Presentation of WCHT

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During our practice, frequently, we noticed some patients suuffering from high BP during BP measurement , and quite normal BP outside the office, condition , called whitecoat hypertension , in this topic, I discussed the definition, prevalence , mechanisms and therapeutic approach for whitecoat hypertension

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By WCHT Is it a True Phenomenon? Dr.Abdel Salam Sherif MD Cardiology

Classification of adult according to average level of systolic and diastolic PB:

Classification of adult according to average level of systolic and diastolic PB BP classification Systolic BP (mmHg) Diastolic BP( mmHg) Normal < 120 < 80 Prehypertension 120 - 139 or 80 - 89 Stage I 140 - 159 or 90 - 99 Stage II ≥ 160 ≥ 100

Prevalence of Hypertension:

Prevalence of Hypertension

Hypertension and Death Risk:

Hypertension and Death Risk

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WCHT Definition According to the ESH working group on BP monitoring, WCHT was defined as a condition characterized by :- 1) Office BP > 140/ 90 mmHg during 3 visits with at least 2 measurements ( < 140/ 90 mmHg) outside the physician's office. 2) A day time ambulatory BP < 130/ 85 mmHg. 3) Absence of target organ damage

Synonymous:

Synonymous 1. Labile hypertension 2. Prehypertension 3. Isolated office hypertension. 4. WC effect

Historical Hints:

Historical Hints 1897 , Riva – Rocci was the 1 st one who described the occurrence of a transient ↑ in BP at the time of BP measurement in the clinic environment. 1940 , Aymen and Goldshine observed that BP values measured at home were invariably < BP values recorded by physicians in their office. 1983 , Mancia et al, provided the quantitative assessment of the phenomenon through use of continuous intra-arterial ambulatory BP recording.

Characteristics of WCHT:

Characteristics of WCHT (1) Actually starts with the beginning of the visit even before the time of actual BP measurement. (2) Persists for approximately 10 – 15 minutes ( the duration of the visit). (3) It is accompanied by a parallel ↑ in HR. (4) Quantitatively relevant, there is maximal ↑in intra-arterial systolic and diastolic BP during the the 1 st 2 -4 min. of the visit( ~ +27/ + 14 mmHg). (5) It is characterized by a pronounced between – subject variability making the prediction of individual pressor response to the physician's visit impossible.

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Intra-arterial BP monitoring during the physician ´ visit

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Normal pattern of BP during ABPM

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WCE during the ABPM

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Pattern of normal BP and WCHT during ABPM

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Pattern of BP monitoring on ABPM

Clinically, the individuals with WCHT characterized by :-:

Clinically, the individuals with WCHT characterized by :- a) Higher BP, when screened at various times. b) Higher systemic vascular resistance. c) More likely to be obese or overwt. d) Higher BMI and LVMI. e) Higher rates of hypertensive retinopathy. f) Higher plasma TG, T. Cholest. and albuminuria.

Clinical significance:

Clinical significance WCHT may lead to 1- Overestimation of initial BP levels. and / or 2- Underestimation of the effect of antihypertensive agents. IN ELSA , showed a limited, but statistically significant –ve correlation between clinic – daytime BP difference and indices of carotid atherosclerosis. IN APTH trial, WCHT carry a significantly better prognosis for CV events than sustained HT. Other studies , showed that patients with WCHT, have a lower risk of LVH, but on other hand patients with WCHT have more a tendency to progress toward sustained HT( which explained by ↑ tonicity and responsiveness of the arterioles to angiotensin II and norepinephrine --> long-term structural changes in the vessels -->sustained HT) And have more pronounced target organ changes than normotensive patients

Pathophysiology:

Pathophysiology WCE depends on an alarm reaction associated with the physician's visit, not the result of BP measurement's techniques as evident by that the pressor reaction ; 1) Is observed even before performance of the arm cuff measurement. 2) Is more pronounced if BP is measured by a physician than by a nurse. 3) Is not triggered by automatic measurement.

Assessment of WCHT:

Assessment of WCHT The most common methods used to assess the WCHT include:- (1) The difference between office and average daytime ambulatory or home BP values obtained by automated measurements. (2) The comparison of clinic with home BP values.

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Therapeutic approach for Hypertension

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Non pharmacological approach for hypertension

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Non pharmacological approach for hypertension

Management of WCHT:

Management of WCHT SAMPLE study, showed a ↓ in clinic- daytime and clinic – home BP differences in treated hypertensive patients, that attenuation can be attributed to :- a) The habituation of the patients to the repeated BP measurement procedures. b) Antihypertensive treatment per se. But, this attenuation did not have any influence on the regression of target organ damage over one year. Thus, no evidence that patients with WCHT can benefit from antihypertensive treatment.

PowerPoint Presentation:

According to WHO/ ISH( 1999) and ESH/ ESCH ( 2003) guidelines, management of patients with WCHT can be approached as following: I. Patients with overall low CV risk, need; * careful follow up. * non pharmacological measures. II. Patients with high CV risk, need; * beside above measures. * Initiation of typical pharmacological treatment,

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Therapeutic algorithm

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While JNC VI and VII does not differentiate between patients with WCHT or patients with sustained HT, suggest that: All low and moderate CV risk patients --> non pharmacological measures should be initiated and medical treatment should be started if office BP remain elevated after 6- 12 months.

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