Decoding white coat hypertension

Establishment of a scoring model for the differential diagnosis of white coat hypertension and sustained hypertension

OBJECTIVES

This study aimed to establish a scoring model for the differential diagnosis of white coat hypertension (WCH) and sustained hypertension (SHT).

METHODS

This study comprised 553 adults with elevated office blood pressure, normal renal function, and no antihypertensive medications. Through questionnaire investigation and biochemical detection, 17 parameters, such as gender and age, were acquired. WCH and SHT were distinguished by 24 h ambulatory blood pressure monitoring. The participants were randomly divided into a training set (445 cases) and a validation set (108 cases). The above parameters were screened using least absolute shrinkage and selection operator regression and univariate logistic regression analysis in the training set. Afterward, a scoring model was constructed through multivariate logistic regression analysis.

RESULTS

Finally, six parameters were selected, including isolated systolic hypertension, office systolic blood pressure, office diastolic blood pressure, triglyceride, serum creatinine, and cardiovascular and cerebrovascular diseases. Multivariate logistic regression was used to establish a scoring model. The R2 and area under the ROC curve (AUC) of the scoring model in the training set were 0.163 and 0.705, respectively. In the validation set, the R2 of the scoring model was 0.206, and AUC was 0.718. The calibration test results revealed that the scoring model had good stability in both the training and validation sets (mean square error = 0.001, mean absolute error = 0.014; mean square error = 0.001, mean absolute error = 0.025).

CONCLUSION

A stable scoring model for distinguishing WCH was established, which can assist clinicians in identifying WCH at the first diagnosis.

Effects of Nondipping Blood Pressure Changes: A Nephrologist Prospect

Blood pressure (BP) variations depend on various internal, environmental, and behavioral factors. BP fluctuations occur both in normotensive and hypertensive people. Although it fluctuates over the 24-hr day and night, the morning BP increases after waking up and declines throughout sleep. It is typical for BP to decrease by 10% to 20%, while sleeping, known as dipping BP. However, if there is no decrease in nighttime mean systolic BP or a drop of less than 10 mmHg, it is called nondipping BP. Conversely, reverse dipping BP means an increase in mean systolic BP instead of a drop during the night. Reverse dipping is observed in hypertension (HTN), diabetes mellitus (DM), chronic kidney disease (CKD), and obstructive sleep apnea (OSA) syndrome. The introduction of ambulatory BP monitoring (ABPM) led to the emergence of identifying normal and elevated BP patterns. Non-dipping BP increases the risk of cardiovascular system (CVS) complications such as left ventricular hypertrophy, proteinuria, glomerular filtration rate (GFR) reduction, and CKD progression. A loss or blunting of the normal BP profile is recognized as a deleterious variant, and restoring abnormal BP patterns has been reported to significantly impact end-organ damage, morbidity, and mortality. In this non-systematic clinically-oriented, comprehensive review, we aim to update the BP variables and the pathophysiology of nondipping BP and point out the areas which need more investigation from a nephrology perspective because the nondipping BP increases the risk of proteinuria, GFR reduction, and CKD progression. A literature search of PubMed, Google, EMBASE, and Google Scholar was conducted. Checks of selected papers and relevant reviews complemented the electronic search. With improved BP measurement methods, the physiology of BP profile variations is readily detectable during the day and night. A nondipping BP profile is a distinct BP pattern that may have significant end-organ damage effects and therapeutic importance for nephrologists. The pathophysiology of the nondipping BP variant must be clarified to prevent complications, and further investigations are required. Furthermore, there is debate about the best BP index to utilize: systolic BP, diastolic BP, mean arterial pressure, or a mixture of all. All these areas are important and need new research projects.

