How is masked hypertension managed?

Management of Masked Hypertension

Masked hypertension should be treated with antihypertensive medications and lifestyle modifications similar to sustained hypertension, given its equivalent cardiovascular risk profile including doubled mortality compared to normotensive individuals. 1

Diagnostic Confirmation

Before initiating treatment, confirm the diagnosis using out-of-office blood pressure measurements:

• Screen with home blood pressure monitoring (HBPM) in patients with normal office BP (<140/90 mmHg) who have target organ damage, increased cardiovascular risk, or office readings consistently 120-129/75-79 mmHg 1
• Consider ambulatory blood pressure monitoring (ABPM) for confirmation before treatment intensification, as ABPM provides stronger cardiovascular risk prediction than HBPM (only 60-70% overlap between methods) 1
• Masked hypertension is defined as normal office BP with elevated out-of-office readings (HBPM ≥135/85 mmHg or daytime ABPM ≥135/85 mmHg) 1

Treatment Approach

Pharmacologic Management

Initiate antihypertensive drug therapy using the same agents and targets as for sustained hypertension 1:

• First-line agents include thiazide diuretics, ACE inhibitors, angiotensin receptor blockers, calcium channel blockers, or beta-blockers 1
• Consider two-drug combination therapy at initiation for patients with markedly elevated out-of-office BP or high cardiovascular risk 1
• Fixed-dose combinations in a single tablet improve adherence and are recommended 1

Lifestyle Modifications

Implement comprehensive lifestyle changes alongside pharmacotherapy 1:

• Weight reduction if overweight/obese
• Dietary modifications (reduced sodium, DASH diet)
• Regular physical activity
• Smoking cessation
• Limited alcohol intake

Monitoring Strategy

Assess treatment efficacy using out-of-office BP measurements, not office readings 1:

• Use HBPM or ABPM to monitor response to therapy, as office BP will remain normal by definition 1
• Screen for masked uncontrolled hypertension in treated patients with controlled office BP but persistent target organ damage or high cardiovascular risk 1

Risk Assessment Considerations

Recognize the clinical significance of masked hypertension 1:

• Cardiovascular disease and all-cause mortality risk is similar to sustained hypertension and approximately twice that of normotensive individuals 1
• Prevalence ranges from 10-30% in normotensive clinic populations 1
• Associated with increased target organ damage including left ventricular hypertrophy, increased carotid intima-media thickness, and microalbuminuria 1
• In CKD populations, prevalence reaches 28-43%, making screening particularly important in this group 1

Common Pitfalls to Avoid

• Do not rely solely on office BP measurements for diagnosis or treatment monitoring in patients with suspected masked hypertension 1
• Do not withhold treatment based on normal office readings when out-of-office measurements confirm hypertension, as cardiovascular risk equals sustained hypertension 1
• Do not assume HBPM alone is sufficient for high-risk patients; ABPM provides superior cardiovascular risk stratification when feasible 1
• Be aware that masked hypertension may indicate medication non-adherence in treated patients 1

Special Populations

In patients with chronic kidney disease, masked hypertension is particularly common (28-43% prevalence) and should prompt aggressive screening with out-of-office BP monitoring 1. African American populations show associations between poor cardiovascular health metrics and higher masked hypertension prevalence 2.