White Coat Hypertension

White Coat Hypertension: No longer a benign condition

White-coat hypertension (WCH) is defined as elevated blood pressure of an individual in a clinical environment, while having normal blood pressure readings at home. This effect is mainly due to patients’ alerting psychological reaction to the “formal” environment with potential threat stimulus, causing a transient increase in blood pressure, whereas their readings are usually normal at home, measured by ambulatory blood pressure monitoring (ABPM). The prevalence of the white coat effect is about 15%-30% of patients with office hypertension. It was previously being labeled as “benign”, as the pressure elevation was due to the subject’s response to different setting/ environment. 

However, recent European guidelines proposed an alternative definition of “white coat hypertension” as office systolic/diastolic blood pressure readings of ≥140/90 mmHg and a 24-hour blood pressure <130/80 mmHg. The changing of definition shows that, further quantification and assessment should be done on individuals with white-coat effects. It is shown by studies and researches that white coat effect is not as benign as it looks. 

According to a study done in 1998, individuals with WCH are found to have higher risks of developing cardiac remodeling, which is the increase of left ventricular mass. In other words, those patients whom are diagnosed with WCH but failed to continue follow up and monitoring are prone to have left ventricular hypertrophy. This may lead to increased cardiovascular risks in the long run, such as myocardial infarction, cardiac arrhythmic. In another recent case-study done in year 2015, which showed that  individuals with WCH showed progression over time to sustained hypertension, but the majority of longitudinal studies and meta-analysis show no evidence of significant increased cardiovascular event risk as compared with normotensive controls. Out of those with sustained hypertension, majority of related studies proven to have metabolic syndrome and increased target organ damage. 

From the evidence-based reviews we can conclude that part of WCH patients will progress to sustained hypertension. If they are not properly under monitoring, things might get worse when there is cardiac remodeling and target organ damage. Hence, it is important to raise the awareness among the public about WCH. It is important to continue blood pressure monitoring, either self ABPM, or continue care under a doctor from time to time. The best cure for cardiovascular event is PREVENTION. 

Moreover, individuals with WCH should practice a healthy dietary habit and lifestyle. Moderate intensity physical activities for capable individuals for at least 150 minutes per week, 30 minutes per session. Dietary should be balanced, with a low salt and low fat content. Also not to forget about proper mental health practice, for proper stress and anxiety management. Blood profile check for sugar profile, liver and kidney functions are advised to be done in proper intervals for monitoring purpose. If preventive measures are done together with continuous monitoring, complications of WCH can be detected and treated early, to avoid irreversible morbidity & mortality. 

References
1.  Muscholl MW, et al. Changes in left ventricular sstructure and function in patients with white coat hypertension: cross sectional survey. BMJ. August 29, 1998; 317:565–70
2.  Franklin SS et al. White-Coat Hypertension - New Insights From Recent Studies. AHA journals. 2013;62:982–987

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