Closer look at white-coat hypertension

White-coat hypertension in pregnant women: risk factors, pregnancy outcomes, and biomarkers

Hypertensive disorders of pregnancy are a worldwide health problem for women. They cause complications in up to 10% of pregnancies and are associated with increased maternal and neonatal morbidity and mortality. Traditional blood pressure measurement in clinical practice is the most commonly used procedure for diagnosing and monitoring hypertension treatment, but it is prone to significant inaccuracies caused, on the one hand, by the inherent variability of blood pressure and, on the other, by errors arising from measurement technique and conditions. Some studies have demonstrated a better estimate of the prognosis for the development of cardiovascular diseases using ambulatory blood pressure monitoring. We can detect white-coat hypertension using this method, which helps to avoid overdiagnosis and overtreatment in many cases, and we can also detect masked hypertension, which helps to avoid underdiagnosis and a lack of prescribed treatment if needed. White-coat hypertension is not a benign condition - it has been shown to be associated with higher risks of developing preeclampsia, preterm birth, and small-for-gestational-age babies. In this regard, it is extremely important for clinicians to be aware of the risk factors and outcomes associated with this condition. Pregnant women should be medically monitored both during pregnancy and after delivery to detect target organ damage, cardiovascular risk factors, or a metabolic syndrome.

Insight on Cardiac Chronobiology and Latest Developments of Chronotherapeutic Antihypertensive Interventions for Better Clinical Outcomes

Cardiac circadian rhythms are an important regulator of body functions, including cardiac activities and blood pressure. Disturbance of circadian rhythm is known to trigger and aggravate various cardiovascular diseases. Thus, modulating the circadian rhythm can be used as a therapeutic approach to cardiovascular diseases. Through this work, we intend to discuss the current understanding of cardiac circadian rhythms, in terms of quantifiable parameters like BP and HR. We also elaborate on the molecular regulators and the molecular cascades along with their specific genetic aspects involved in modulating circadian rhythms, with specific reference to cardiovascular health and cardiovascular diseases. Along with this, we also presented the latest pharmacogenomic and metabolomics markers involved in chronobiological control of the cardiovascular system along with their possible utility in cardiovascular disease diagnosis and therapeutics. Finally, we reviewed the current expert opinions on chronotherapeutic approaches for utilizing the conventional as well as the new pharmacological molecules for antihypertensive chronotherapy.

The association of dynamic thiol-disulphide balance with white-coat hypertension

OBJECTIVE

Dynamic thiol-disulphide homeostasis is an indicator of the antioxidant system that interacts early with the oxidative environment. This study aimed to assess the dynamic thiol/disulphide balance in individuals with white-coat hypertension (WCH).

METHODS

This cross-sectional study included a total of 117 individuals who presented to our outpatient cardiology clinic. Seventy patients were diagnosed with WCH. All blood samples were obtained from the patients after a minimum of 8 h of fasting, centrifuged immediately, stored in Eppendorf tubes, and protected at -80°C.

RESULTS

The two groups were well-balanced in terms of age, gender, and BMI. Native thiol and total thiol levels were lower in the WCH group than in normotensive individuals. However, disulphide levels were higher in the former. Serum disulphide concentration positively correlated with 24-h SBP, and 24-h DBP. In backward stepwise logistic regression analysis, serum disulphide [odds ratio (OR) = 1.165 (1.089-1.245), 95% confidence interval (CI), P < 0.001] and serum total thiol levels [OR = 0.992 (0.984-1.000), 95% CI, P = 0.050] were independently associated with WCH.

CONCLUSION

We demonstrated that dynamic thiol/disulphide balance shifted strongly towards disulphide formation due to thiol oxidation in patients with WCH.

Association of circulating miR-155 expression level and inflammatory markers with white coat hypertension

Circulating miR-155 play a vital role in hypertension. The aim of the present study was to explore the association of miR-155 with blood pressure and inflammatory markers, and to investigate the predictive value of circulating miR-155 for white coat hypertension (WCH). This cross-sectional study was continuously enrolled 105 subjects and was divided into three groups based on office blood pressure monitoring and 24-h ambulatory blood pressure monitoring (ABPM): normal hypertension, WCH, and hypertension group. Circulating miR-155 was assessed by quantitative real-time polymerase chain reaction (qRT-PCR). Spearman correlation coefficient and area under the ROC curve (AUC) were used. We found miR-155 in hypertension group were significantly higher than those in the WCH and normal hypertension group. The level of miR-155 was positively correlated with C-reactive protein, interleukin-6, office systolic blood pressure (SBP), and diastolic blood pressure (DBP), and ABMP parameters (24-h SBP, 24-h DBP, 24-h daytime SBP, 24-h daytime DBP, 24-h nighttime SBP and 24 h nighttime DBP) (all P < 0.05). Circulating miR-155 yielded an AUC of 0.843 (95% CI: 0.753, 0.933; P < 0.001) and 0.832 (95% CI: 0.736, 0.928; P < 0.001) for differing hypertension and WCH from control subjects, respectively. Our results suggested that miR-155 was significantly associated with inflammatory markers, and may become a potential noninvasive marker for WCH detection.

