White Coat Hypertension: Causes, Diagnosis, and Management
Definition
White coat hypertension (WCH): Office BP ≥130/80 mmHg with normal out-of-office BP (<130/80 on ABPM or <135/85 home). Affects 15–30% of adults; higher in elderly, women, those with clinic anxiety.
Pathophysiology
- Conditioned stress response: Medical environment → sympathetic activation (catecholamines) → vasoconstriction, ↑CO.
- Altered baroreflex sensitivity.
- Not benign: WCH carries intermediate CV risk between normotension and sustained hypertension; may progress to sustained HTN.
Diagnosis
- Office BP elevated on ≥2–3 visits.
- Confirm with 24-hour ABPM (gold standard) or structured home BP monitoring (7 days, duplicate morning/evening).
- Exclude masked hypertension (normal office, elevated out-of-office).
Management
- Lifestyle: DASH diet, Na⁺ <2.3 g, weight loss, exercise, moderation of alcohol, smoking cessation.
- Monitoring: Annual ABPM/home BP to detect transition to sustained HTN.
- Pharmacotherapy: Not routinely recommended for WCH alone; consider if high CV risk (diabetes, CKD, ASCVD) or progression to sustained HTN.
- Anxiety reduction: Relaxation training, CBT, mindfulness; measure BP after 5-min quiet rest, automated device, proper cuff size.
Key Message
WCH is a real hemodynamic phenomenon with prognostic significance. Out-of-office confirmation is essential before labeling or treating.
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