What are the key recommendations for a seminar on masked hypertension?

Masked Hypertension: Key Educational Content for Seminar

Definition and Clinical Significance

Masked hypertension is defined as normal office blood pressure (<130/80 mm Hg by ACC/AHA criteria or <140/90 mm Hg by ESC/ESH criteria) but elevated out-of-office blood pressure (home BP ≥130/80 mm Hg or daytime ambulatory BP ≥135/85 mm Hg), and carries cardiovascular risk equivalent to sustained hypertension. 1

• This condition affects approximately 10-19% of adults in the general population, with higher prevalence (28-32%) when expressed as a proportion of patients with normal office BP 2, 3
• Masked hypertension is associated with a 2-fold increased risk of fatal and non-fatal cardiovascular events (RR 2.09), comparable to sustained hypertension (RR 2.26) 3
• The condition frequently goes undetected because routine office measurements appear normal, yet patients experience the same target organ damage as sustained hypertensives 2, 4

Epidemiology and Risk Factors

Screen for masked hypertension in patients with office BP 120-129/75-79 mm Hg, particularly those with additional risk factors. 1

High-Risk Populations to Screen:

• Younger age and male sex (66.9% of masked hypertension patients are men) 5, 2, 4
• Current smokers (18% higher prevalence than normotensives) 2, 6
• Alcohol consumption and physical activity/exercise-induced hypertension 1, 6
• Obesity, diabetes mellitus, and chronic kidney disease 1, 6
• Job stress, anxiety, and increased reactivity to daily stressors 1, 6
• Family history of hypertension 1
• Patients with target organ damage or increased overall CVD risk despite normal office readings 1

Diagnostic Approach

Confirm masked hypertension using home blood pressure monitoring (HBPM) or ambulatory blood pressure monitoring (ABPM), with ABPM preferred for definitive diagnosis. 1

Blood Pressure Thresholds for Diagnosis:

Measurement Type	Threshold for Masked HTN
Office BP	<130/80 mm Hg (ACC/AHA) or <140/90 mm Hg (ESC/ESH)
Home BP	≥130/80 mm Hg or ≥135/85 mm Hg
Daytime ABPM	≥135/85 mm Hg
Nighttime ABPM	≥120/70 mm Hg
24-hour ABPM	≥130/80 mm Hg

1

Measurement Protocols:

For Home BP Monitoring: 1, 7

• Use validated electronic upper-arm cuff devices (verify at www.stridebp.org)
• Quiet room, comfortable temperature, empty bladder
• No smoking, coffee, or exercise for 30 minutes prior
• Rest quietly for 3-5 minutes before measurement
• Take 3 measurements at 1-minute intervals
• Record measurements twice daily (morning and evening) for at least 1 week
• Use average of last 2 measurements

For ABPM: 1

• ABPM provides superior sensitivity (22% detection rate vs 16% for HBPM when both applied to same cohort) 3
• Captures nighttime BP, which is critical for complete risk assessment
• Recommended when HBPM suggests masked hypertension but confirmation needed before treatment intensification 1

Diagnostic Agreement:

• The diagnostic agreement between ABPM and HBPM is only modest (kappa = 0.46), despite 83% percentage agreement 3
• Both ABPM and HBPM should be considered in high-risk patients to maximize detection 3

Target Organ Damage Assessment

Patients with masked hypertension demonstrate similar target organ damage to sustained hypertensives. 2, 6

• Left ventricular mass index is significantly elevated (110 g/m² in masked hypertension vs 98 g/m² in normotensives, similar to 109 g/m² in sustained hypertensives) 2
• Increased pulse wave velocity (9.3 m/s vs 8.3 m/s in normotensives) 5
• Higher coronary artery calcium scores (OR 1.65 for CACS ≥100) 5
• Increased carotid intima-media thickness and impaired large artery distensibility 6

Management Recommendations

Treat masked hypertension with antihypertensive medications targeting out-of-office BP normalization, as cardiovascular risk equals sustained hypertension. 1, 3

Treatment Approach:

• Initiate pharmacologic therapy from first-line drug classes: thiazide diuretics, calcium channel blockers, ACE inhibitors, or ARBs 1
• Treatment goal: normalize out-of-office BP to <130/80 mm Hg (home/daytime ABPM <135/85 mm Hg) 1
• The cardiovascular risk profile justifies treatment despite normal office readings 1

Lifestyle Modifications:

• Implement comprehensive lifestyle interventions including weight loss, DASH diet, sodium restriction, increased physical activity, smoking cessation, and alcohol moderation 1
• These modifications are essential even before pharmacologic therapy 1

Monitoring Strategy:

• Confirm diagnosis with repeated office and out-of-office measurements within 3-6 months 1, 7
• Continue regular HBPM for treatment titration 1, 7
• Reassess with ABPM if HBPM readings remain elevated despite treatment 1
• Follow-up within 3-6 months to assess treatment response 7

Special Populations

Masked Uncontrolled Hypertension (MUCH):

• Occurs in 13% of treated hypertensive patients (43% of those with normal office BP on treatment) 3
• Screen for MUCH in treated patients with office BP at goal but with target organ damage or increased CVD risk 1
• Confirmation by ABPM may be reasonable before intensifying therapy 1

Children and Adolescents:

• Prevalence approximately 7% in pediatric populations 2
• May represent a precursor to sustained hypertension in adulthood 4

Common Pitfalls to Avoid

The most critical error is dismissing patients with occasional high BP readings who appear normotensive in the office. 4

• Do not rely solely on office BP measurements in high-risk patients 1
• Avoid assuming normal office BP equals low cardiovascular risk without out-of-office confirmation 3
• Do not delay screening in patients with office BP in the 120-129/75-79 mm Hg range, especially with risk factors 1
• Ensure proper home BP measurement technique, as poor technique is a primary reason for false-positive masked hypertension diagnosis 1
• Do not use non-validated BP devices for diagnosis 1, 7

Prognosis and Long-Term Implications

• Approximately 30-40% of patients with masked hypertension progress to sustained hypertension within 5-10 years 8
• The condition represents intermediate cardiovascular risk between normotension and sustained hypertension when untreated 1, 8
• Early detection and treatment can potentially prevent progression and reduce cardiovascular events 1, 3