Long-term cardiovascular risk of white-coat hypertension with normal night-time blood pressure values

BACKGROUND

The prognostic impact of white-coat hypertension (WCHT) is still a matter of debate and controversy. Night-time blood pressure (NBP) is related strongly to cardiovascular (CV) prognosis, but this has not been considered currently in the definition of WCHT.

PATIENTS AND METHODS

We investigated the long-term CV prognosis of 2659 patients submitted at admission to 24 h-ambulatory blood pressure (BP) monitoring divided into three groups: normotension (NT) (n=812; 59% female; ageing 49±13 years), sustained hypertension (SHT) (n=1230; 56% female; ageing 51±13 years) and WCHT (n=617; 55% female; ageing 50±3 years) defined as office BP of at least 140/90 mmHg, daytime BP less than 135/85 mmHg and NBP less than 120/70 mmHg.

RESULTS

The median follow-up was 7.6 years (range: 0.4-24.4), during which a total of 257 CV events (36 fatal) occurred (46% strokes, 32% coronary and 22% others), 38 in NT, 31 in WCHT and 188 in SHT. The event rate per 100 patient-years was 0.60 in the WCHT group, 0.66 in the NT group and 2.09 in the SHT group. Cox's regression analysis adjusted for covariables showed a higher risk of CV events in patients with SHT than WCHT [hazard ratio (HR)=2.230, 95% confidence interval: 1.339-3.716, P=0.002], whereas there was no difference between WCHT and NT groups. Event-free survival was significantly different from SH versus WCHT and NT groups. Within the group of WCHT, 29% of patients received sustained antihypertensive medication during the follow-up, but the HR of CV events between WCHT either treated or not treated did not differ: HR=0.76 (95% confidence interval: 0.37-1.51, P=0.42).

CONCLUSION

In patients with WCHT defined by normal daytime and NBP values, the risk of CV events was significantly lower than that of SHT and similar to that of NT patients, suggesting that NBP should be included in the WCHT definition and in its prognostic stratification.

Utility of ambulatory blood pressure monitoring for the management of hypertension

PURPOSE OF REVIEW

Hypertension is a leading cause of cardiovascular morbidity and mortality, affecting nearly 80 million individuals in the United States alone. Accurate measurement of blood pressure (BP) is the crucial first step to reduce the associated cardiovascular risk of hypertension. For decades, clinicians have relied on office BP measurements for the diagnosis and subsequent management of hypertension. However, it has been clearly demonstrated that ambulatory BP measurements are a better predictor of cardiovascular risk and can provide clinicians with important additional information to improve BP control and reduce cardiovascular risk. This article reviews the available data and provides clinical insights into the use of ambulatory BP monitoring for the management of hypertension.

RECENT FINDINGS

Ambulatory BP monitoring is uniquely capable of identifying patients with white-coat hypertension (WCH), masked hypertension and abnormal nocturnal BP profiles. Recently, ambulatory BP data have demonstrated the negative impact of WCH on right ventricular function, a greater prevalence of masked hypertension than previously recognized and the detrimental impact of nocturnal hypertension even in controlled hypertension.

SUMMARY

Ambulatory BP monitoring provides clinicians with the most comprehensive evaluation of hypertension and the ability to define individual BP phenotypes. Hence, these out-of-office measurements can be utilized to improve hypertension control, translating into a reduction of cardiovascular events.

The impact of protein oxidation on sustained and white coat hypertension

Objective:

The present study compared the unfavorable effects of protein oxidation and deoxyribonucleic acid damage on patients with white coat hypertension (WCH), sustained hypertension (HT), and normotensives.

Methods:

Participants were allocated into 3 groups: 40 healthy controls, 36 patients with WCH, and 40 patients with sustained HT. Patients with risk factors for atherosclerosis, endocrine diseases, alcoholism, or masked hypertension were excluded. Plasma level of protein carbonyl (PCO), ischemia modified albumin (IMA), total thiol (T-SH), prooxidant-antioxidant balance (PAB), advanced protein oxidation products (AOPPs), and urinary level of 8-hydroxy-2’-deoxyguanosine (8-OHdG) were measured and relationship between these oxidative stress parameters and WCH and sustained HT was analyzed.

Results:

Ambulatory 24-hour, daytime and night-time systolic and diastolic blood pressure readings of sustained HT group were significantly higher than those of WCH and control groups (p<0.001, all). AOPPs, PCO, IMA, 8-OHdG, and PAB levels were significantly higher in HT group than WCH and control groups (p<0.001, all). Additionally, T-SH level was significantly lower in HT group than WCH and control groups (p<0.001). A similar statistically significant relationship was detected between WCH and control groups.

