T or F: It appears that masked hypertension is often the consequence of nocturnal blood pressure elevations.
In my previous review of white coat hypertension (WCH), I stressed that ambulatory blood pressure monitoring (ABPM) has found a place in the management of hypertension.1 Blood pressures obtained with ABPM are superior to office readings for the prediction of hypertensive end-organ damage.2 In fact, the diagnosis of WCH requires ABPM.2
This discussion leads us to another diagnosis that necessitates ambulatory monitoring-masked hypertension. This condition may be defined as normal blood pressure readings in the physician’s office and elevated readings outside the office as measured by ABPM.2 Test your current knowledge of masked hypertension with this brief 2-question quiz:
1. Which of the following statements is/are true?
A. Masked hypertension is more common in persons with stressful occupations, obstructive sleep apnea, and chronic kidney disease.
B. Masked hypertension is not more common in persons with diabetes.
C. In persons described as normotensive, masked hypertension is associated with increased cardiovascular risk-in fact, twice the risk.
D. It appears that masked hypertension is often the consequence of nocturnal blood pressure elevations.
Answer: Options A, C, and D are true; Option B is false (masked hypertension is more common in persons with diabetes).2,3
Unfortunately, there are no data about cardiovascular outcomes attained by the treatment of masked hypertension, although data from certain demographic groups suggest the benefits of treatment.2 However, in patients who are treated for hypertension, those who have normal pressures at physician visits and elevated pressures on ambulatory monitoring carry a higher cardiovascular risk than patients with masked hypertension who are untreated.2
2. Choose the most accurate statement:
A. Antihypertensive monotherapy lowers the incidence of microalbuminuria in patients with masked hypertension and diabetes.
B. Treatment of patients who have chronic kidney disease and masked uncontrolled hypertension with a mineralocorticoid receptor antagonist achieves blood pressure control in 65% of those treated.
C. African American persons have a minimal risk of masked hypertension (less than 10%).
Answer: Option B is correct.2
There are no data about the treatment of masked hypertension in persons with diabetes. The incidence of masked hypertension among African American patients enrolled in the Jackson Heart Study was nearly 30%.4
The bottom line
ABPM has opened new vistas in the management of hypertension. In addition to lowering office blood pressures, we need to consider 2 important categories: WCH and masked hypertension. The notion that WCH is an innocuous clinical diagnosis is wrong. It also appears that masked hypertension has many unfortunate clinical accompaniments.
1. Rutecki GW. White coat hypertension. Practical Cardiology. [URL to come]. Published [date]. Accessed [date].
2. Campbell PT, White WB. Utility of ambulatory blood pressure monitoring for the management of hypertension. Curr Opin Cardiol. 2017 Mar 16. doi: 10.1097/HCO.0000000000000399. [Epub ahead of print]
3. Naser N, Dzubur A, Durak A, et al. Blood pressure control in hypertensive patients, cardiovascular risk profile and the prevalence of masked uncontrolled hypertension. Med Arch. 2016;70:274-279.
4. Booth JN III, Diaz KM, Seals SR, et al. Masked hypertension and cardiovascular disease events in a prospective cohort of blacks: the Jackson Heart Study. Hypertension. 2016;68:501-510.