office, also known as white coat hypertension, involves several strategies.

• Home blood pressure monitoring (HBPM) is a reliable and convenient method for diagnosing and managing hypertension, and is recommended by current guidelines 2, 3, 4.
• HBPM can help identify patients with white coat hypertension or masked hypertension, and can provide important diagnostic information beyond in-office blood pressure readings 3.
• Best practices for HBPM include using an appropriately fitting upper-arm cuff, avoiding caffeinated beverages, and taking multiple readings at different times of the day 3.
• The use of HBPM can help optimize reductions in blood pressure, improve blood pressure control, and reduce target organ damage and cardiovascular risk 2.
• Non-pharmacological interventions, such as lifestyle modifications, dietary changes, exercise, and stress reduction, can also be effective in managing hypertension and reducing blood pressure 5.
• In some cases, ambulatory blood pressure monitoring may be necessary to confirm the diagnosis of white coat hypertension or to identify patients with masked or sustained hypertension 6.

Diagnostic Considerations

• The diagnosis of white coat hypertension is typically made based on the results of HBPM or ambulatory blood pressure monitoring, which show elevated blood pressures in the office but normal blood pressures at home 3, 6.
• The use of HBPM can help identify patients with white coat hypertension, but may not always be sufficient to rule out masked or sustained hypertension 6.
• In some cases, additional testing, such as ambulatory blood pressure monitoring, may be necessary to confirm the diagnosis and guide treatment 6.

Treatment Approaches

• The treatment of white coat hypertension typically involves lifestyle modifications and non-pharmacological interventions, such as dietary changes, exercise, and stress reduction 5.
• In some cases, pharmacological therapy may be necessary to control blood pressure and reduce cardiovascular risk 2, 4.
• The use of HBPM can help guide treatment decisions and monitor the effectiveness of therapy 2, 3, 4.