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VOL 54, NO 6 / JUNE 2005www. What is the best way to identifypatients with white-coat hypertension? BASEDANSWER monitoring for ruling out white-coat hypertensiondemonstrating reduced morbidity and mortalitywith hypertension treatment did not differentiateessential from white-coat hypertension. Patientswere included based on elevated office-basedblood pressure measurements. Since we nowknow that the prevalence of white-coat hyper-tension is high, it should be ruled out beforeimplementing antihypertensive therapy. Ambulatory blood pressure monitoring ismore accurate than home monitoring for rulingout white-coat hypertension. However, ease, simplicity, and availability makes home monitoringa more realistic option for routine clinical practice.When home blood pressure monitoring is used,reliable measurement devices (eg, newer automatic or manual home devices) should regarding proper use and documentation of blood pressure values to facilitate an appropriateclinical assessment.Joseph Saseen, PharmD, FCCP, BCPSUniversity of Colorado Health Sciences Center, DenverAmbulatory blood pressure monitoring is current-ly the gold standard for detecting patients withwhite-coat hypertension. Women and all patientswith lower office systolic blood pressures, stage I hypertension, and no target organ damage aremore likely to have white-coat hypertension(strength of recommendation [SOR]: prospective cohort studies) (TABLESelf or home blood pressure monitoring hasalso been used to detect patients with white-coathypertension. However, it has a low sensitivity, short-term prospective CLINICALCOMMENTARY isolated office hypertension, refers to ele-�office blood pressure of 140 mm Hg sys-�tolic or 90 mm Hg diastolic on at least 3sure of Hg diastolic on ambulatory blood pressuresure monitoring are mm Hg for night-time blood pressure.difference between patients with white-of whom have Stage I hypertension(140Ð159/90Ð99 mm Hg), anywhere from10% to 50% have white-coat hyper-Michael Fisher, MD, MPH, Jean Blackwell, MLSUniversity of North Carolina-Chapel Hill CLINICAL INQUIRIES CONTINUED brought to you by CORE View metadata, citation and similar papers at core.ac.uk provided by University of Missouri: MOspace Women, older VOL 54, NO 6 / JUNE 2005 THE JOURNAL OF FAMILY PRACTICE CLINICAL INQUIRIES FAST FAST FAST TABLE).In a joint multivariateenrolled 1564 subjects with uncomplicat-hypertension was associated with lowergender, and nonsmoking.Similarly, ajects found

that women, older subjects,and those with lower and fewer officewere more likely to have white-coat1333 Italian subjects, the prevalence ofwhite-coat hypertension was 33.3% inthose with stage I hypertension, 11%with stage II, and 3 % with stage III. TABLE ATTRIBUTESUBJECTSCOMPARISONVALUE Gender,% with WCH5716* 17% of females% female WCH v SH group156445% v 33%.002Ratio female: male with WCH2634(95% CI, 1.45Ð2.54), WCH vs SH156440 vs 39 years.52% with WCH in 4 age groups5716*, % with WCH5716*No=16.7%, Yes=11.3%Currently smoking % WCH v SH7% v 24% .04, % WCH in 3 groups5716*NSBMI, WCH group vs SH group156425.4 vs 25.9 NS23.9 vs 24.7.05, % with WCH5716*140Ð159=31.2% 171Ð180=11.8% 140Ð150=65% .004LV Mass(g), WCH v SH1564160 vs 180.001LV Mass Index (g/m2) WCH v SH414126 vs 136WCH, white coat hypertension; SBP, systolic blood pressure; SH, sustained hypertension; CI, confidence interval; BMI, body-mass index; NS, not significant; LV, left ventricular.*Patients referred to a blood pressure unit over 22-year period.  A combination of 2 studies of clinic patients with stage I hypertension (140Ð159/90Ð99 mm Hg).à 50-year-old men in a community in Finland invited to a health survey with a 20-year follow-up.