Circulation, Vol 90, 2291-2298, Copyright © 1994 by American Heart Association
MA Weber, JM Neutel, DH Smith and WF Graettinger
BACKGROUND--Between 20% and 30% of patients with clinically diagnosed
hypertension have normal blood pressure (BP) values during automated
ambulatory 24-hour BP monitoring. It has not been clear, however, whether
these patients can be regarded as normotensive or whether they should be
treated in the same way as confirmed hypertensive patients. METHODS AND
RESULTS--Ambulatory BP monitoring was performed in 88 normal control
subjects and 171 hypertensive patients (office diastolic BP > or = 90 mm
Hg on three visits; never treated or off treatment for more than 6 months).
Hypertensive patients were classified as nonconfirmed or white coat (n =
58) if their 24-hour diastolic averages were < 85 mm Hg and at least 15
mm Hg lower than their office values. For comparisons, white coat patients
were pair-matched with normal subjects by 24-hour diastolic averages and
sex, and by similar age and weight; there were 40 such pairs. White coat
patients were likewise pair-matched with confirmed hypertensive patients by
identical office BPs (51 pairs). Participants were studied by
individualized treadmill testing, Doppler echocardiography, and assays of
resting plasma catecholamines, upright plasma renin and aldosterone, and
lipid, glucose, and insulin concentrations. Because of the matching,
compared with normal subjects, patients with white coat hypertension and
normal subjects had identical 24-hour BP averages. The white coat patients
exhibited slightly greater variability among individual readings (obtained
each 15 minutes) throughout the day [P < .05]), but there were no
differences in hemodynamic responses to exercise. Plasma norepinephrine (P
< .05), renin and aldosterone (P < .01 for each), and insulin and
low-density lipoprotein cholesterol levels (P < .01 for each) were
higher in the white coat group, as were left ventricular septal wall (P
< .05) and muscle mass (P = .07) echocardiographic measurements. When
compared with the confirmed hypertensive patients, the white coat patients
had higher renin (P < .01) but were otherwise similar. Within the white
coat group, plasma norepinephrine correlated with total cholesterol and
triglycerides (P < .05 for each), and aldosterone correlated with left
ventricular mass (P < .01); there were no significant correlations
within the normal control subject or confirmed hypertension groups.
CONCLUSIONS--Patients with white coat hypertension differ in metabolic,
neuroendocrine, and cardiac findings from normal control subjects and have
greater BP variability. These changes appear to be mediated by heightened
activity of the sympathetic and renin-angiotensin systems. Although these
characteristics could reflect an alerting reaction in the clinic due to
awareness of their diagnosis, the white coat hypertensive patients also
have evidence for additional, more-sustained differences from normal
subjects. Thus, this condition appears to be a true variant of
hypertension.
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Diagnosis of mild hypertension by ambulatory blood pressure monitoring
Hypertension Center, Veterans Affairs Medical Center, Long Beach 90822.
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