Possible cardiovascular risks of white coat hypertension: updated

White-coat hypertension (WCH) has been defined as an increased blood pressure (BP) in the doctor's office and a normal BP outside the office by 24 hr ambulatory BP monitoring (ABPM) or home BP measurement. It is generated by fear and anxiety of whether an abnormal value could be found and indicate the existence of hypertension. When first described, it was defined as a neuro-defense reaction related to the presence of the doctor in their office or clinic and associated with an increase in heart rate. Initially it was considered a benign condition, not associated with the hypertension mediated organ damage (HMOD) and not requiring treatment. However, recent studies have shown that WCH is not a benign condition and is associated with HMOD and cardiovascular (CV) events (CVE). According to recent ACC/AHA guidelines, the outside of office normal BP should be < 130/80 mmHg and according to the ESC/ESH guidelines, the outside of office normal BP should be < 135/85 mmHg. The prevalence of WCH varies by different studies from 15% to 40% and up to 50% in older subjects. Currently, the management of WCH if not associated with CV risk factors should be conservative with healthy lifestyle changes and exercise. Drug therapy should be considered if these measures do not work or in the presence of CV risk factors, HMOD, or preexisting cardiovascular disease.

Ageing modifies acute resting blood pressure responses to incremental consumption of dietary nitrate: a randomised, cross-over clinical trial

Beetroot (BR) is a rich source of nitrate (NO₃-) that has been shown to reduce blood pressure (BP). Yet, no studies have examined the vascular benefits of BR in whole-food form and whether the effects are modified by age. This study was a four-arm, randomised, open-label, cross-over design in twenty-four healthy adults (young n 12, age 27 ± 4 years, old n 12, age 64 ± 5 years). Participants consumed whole-cooked BR at portions of (NO₃- content in brackets) 100 g (272 mg), 200 g (544 mg) and 300 g (816 mg) and a 200-ml solution containing 1000 mg of potassium nitrate (KNO₃) on four separate occasions over a 4-week period (≥7-d washout period). BP, plasma NO₃- and nitrite (NO₂-) concentrations, and post-occlusion reactive hyperaemia via laser Doppler, were measured pre- and up to 5-h post-intervention. Data were analysed by repeated-measures ANOVA. Plasma NO₂- concentrations were higher in the young v. old at baseline and post-intervention (P < 0·05). All NO₃- interventions decreased systolic and diastolic BP in young participants (P < 0·05), whereas only KNO₃ (at 240-300 min post-intake) significantly decreased systolic (-4·8 mmHg, -3·5 %, P = 0·024) and diastolic (-5·4 mmHg, -6·5 %, P = 0·007) BP in older participants. In conclusion, incremental doses of dietary NO₃- reduced systolic and diastolic BP in healthy young adults whereas in the older group a significant decrease was only observed with the highest dose. The lower plasma NO₂- concentrations in older participants suggest that there may be mechanistic differences in the production of NO from dietary NO₃- in young and older populations.

“What if It’s not Just an Item of Clothing?” – A Narrative Review and Synthesis of the White Coat in the Context of Aged Care

Although increasingly disputed, the white coat uniform is ubiquitous in geriatric care, which may reflect a phenomenon called medicalisation of ageing. This narrative review is the first attempt at integrating several theoretical approaches, such as the “white coat effect” and “enclothed cognition”, in order to gain a comprehensive understanding of the use of this clothing item. Based on extensive empirical evidence, we will examine the consequences of wearing a uniform, not only on patients (in this case, older patients) and healthcare professionals, but also on their relationship. The white coat has powerful symbolic functions for healthcare professionals and is still preferred by older adults. However, the negative repercussions of wearing a uniform require us to question its use, particularly in environments where older persons live, such as nursing homes.

White Coat Uncontrolled Hypertension in Teleconsultation: A New and Frequent Entity

Introduction

Cardiovascular risk seems not to be greater in patients with white coat uncontrolled hypertension (WUCH) than in patients with sustained blood pressure (BP) control. Therefore, its detection is important to avoid overtreatment. The COVID-19 pandemic determined a massive migration of hypertension consultations from the face-to-face modality to teleconsultations, and it is unknown whether WUCH exists in this context.