Conclusion:

Results indicate that increased level of AOPPs, PCO, IMA, 8-OHdG, PAB, and decreased level of T-SH are likely to be indicators of oxidative stress, which may play a key role both in WCH and sustained HT.

Characteristics Associated With Antihypertensive Treatment and Blood Pressure Control: A Population-Based Follow-Up Study in Peru

BACKGROUND

Over one-quarter of the world's adult population has hypertension, yet achieving adequate treatment or control targets remains a challenge.

OBJECTIVE

This study sought to identify, longitudinally, characteristics associated with antihypertensive treatment and blood pressure (BP) control among individuals with hypertension.

METHODS

Data from individuals enrolled in the population-based CRONICAS Cohort Study (adults ≥35 years, living in 4 different rural/urban and coastal/high-altitude Peruvian settings) with hypertension at baseline were used. Antihypertensive treatment and BP control were assessed at baseline and at 15 months. Multinomial logistic regressions were used to estimate relative risk ratios (RRR) and 95% confidence intervals (95% CI) of factors associated with antihypertensive treatment and BP control at follow-up.

RESULTS

At baseline, among 717 individuals with hypertension (53% women, mean age 61.5 ± 12.4 years), 28% were unaware of their hypertension status, 30% were aware but untreated, 16% were treated but uncontrolled, and 26% were treated and controlled. At follow-up, 89% of unaware and 82% of untreated individuals persisted untreated, and only 58% of controlled individuals remained controlled. Positive predictors of receiving treatment and being controlled at follow-up included age (RRR: 0.81; 95% CI: 0.73 to 0.91 for every 5 years) and family history of a chronic disease (RRR: 0.53; 95% CI: 0.31 to 0.92 vs. no history); whereas Puno rural site (RRR: 16.51; 95% CI: 1.90 to 143.56 vs. Lima) and male sex (RRR: 2.59; 95% CI: 1.54 to 4.36) were risk factors. Systolic BP at baseline (RRR: 1.27; 95% CI: 1.16 to 1.39 for every 5 mm Hg) and male sex (RRR: 1.75, 95% CI: 1.02 to 2.98) were risk factors for being treated but uncontrolled at follow-up.

CONCLUSIONS

Large gaps in treatment of hypertension were observed. Targeting specific populations such as men, younger individuals, or those without family history of disease may increase coverage of antihypertensive treatment. Also, targeting male individuals or those with higher systolic BP could yield better rates of BP control in the short term.

A Comparison of Casual In-Clinic Blood Pressure Measurements to Standardized Guideline-Concordant Measurements in Severely Obese Individuals

Background/Objectives. The objective of this study was to compare casual BP taken in a bariatric clinic to standardized guideline-concordant BP. Subjects/Methods. A cross sectional analysis was performed using baseline data from a weight management trial. Patients were recruited from a Canadian bariatric care program. Standardized BP was performed using a Watch BP oscillometric device. Casual in-clinic BP single readings, taken using a Welch Allyn oscillometric device, were chart-abstracted. Paired t-tests, Bland-Altman plots, and Pearson's correlations were used for analysis. Results. Data from 134 patients were analyzed. Mean age was 41.5 ± 8.9 y, mean BMI was 46.8 ± 6.5 kg/m(2), and 40 (30%) had prior hypertension. Mean casual in-clinic BP was 128.8 ± 14.1/81.6 ± 9.9 mmHg and mean standardized BP was 133.2 ± 15.0/82.0 ± 10.3 mmHg (difference of -4.3 ± 12.0 for systolic (p < 0.0001) and -0.4 ± 10.0 mmHg for diastolic BP (p = 0.6)). Pearson's coefficients were 0.66 (p < 0.0001) for SBP and 0.50 (p < 0.0001) for DBP. 28.4% of casual versus 26.9% of standardized measurements were ≥140/90 mmHg (p < 0.0001). Conclusion. In this bariatric clinic, casual BP was unexpectedly lower than standardized BP. This could potentially lead to the underdiagnosis of hypertension.

White coat hypertension: improving the patient-health care practitioner relationship

White coat hypertension is characterized by the variability of a patient’s blood pressure measurements between the physician’s office and the patient’s home environment. A patient with white coat hypertension has high blood pressure levels in the physician’s office and normal blood pressure levels in their typical environment. This condition is likely caused by the patient’s anxiety within the physician’s office and in the presence of the physician. Research has shown that improving the relationship between a patient and their health care provider can decrease the patient’s anxiety, with the implication of decreasing the patient’s likelihood of demonstrating white coat hypertension. This review provides an overview of the previous literature regarding white coat hypertension, its prevalence, and the consequences for those who develop persistent hypertension. Furthermore, this review discusses the implications of improving patient and health care provider interactions through effective communication, empathy, and trust, as well as the implications for future research studies in improving the patient and health care provider’s relationship.