Does white coat hypertension lead to long-term hypertension?

From the Guidelines

White coat hypertension can lead to long-term hypertension, with an incidence of conversion to sustained hypertension ranging from 1% to 5% per year, as reported in the 2017 ACC/AHA guideline 1. The risk of progression to sustained hypertension is higher in individuals with elevated blood pressure, older age, obesity, or black race. According to the guideline, ambulatory blood pressure monitoring (ABPM) and home blood pressure monitoring (HBPM) are better predictors of cardiovascular disease (CVD) risk due to elevated blood pressure than office blood pressure measurements. The overlap between HBPM and ABPM in diagnosing white coat hypertension is only 60% to 70%, with ABPM being the preferred measurement option 1. Some key points to consider in managing white coat hypertension include:

• Monitoring blood pressure regularly at home using a validated device
• Maintaining a healthy lifestyle with regular exercise and a low-sodium diet
• Limiting alcohol consumption and avoiding smoking
• Having regular follow-up appointments with a healthcare provider
• Considering periodic monitoring with ABPM or HBPM to detect transition to sustained hypertension, as recommended in the KDOQI US commentary on the 2017 ACC/AHA hypertension guideline 1. It is essential to note that while medication is not typically prescribed initially for white coat hypertension alone, these preventive measures are crucial to potentially delay or prevent progression to sustained hypertension. The mechanism behind the progression from white coat hypertension to sustained hypertension likely involves underlying vascular and autonomic nervous system abnormalities that initially manifest only during stress but eventually become persistent 1. Overall, individuals with white coat hypertension should not dismiss their elevated readings and should work with their healthcare provider to implement a plan to monitor and manage their blood pressure.

From the Research

White Coat Hypertension and Long-Term Hypertension

• White coat hypertension (WCH) is defined as elevated blood pressure in a medical setting, but normal blood pressure in daily life 2.
• The prevalence of WCH varies from 15% to over 50% of all patients with mildly elevated office blood pressure values 2.
• Studies have shown that WCH is associated with a worse or equal cardiovascular prognosis than normotensives, but a better one than those with sustained hypertension 2, 3.

Risk of Developing Long-Term Hypertension

• WCH is sometimes considered a prehypertensive state, but data on the long-term evolution of subjects with WCH are scarce 2.
• A study found that WCH without organ damage is accompanied by a noticeable increase in long-term risk of mortality, new hypertension, and new organ damage 3.
• Another study found that WCH is associated with cardiovascular risk factors, including the development of sustained hypertension and the presence of target organ damage 4.

Treatment and Management

• There is insufficient evidence from randomized controlled trials to determine whether WCH warrants treatment 4.
• A study found that antihypertensive treatment can effectively and durably reduce office blood pressure in WCH, but is accompanied by the inability to lower ambulatory blood pressure from normal values 5.
• Patients with WCH and a high cardiovascular risk or proven target organ damage should be pharmacologically treated, while subjects with uncomplicated WCH should probably not receive medical therapy, but a close follow-up is warranted 2.

Key Findings

• WCH is associated with an increased risk of developing long-term hypertension and cardiovascular disease 3, 6.
• The treatment and management of WCH is still a topic of debate, with some studies suggesting that antihypertensive treatment may be beneficial in reducing cardiovascular risk 5.
• Further research is needed to fully understand the implications of WCH and to determine the best course of treatment and management 4.