Aim

We aimed to evaluate the prevalence of WUCH through home BP monitoring (HBPM) in treated hypertensive patients evaluated by teleconsultation.

Methods

We included treated hypertensive patients that owned a digital BP monitor. During teleconsultation, patients were asked to perform two BP measurements and then a 7-day HBPM, using the same device. Patients were classified as having WUCH if BP was ≥ 140 and/or 90 mmHg in teleconsultation and < 135/85 mmHg on HBPM. The prevalence of WUCH and its 95% confidence interval were estimated. One-way ANOVA, the Chi-square test or Fisher’s exact test were used to compare the characteristics of these patients with the other groups.

Results

We included 341 patients (45.2% male, mean age 62.3 years). The prevalence of WUCH was 33.1% (95% CI 28.3–38.3%). Significant differences were found in terms of age, the number of antihypertensive drugs and the use of calcium channel blockers, all lower in the WUCH group as compared with the groups with elevated BP on HBPM.

Conclusion

WUCH exists in teleconsultation and is very frequent. It can be easily detected though HBPM, thus avoiding overmedication, and its potential impact on side-effects and health costs.

Interaction between hypotension and age on adrenal crisis diagnosis

Objective

To determine whether adrenal crisis (AC) identification may be affected by the definition of hypotension.

Context

Delays in AC diagnosis can result in adverse outcomes. AC-related cardiovascular compromise may vary according to baseline blood pressure and may be associated with delayed AC detection in some patients.

Design

A retrospective study of paired systolic blood pressure (sBP) measurements in hospitalized patients with primary AI (PAI).

Patients

Patients with PAI and an acute illness admitted for urgent treatment between 2000 and 2017.

Measurements

A comparison between sBP on hospital arrival and on discharge. Hypotension was classified as either absolute hypotension (sBP 100mg or lower) or relative hypotension (sBP over 100 mg but at least 20 mm Hg lower than discharge sBP).

Results

Of 152 admissions with paired blood pressure measurements, 46 (30.3%) included a medically diagnosed AC. Absolute hypotension was found in 38 (25.0%) records, and a further 21 (13.8%) patients were classified as having relative hypotension. Patients aged 65 years and older had the lowest (14.8%, n = 8) proportion with absolute hypotension but the highest (27.8%, n = 15) with relative hypotension. Use of either absolute or relative hypotension as the criterion for AC diagnosis increased the proportion of patients with an AC by 28.3% and the proportion of patients with an AC in the oldest age group by 130%.

Conclusions

Failure to detect cardiovascular compromise is common in older AI patients, may underestimate the AC rate in this group, and delay essential treatment. Relative hypotension may play a role in AC diagnosis.

Internal migration, urban living, and non-communicable disease risk in South Africa

This paper offers theoretical and substantive contributions to migration-health scholarship by employing rich panel data with biomarkers to estimate the effect of migration and urban living on non-communicable disease risk in South Africa. Internal migration and urbanization continue to be pervasive demographic and socio-economic phenomena that structure daily life in low- and middle- income countries (LMICs). Yet, how these processes affect illness and disease in low-resource settings is still not well understood. Five waves (2008-2017) of South Africa's National Income Dynamics Study data and fixed-effects modeling are used to estimate the relationship between urban residence, migration, and health. Results indicate that the migration-health relationship differs by gender: urban living for men is associated with lower blood pressure. While urban residence appears to convey a health advantage when men reside in urban compared with rural places, there is no evidence of an urban health advantage among women. Migration does, however, negatively affect women's health through higher blood pressure (BP). These findings highlight the need for further interrogation of the ways in which processes and health consequences of migration and urban living are structured by gender in LMICs. Given the importance of urbanization and the prevalence of migration in LMICs, the gendered determinants of blood pressure may be key to understanding rising hypertension incidence in contexts like South Africa.

