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Masked Hypertension in Patients With Office BP <130/80 mm Hg
Study Questions:
Recent guidelines propose new values for defining hypertension as office blood pressure (BP) ≥130 systolic or ≥80 mm Hg diastolic and the target for drug treatment <130/80 mm Hg. 24-hour ambulatory BP monitoring (ABPM) and home BPs are usually used to detect “white-coat” hypertension. In contrast, masked hypertension (MH) refers to normal office BP and hypertension in the home or on 24-hour ABPM. What is the prevalence of MH and of masked uncontrolled hypertension (MUCH) based on 24-hour ABPM in patients with office BP <130/<80 mm Hg (guideline suggestion), drawn from the Spanish ABPM Registry?
Methods:
Values of 125/75, 130/80, and 110/65 mm Hg have been proposed for 24-hour, daytime, and nighttime periods corresponding to the office cut-off of 130/80 mm Hg. Primary care office BP was measured using standardized procedures. The registry had 115,708 patients (45,020 untreated and 70,688 treated or hypertension), of which 90% was from primary care centers and 10% from hypertension or cardiology clinics. According to the American College of Cardiology (ACC)/American Heart Association (AHA) hypertension guidelines, MH and MUCH were estimated by considering patients with mean 24-hour ABP ≥125 or ≥75 mm Hg, mean daytime BP≥130 or ≥80 mm Hg, mean nighttime BP ≥110 or ≥65 mm Hg, or any of the above. European Society of Hypertension (ESH) recommendations are 5 mm Hg higher for mean and daytime ABPM and 10 mm Hg higher for nighttime ABPM.
Results:
Mean age (standard deviation) was 59 (14) years, and 47% were women. Office BP was <130/<80 mm Hg in 7.7% and 8.4% of treated patients. Using mean daytime BP, prevalence of MH was 14% and MUCH in treated patients was 15% with the ESH criteria and 28%-30% with those proposed by the ACC/AHA guidelines. Corresponding figures by using mean 24-hour ABPM were 20% and 39%, respectively. When compared with patients with both normal office and ambulatory BP, MH or MUCH was associated with a worse cardiovascular risk profile, being older, more frequently males and smokers with higher office systolic BP, and more frequent cardiovascular disease.
Conclusions:
The high prevalence of MH observed in untreated and treated individuals with normal BP in the office supports a wider use of ABPM in routine clinical practice.
Perspective:
In a recent article by the same group (Banegas et al., N Engl J Med 2018;378;1509-20), the authors reported that ABP measurements were a stronger predictor of all-cause and cardiovascular mortality than clinic BP measurements. White-coat hypertension was not benign, and most importantly, MH was associated with a greater risk of death and cardiovascular death than sustained hypertension when adjusted for the office BP. Additionally, MUCH had a >2-fold risk for all-cause and cardiovascular mortality than those with controlled treated hypertension. Of course the lower choice of target BP and lower definition of hypertension and pre-hypertension increase the potential value of 24-hour ABPM. An outcome study comparing moderate and more intense BP targets in which office BP and 24-hour ABPM are compared for predicting outcome would be complicated, but would answer many questions that are presently debated by the hypertension community.
Keywords: Blood Pressure, Blood Pressure Determination, Blood Pressure Monitoring, Ambulatory, Cardiovascular Diseases, Hypertension, Masked Hypertension, Metabolic Syndrome, Outcome Assessment, Health Care, Prehypertension, Primary Prevention, Risk Factors, Smoking, Systole, White Coat Hypertension
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