¤ Data from 24 pooled studies of ambulatory blood pressure monitoring. Patient attributes and white-coat hypertension CONTINUED If home bloodpressure returnshypertension, two thirds willsustained VOL 54, NO 6 / JUNE 2005 THE JOURNAL OF FAMILY PRACTICE CLINICAL INQUIRIES FAST years in Finland compared those whothose with sustained hypertension. Thehypertensive patients had more microal-a greater body-mass index (all than patients with white-coat hyperten-groups, in contrast to other studies.recent study did not find body-massindex distinguished white-coat hyperten-sion from sustained hypertension.screening tool is a problem because of thelow sensitivity and poor PV+. In theTHOP study (247 subjects), which usedthe reference method, home blood pres-low PPV (33%).In other words, ifsion, there is a 97% chance the patienthas sustained hypertension, but if homeblood pressure returns to normal inpatients with office hypertension, twothirds of patients will still have sustainedenrolled patients from a hypertensionclinic, 133 untreated patients with dias-sensitivity of home blood pressure moni-toring in identifying white-coat hyperten-sion was 61% and the PV+ was 48%.Recommendations from othersThe European Society of HypertensionWorking Group on Blood Pressur

eMonitoring recommends that subjectswith blood pressure 140Ð159/90Ð99 mmHg at several visits should have ambula-33% of those people will have white-coathypertension. Women, nonsmokers,those with recent hypertension, a limitednumber of blood pressure determinationsand small left ventricular mass on echosure monitoring. There should be asearch for metabolic risk factors and tar-side the office should be considered forThe latest Joint National Committeereport (JNC VII) indicates that ambula-useful to detect white-coat hypertension1.OÕBrien E, Asmar R, Beilin L, et al, on behalf of theEuropean Society of Hypertension Working Group onBlood Pressure Monitoring. European Society ofHypertension recommendations for conventional,ambulatory and home blood pressure measurement. 2003; 21:821Ð848.2.Verdecchia P, Palatini P, Schillaci G, Mormino P,Porcellati C, Pessina AC Independent predictors of iso-lated clinic (Ôwhite-coatÕ) hypertension. 2001; 19:1015Ð1020.3.Rao S,Liu C-T, Wilder L. What is the best way to treatpatients with white-coat hypertension? J Fam Pract2004; 53:408Ð412.4.Staessen JA, OÕBrien ET, Atkins N, Anery AK, on behalfof the Ad-Hoc Working Group: Short report:Ambulatory blood pressure in normotensive com-pared with hypertensive subjects. 5.Verdecchia P, Schillaci G, Borgioni C, et al. White-coathypertension and white-coat effect: Similarities andAm J Hypertens1995; 8:790Ð798.6.Bjorklund K, Lind L, Vessby B, Andren B, Lithell H.Different metabolic predictors of white-coat and sus-tained hypertension over a 20-year follow-up period.2002; 106:63Ð68.7.Dolan E, Stanton A, Atkins N, et al. Determinants ofwhite-coat hypertension. Blood Pressure Monit8.Den Hond E, Celis H, Fagard R, et al. Self-measuredversus ambulatory blood pressure in the diagnosis ofhypertension. 2003; 21:717Ð722.9.Stergiou GS, Skeva II, Baibas NM, Kalkana CB,Roussias LG, Mountokalakis TD. Diagnosis of hyper-tension using home or ambulatory blood pressuremonitoring: comparison with the conventional strate-gy based on repeated clinic blood pressure measure-2000; 18:1745Ð1751.10.Verdecchia P, O'Brien E, Pickering T, et al. When canthe practicing physician suspect white coat hyperten-sion? Statement from the Working Group on BloodPressure Monitoring of the European Society ofAm J Hypertens2003; 16:87Ð91. 11.Chobanian AV, Bakris GL, Black HR, et al. SeventhReport of the Joint National Committee on Prevention,Detection, Evaluation, and Treatment of High Blood2003; 42:1206Ð125