Current status of white coat hypertension: where are we?

White coat hypertension (WCH) is characterised by an elevated clinic blood pressure (BP) with normal ambulatory or home BP. It is well recognised in clinical practice and occurs in approximately one-third of untreated patients with elevated clinic BP. Current evidence suggests that WCH is associated with cardiovascular risk factors, including the development of sustained hypertension and the presence of target organ damage. However, its effects on cardiovascular outcomes remain a matter of debate. There is also insufficient evidence from randomised controlled trials to determine whether WCH warrants treatment. This narrative review aims to provide an update on the current understanding of WCH. It focuses on the clinical characteristics and potential implications of WCH, its relationship to cardiovascular risk and the evidence regarding treatment. Gaps in existing research are also highlighted.

Effects of white-coat, masked and sustained hypertension on coronary artery stenosis and cardiac arrhythmia

This study aimed to investigate whether hypertension phenotypes such as white-coat hypertension (WCHT), diagnosed with the addition of nighttime blood pressure (BP) criteria, are related to coronary artery stenosis (CAS) and cardiac arrhythmia. In this cross-sectional observational study, 844 participants who did not use antihypertensive, lipid-lowering, and antiplatelet drugs were selected. The subjects were divided into normotensive (NT), WCHT, masked hypertension (MHT), and sustained hypertension (SHT) groups based on the results of clinic BP measurement and ambulatory BP monitoring. Coronary angiography and ambulatory electrocardiography were performed to determine the participants' CAS and cardiac arrhythmia status. Coronary angiography revealed 556 patients with CAS and 288 participants with normal coronary arteries. The chi-squared test showed that the incidence of CAS was higher in the MHT and SHT groups than in the NT group, while no significant change was found in the WCHT group (P = 0.003, P < 0.001, P = 0.119). The logarithm of the Gensini score was used to compare the degree of CAS between the groups. Multiple linear regression analysis showed that the degree of CAS was higher in the WCHT, MHT, and SHT groups than in the NT group (P < 0.05). The incidences of frequent atrial premature beats, atrial tachycardia, and ventricular cardiac arrhythmia were significantly higher in the WCHT and SHT groups than in the NT group, while only ventricular cardiac arrhythmia changes were observed in the MHT group. This study found that hypertension phenotypes such as WCHT were closely associated with CAS and cardiac arrhythmia.

Can an automatic oscillometric device replace a mercury sphygmomanometer on blood pressure measurement? a systematic review and meta-analysis

OBJECTIVE

A mercury sphygmomanometer has been considered a gold standard for measuring blood pressure. However, by the Minamata Convention on Mercury, the traditional mercury sphygmomanometer is being replaced by an automated oscillometric device. This study aimed to provide scientific evidence to determine whether an automated oscillometric device can replace a mercury sphygmomanometer and if it is applicable in routine practice.

METHODS

MEDLINE, EMBASE, the Cochrane Library, and CINAHL were searched on 4 May 2018. Studies comparing blood pressure measurements between automated oscillometric devices and mercury sphygmomanometers were included. Study characteristics were abstracted using the evidence table, and random-effects meta-analyses were conducted.

RESULTS

Data were compiled from 24 studies comprising 47 759 subjects. The results of meta-analysis showed that automated oscillometric devices measured lower than mercury sphygmomanometers for both systolic blood pressure (mean differences -1.75 mmHg, 95% confidence intervals: -3.05 to -0.45, I = 91.0%) and diastolic blood pressure (mean differences -1.20 mmHg, 95% confidence intervals: -2.16 to -0.24, I = 95.0%). In sub-group analyses by manufacturer, BpTRU measured lower than the mercury sphygmomanometer and OMRON showed no difference compared to the mercury sphygmomanometer for both systolic and diastolic blood pressure, but the results differed depending on the devices.

CONCLUSION

As a result of this review, the difference in blood pressure between the mercury sphygmomanometer and the automated oscillometric device was within 5 mmHg, but the heterogeneity between the studies was very high. The automated oscillometric devices showed differences in blood pressure results according to the manufacturer and product type.

Is spontaneous normalization of systolic blood pressure within 24 hours after ischemic stroke onset related with favorable outcomes?

Background

In acute ischemic stroke, blood pressure (BP) tends to rise initially and fall to a baseline level within 24–48 hours. Previous studies reported several different effects of BPs during acute ischemic stroke on clinical outcomes, which was partly due to the different time intervals from stroke onset to BP measurement.

Methods

All patients with acute ischemic stroke (onset ≤3 hours) who lived independently before the stroke, were consecutively enrolled for a 62-month period. BPs at 0, 12, and 24 hours after admission were collected. A favorable outcome was defined as a modified Rankin Scale (mRS) score 0–2 at discharge. For different standards of BP management, patients were grouped and analyzed according to intravenous (IV) tissue plasminogen activator (tPA) treatment and favorable outcome.

Results

Among the 446 enrolled patients, 227 patients underwent IV tPA treatment and 216 had mRS score 0–2 at discharge. Patients with favorable outcomes had lower initial NIH Stroke Scale (NIHSS) scores, less frequent progressive neurological deficits, and lower systolic BP (SBP) 12 and 24 hours after admission than patients with unfavorable outcomes, regardless of whether they underwent tPA treatment or not (p <0.05). The BP decreased over a period of 24 hours after admission. In logistic regression analysis, the independent variables associated with favorable outcome were the initial NIHSS score, a progressive neurological deficit, a previous stroke, and the SBP 24 hours after admission in the patients who underwent tPA treatment and the initial NIHSS score and a progressive neurological deficit in the patients who did not undergo tPA treatment (p <0.05).

Conclusions

The SBPs at 12 and 24 hours after admission were lower in acute stroke patients with favorable outcomes than in the other patients, regardless of whether the patients underwent tPA therapy and the SBP at 24 hours was an independent predictor of favorable outcomes among the patients who underwent tPA treatment.

Characteristics of Gut Microbiota in Patients with Hypertension and/or Hyperlipidemia: A Cross-Sectional Study on Rural Residents in Xinxiang County, Henan Province

Human gut microbiota can be affected by a variety of factors, including geography. This study aimed to clarify the regional specific characteristics of gut microbiota in rural residents of Xinxiang county, Henan province, with hypertension and hyperlipidemia and evaluate the association of specific gut microbiota with hypertension and hyperlipidemia clinical indices. To identify the gut microbes, 16S rRNA gene sequencing was used and a random forest disease classifier was constructed to discriminate between the gut microbiota in hypertension, hyperlipidemia, and the healthy control. Patients with hypertension and hyperlipidemia presented with marked gut microbiota dysbiosis compared to the healthy control. The gut microbiota related to hypertension and hyperlipidemia may consist of a large number of taxa, influencing each other in a complex metabolic network. Examining the top 35 genera in each group showed that Lactococcus, Alistipes, or Subdoligranulum abundances were positively correlated with systolic blood pressure (SBP) or diastolic blood pressure (DBP) in hypertensive patients with treatment-naive hypertension (n = 63). In hypertensive patients undergoing anti-hypertensive treatment (n = 104), the abundance of Megasphaera or Megamonas was positively correlated to SBP. In the hyperlipidemia group, some of the top 35 genera were significantly correlated to triglyceride, total cholesterol, and fasting blood glucose levels. This study analyzed the characteristics of the gut microbiota in patients with hypertension and/or hyperlipidemia, providing a theoretical basis for the prevention and control of hypertension and hyperlipidemia in this region.

Clinician accountability in a primary care clinic time-interval blood pressure measurements study: Practice implications

BACKGROUND

Accurate blood pressure measurements (BPM) are important, as clinicians are tasked daily with using such measurements to make clinical diagnoses and patient care judgments. Research studies and controlled trials hold such measurements to a higher standard than everyday clinical practice.

OBJECTIVE

The aim of this study was to evaluate difference in BPM outcomes of individuals in a clinic setting when clinicians collect BPM as usual vs BPM after 5- (USPSTF recommendation) and 10- minute (study unique intervention) timed rest interval.

METHODS

A repeated-measures design was used to examine individual BPMs at the intervals of baseline, after a 5-minute rest interval post-baseline, and after a 10-minute rest interval post-baseline. Results Pairwise comparisons indicated that baseline SBP was the highest when compared to SBP measured at both 5- and 10-minutes post-baseline. SBP measured at 5-minutes was also significantly higher compared to SBP collected at 10-minutes post-baseline (ps < .05). For DBP, the repeated-measures ANOVA indicated that there was no significant difference across BPMs, F(2,198) = 1.25, p = .29.

CONCLUSIONS

Results from this study revealed that implementing a 5-minute rest interval before BPMs are taken in a clinic setting produces a "clinically observable" reduction in the overall mean systolic BPs as seen at both 5- and 10-minute BPM intervals. It is important for all healthcare clinicians to recognize the importance of accurate BPM and the need to encourage better regulated BPM standard in everyday practice.

White coat syndrome and its variations: differences and clinical impact

Hypertension is closely linked to increased cardiovascular risk and development of target organ damage (TOD). Therefore, proper clinical follow-up and treatment of hypertensive subjects are mandatory. A great number of individuals present a variation on blood pressure (BP) levels when they are assessed either in the office or in the out-of-office settings. This phenomenon is defined as white coat syndrome - a change in BP levels due to the presence of a physician or other health professional. In this context, the term "white coat syndrome" may refer to three important and different clinical conditions: 1) white coat hypertension, 2) white coat effect, and 3) masked hypertension. The development of TOD and the increased cardiovascular risk play different roles in these specific subgroups of white coat syndrome. Correct diagnose and clinical guidance are essential to improve the prognosis of these patients. The aim of this review was to elucidate contemporary aspects of these types of white coat syndrome on general and hypertensive population.

The differential diagnostic value of serum homocysteine for white coat hypertension

Objective

To assess the value of serum homocysteine (Hcy) in differential diagnosis of white coat hypertension (WCH).

Results

In this retrospective study, serum Hcy levels were elevated in hypertensive patients (P < 0.001) compared to WCH patients. Serum Hcy levels were positively correlated with 24-h mean systolic blood pressure, r = 0.1378, P < 0.001. The results of the receiving operating characteristic (ROC) curve showed that the AUC value of Hcy was 0.80 (95% CI, 0.77–0.83), the cut-off value was 13.8 μmol/L, the sensitivity was 68.58% and the specificity 87.21%. In the prospective study, the AUC value of Hcy was 0.73 (95% CI: 0.67–0.78), higher than N - terminal pro - brain natriuretic peptide(NT-pro-BNP) (0.64, 95% CI:0.58–0.70) and cystatin C (Cys-C) (0.62, 95% CI:0.55–0.68). Hcy, NT-proBNP and Cys-C combined, provided a better indication of a differential diagnosis of WCH, than Hcy alone.

Materials and Methods

This investigation involved both a retrospective and a prospective study. Clinical data including blood pressure, age, sex, height, weight, BMI, smoking status, past history, and behavioral electrocardiogram of patients who had undergone 24-hour ambulatory blood pressure monitoring (ABPM) with elevated clinical blood pressure (BP) were recorded. Pearson correlation analysis was used to test the correlation between Hcy and BP. The ROC curve was used to analyze the value of measuring Hcy levels in differential diagnosis of WCH.

Conclusions

Serum Hcy was decreased in WCH patients and therefore could be a biomarker for differential diagnosis of WCH.